Every finding on record at Clearvista Lake Health Campus

Based on interview and record review, the facility failed to assess, monitor, and complete a timely Interdisciplinary Team (IDT) review of a resident's skin condition, per facility policy, for 1 of 3 residents reviewed for assistance with transfers. (Resident D)Findings include:The clinical record for Resident D was reviewed on 7/20/26 at 11:20 a.m. Resident D's diagnoses included, but were not limited to, dementia (decline in mental ability severe enough to interfere with daily life). Resident D was admitted to the facility on [DATE].The Hospice Residential Communication Form, dated 6/19/26, from Resident D's hospice binder located at the nurses' station indicated, Shower complete. New bruising reported to facility ED [Executive Director] and [name of hospice company] nurses. Patient daughter notified as well. The form was signed by Hospice Aide (HA) 2.There was no assessment, monitoring, or IDT review documentation in Resident D's clinical record of the bruising referenced in the above communication form.The June and July, 2026 grievances and incident reports were provided by the ED on 7/20/26 at 2:00 p.m. None of these referenced Resident D's bruising found by HA 2 on 6/19/26.An interview was conducted with HA 2 and the Hospice Manager of Clinical Services (HMCS) on 7/20/26 at 2:13 p.m. HA 2 indicated about a month ago, when she was assisting Resident D with a shower, Resident D lifted her left arm to show bruising on the top of her left forearm. Resident D pointed out an aide, who worked at the facility, as the one who caused the bruising during a transfer. HA 2 informed the hospice nurse and Executive Director (ED) of the facility of Resident D's bruising. The ED looked at Resident D's bruising after being informed. The HMCS indicated there were two primary bruises on Resident D's left forearm. One was approximately 1.5 inches by 0.75 inches, and the other one was an inch away, about the size of a half-dollar coin.An interview was conducted with the ED on 7/20/26 at 1:30 p.m. The ED indicated HA 2 reported to her that Resident D had bruising. The ED went to the nurse's station to look at the bruising afterwards. The ED pulled up Resident D's sleeve and saw a slight bruise on her left forearm. The ED thought she had one of the nurses look at the bruising. An interview was conducted with the Director of Nursing (DON) on 7/20/26 at 1:00 p.m. The DON indicated Resident D had bruising on her left forearm about a month ago. By the time the DON saw the bruise, it had faded, like it could have been there for a while. The DON discussed the bruising with Resident D's family member as well. If bruising was found on a resident, they continued to monitor it. Beyond that, she was unsure of any additional assessment and review required and would need to refer to the facility's policy.An interview was conducted with the DON on 7/20/26 at 3:16 p.m. The DON indicated they had no verification of assessment, monitoring, and review of Resident D's bruising found on 6/19/26.On 2/21/26 at 9:51 a.m., the Nurse Consultant provided a bruising event assessment for Resident D, dated 2/20/26, from previous bruising found on Resident D. It included the date, time, and location where the bruising was found; what immediate treatments were given; how many bruises there were; where each bruise was located; measurements of each bruise; whether each bruise was present on admission; measures taken to prevent reoccurrence; physician notification; whether an investigation was completed; whether the resident was sent to the hospital; whether it was considered a major injury; whether the incident was reported to the state agency; and whether a root cause was determined and documented in an IDT note.The Bruise, Rash Lesion, Skin Tear, Laceration Assessment Guidelines policy was provided by the DON on 7/21/26 at 10:00 a.m. It indicated, Bruise.If skin alteration occurs post admission, follow the below steps: a. Complete Bruise incident in EHR (electronic health record) by an RN [Registered Nurse]/LPN [Licensed Practical Nurse] along with the template/assessment progress note. IDT should review this timely and wound nurse or designee complete an assessment in wound management. b. Continue to monitor weekly in wound management. c. Must review for at least 1 week in wound management. Once wound nurse/designee determines that the wound is healing as expected, resolved or becomes a chronic skin condition this wound nurse/designee may heal the wound in wound management.This Federal citation is related to Intake 3054488. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure monitoring of the dishwasher sanitation and maintain clean kitchen flooring. This had a potential to effect 44 of 44 residents that reside in the skilled facility. Findings include: An observation of the kitchen was made with the Dietary Manager (DM) on 1/5/26 at 9:43 a.m. The dishwasher was observed during washing and rinsing cycles. The DM had indicated she had been having trouble with the dishwasher for several months. The service technician had been out to service the machine. The dish machine was a high temperature dishwasher, but with the problems it was having the service technician recommended using it as a low temperature dishwasher until replacement. The dishwasher has been working as a low temperature dishwasher for a couple months. The staff were currently utilizing chemical strips to ensure the sanitation was appropriate. The staff use an electronic charting to document the washing and sanitation temperatures. At that time, [NAME] 5 indicated he checks the dishwasher sanitation nightly. During the kitchen tour, the kitchen flooring was observed throughout the kitchen. The dishwasher area flooring behind the dishwasher and sanitation buckets had black debris along the back wall flooring. The kitchen preparation area and the cooking area had black debris observed along the back of the wall flooring An observation was made of the kitchen on 1/5/26 at 2:59 p.m. The kitchen flooring was observed with black debris along the back wall flooring in the dishwasher area and kitchen preparation and cooking areas. The dishwasher wash and sanitation temperature records for each meal were provided by the Executive Director on 1/5/26 at 3:00 p.m. The logs were recorded with no dates and had one temperature recorded for each meal. The dinner log did not have any logged temperatures documented after 12/28/25.The service technician service report, dated 1/2/26, indicated the dish machine's pressure would not stay up. He had set up the dishwasher to function as a low temperature machine. During a kitchen tour, an interview was conducted with DM on 1/6/25 at 10:00 a.m. She indicated the dishwasher wash and sanitation records were printed from 12/5/25 through 1/5/26. The dietary staff should record the sanitation temperatures twice a day. The dietary staff are not recording the sanitation temperatures. An observation was made of the kitchen with the DM on 1/8/25 at 10:44 a.m. The kitchen flooring in the dishwasher area, food preparation and cook areas were observed. The back wall was observed with black debris. The DM indicated the flooring was last deep cleaned in November 2025. The black debris was stuck on the floor. She was unable to remove. A dish machine temp/sanitizer policy was provided by the Executive Director on 1/6/26 at 1:20 p.m. It indicated, .2. Dish machine temperatures and sanitizer concentration will be recorded at each meal. Temperatures will be recorded according to the temperature gauge readings on the outside of the machine during wash and rinse cycles.3.1-21(i)(2)

Based on observation, interview, and record review, the facility failed to ensure a self medication assessment was completed timely for 2 of 2 residents randomly observed for self medication (Residents 4 and 14)Findings include: 1 The clinical record for Resident 14 was reviewed on 1/5/26 at 10:20 a.m. The resident's diagnosis included, but was not limited to, hypertension. On 1/5/26 at 10:20 a.m., Resident 14 was observed in her room sitting in her wheelchair. A plastic medication cup with 4 pills inside of it was sitting on her overbed table. Resident 14 indicated the nurse had left her medication for her to take. She then put the 4 pills into her mouth and swallowed them with a drink of water. Resident 14 indicated the nurses' usually left her medication for her to take when she was ready. A Self Administration of Medication Assessment, dated 1/5/26 at 12:51 p.m., indicated Resident 14 could self administer all oral medications and that her medications would be kept on the medication cart. The resident's self administration of medication assessment was conducted after the observation on 1/5/26 at 10:20 a.m. Prior to 1/5/26 at 12:51 p.m., the resident's clinical record lacked a self administration of medication assessment. 2. The clinical record for Resident 4 was reviewed on 1/5/24 at 2:46 p.m. The resident's diagnosis included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD). A physician order, dated 10/18/25, indicated the resident was to receive 1 cap of Biotene Dry Mouth Oral Rinse three times a day. The resident was to swish and spit the rinse. A physician order, dated 10/24/25, indicated the resident was to receive 2 puffs of 90 micrograms of albuterol inhaler four times daily as needed. An observation was made of a medication administration for Resident 4 with Qualified Medication Aide (QMA) 6 on 1/8/26 at 10:11 a.m. During the preparation of the medications at the medication cart, QMA 6 had indicated Resident 4 self-administers her inhaler and Biotene mouth rinse, so she would not have to administer those medications. QMA 6 did not administer those medications at that time. An observation was made of a medication administration for Resident 4 with License Practical Nurse (LPN) 10 on 1/8/26 at 11:29 a.m. During the medication administration, Resident 4 indicated she did have an albuterol inhaler that was in a plastic container on her bedside table and Biotene mouth rinse was in her bathroom. She did administer both medications herself. At that time, the albuterol inhaler and Biotene mouth rinse were observed in the resident's room. An interview was conducted with LPN 10 on 1/8/26 at 11:32 a.m. She indicated the resident should have a self-medication assessment for the albuterol inhaler and Biotene mouth rinse medications that are in her room. After review of the resident's chart, LPN 10 was unable to find a self-medicate assessment that had been completed in Resident 4's medical chart. An interview was conducted with the Nurse Consultant (NC) on 1/8/26 at 2:34 p.m. She indicated there should be self medication assessments completed for residents that store and self- medicate their medications. A self-administration policy was provided by the NC on 1/8/26 at 2:34 p.m. It indicated, .Procedure. 1. Residents requesting to self-medicate or has self-medication as a part of their plan of care shall be assessed using the observation Trilogy-Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication. A. The order should include the type of medication(s) the resident is able to self-medicate.6. A Self-Medication plan of care will be initiated and updated as indicated. 7. The Assessment will be reviewed quarterly, and PRN [as needed] with change of condition. 3.1-11(a)

Based on interview and record review the facility failed to ensure a safe method of transfer for 1 of 2 residents reviewed for falls. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 1/5/26 at 1:30 p.m. The diagnoses for Resident 1 included, but were not limited to, vascular dementia, muscle weakness, rheumatoid arthritis and osteoporosis (bone disease that causes bones to become weak, thin and brittle). A Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 1 needed staff to provide half of the assistance with lifting, holding, and trunk or limb support for the resident in a lying to a sitting position. The staff needed to provide all assistance with lifting, hold and trunk or limb support for the resident sitting to standing position and bed to chair positioning. A fall care plan, dated 2/19/25, indicated Resident 1 was a fall risk related to muscle weakness and dementia. The interventions included but were not limited to, start date: 2/19/25, staff to assist Resident with transfers as needed. A care plan, dated 2/19/25, indicated Resident has a diagnosis of osteoporosis and at risk for fracture and increased weakness. The interventions included but were not limited to, staff was to assist as needed with mobility. A resident care needs profile guide care plan, dated 2/19/25, indicated a start date 2/19/25, Transfers: 2 person with hoyer lift [a mechanical lift that assists with transfers], specific to the is resident d/t [due to] right shoulder pain and mobility issues. A physical therapy evaluation, dated 8/9/25, indicated the resident was currently dependent on staff for all ADLS [Activities of Daily Living] and uses a mechanical lift for safety with all functional transfers. Equipment utilized by resident was wheelchair and stand-up lift. A nursing progress note, dated 10/6/25, indicated the nurse was called to the resident's room. Resident 1 was found sitting on the floor clothed with a gait belt around her waist. She was leaning against Certified Medication Aide (QMA) 4's lower extremities. After assessment, the resident was unable to move her left arm. There was a firm bulge on the top inner side of the left arm. QMA 4 reported, upon transferring resident from bed with gait belt to locked w/c [wheelchair] that resident stood with assistance then went downward BUE [bilateral upper extremities] on [QMA 4's] arms, as [QMA 4] was lowering resident to floor [QMA 4] heard a snap. A reportable incident to the Indiana Department of Health, dated 10/7/25, indicated Resident was being transferred from the bed to the wheelchair using a gait belt when her legs buckled shifting her body weight to the CRCA [Certified Resident Care Associate] who was holding onto the gait belt putting pressure into her armpit/shoulder area. The sudden shifting of her body downwards applied enough pressure to her shoulder area that resulted in acute fracture.Resident has a history of degenerative arthritis and osteoporosis in both shoulders with surgical repair of both shoulders noting 6 screws in left shoulder. The acute fracture occurred just distal to the hardware. Resident has limited range of motion in both shoulders with prior therapy treatment. Resident transferred to emergency room and returned to facility same day. New order to wear an immobilizer sling to left arm.hoyer lift for all transfers going forward. The reportable incident's investigation was provided by the Executive Director on 1/8/26 at 1:00 p.m. The investigation included but was not limited to the following: A statement signed by QMA 4, dated 10/7/25, indicated, CRCA [QMA 4] applied the gait belt around the resident's upper waist even with her arms, note her arms have limited range of motion and are in a bent L-shaped contracted state per usual. CRCA counted with resident to 3 to signal to stand, resident started to stand when her legs gave way and she was unable to bear her own weight resulting in her weight relying on the CRCA to hold her up. The CRCA attempted to stabilize and lift the resident with the gait belt by holding onto the sides but with the sudden weight drop the residents body shifted down suddenly and her arms/shoulders shifted up at the same time, the CRCA held on to the gait belt and heard a snap in the shoulder area. CRCA then lowered her to the floor. A point of care history report, dated 9/2/25-10/6/25, indicated Resident 1 was transferred by staff assistance with a mechanical lift (stand up lift) for all transfers except 4 times she was transferred manually. An interview was conducted with Resident 1's Representative on 1/6/26 at 11:53 a.m. She indicated Resident 1 had fallen and had fractured her arm due to staff transferring her by gait belt instead of using the stand-up mechanical lift. The resident's chart was not updated or clear which transferring method the staff was to utilize to transfer her. One place in the resident's care plan said she was supposed to be transferred with a gait belt and another area of the plan of care said she was to be transferred by stand-up mechanical lift. Since the incident, the resident was now transferred by hoyer mechanical lift. An interview was conducted with the Director of Rehab on 1/7/26 at 11:20 a.m. She indicated Resident 1 fluctuated on how she transferred. She had good days and bad days. On a good day the staff would be able to transfer Resident 1 by utilizing a gait belt with 1 to 2 staff members, and on bad days the staff would need to use the stand-up lift for transfers. The staff would need to assess the resident prior to transfer if the resident was having a good day or bad day. Resident 1 was a small lady. If the staff member felt they were able to lift her; then it would be the choice of the staff member as long as they used a gait belt. An interview was conducted with Certified Nursing Assistant (CNA) 11 on 1/8/26 at 2:58 p.m. She indicated the CNA staff can either use the resident's electronic record to find out how the resident transfers or a paper was posted at the nursing station how each resident on the hall transferred. She had provided care to Resident 1 prior to the fall on 10/6/25. She had always transferred Resident 1 by stand-up lift, never manually using a gait belt. The resident currently transfers by hoyer lift. A resident care plan profile timeline for Resident 1 was provided by the Executive Director on 1/9/25 at 9:00 a.m. It indicated on 2/19/25 the resident was to be transferred by 1 to 2 staff members assistance. The care profile was updated on 3/17/25 indicating the resident was to be transferred by 1 to 2 staff members assistance with a gait belt. The profile was updated on 10/6/25 after the fall incident indicating the staff was to transfer the resident with 2 staff member with hoyer lift. An interview was conducted with the MDS Coordinator on 1/9/26 at 10:55 a.m. She indicated she was unsure why the resident's care profile care plan indicated Resident 1 was a hoyer mechanical lift as of 2/19/25. That part of the care plan, the CNA staff would not have access to that information. The CNA staff would only see 1-2 person assist with a gait belt. An interview was conducted with QMA 4 on 1/9/26 at 11:05 a.m. She indicated she was the staff member transferring Resident 1 on the morning of 10/6/25. QMA 4 was getting Resident 1 up for the day and was transferring the resident from bed to wheelchair utilizing a gait belt. The resident was confused and yelling out as that behavior was normal for her. During the transfer the resident's legs gave out, and QMA 4 lowered the resident to the floor. The resident was assessed by the nurse. She always transferred the resident by gait belt. In the resident's electronic record, it indicated the resident was to be transferred by gait belt with 1 to 2 staff members. That was the information she used, but there was also a posted paper at the nurse's station. It indicated Resident 1 was to be transferred by stand-up lift. An interview was conducted with CNA 5 on 1/9/26 at 1:30 p.m. She indicated she had worked here for a few years. She had always transferred Resident 1 with a stand-up lift. She never would transfer her manually using a gait belt. Since the resident's fall she currently was a hoyer lift. A fall management policy was provided by the Nurse Consultant on 1/8/25 at 10:21 a.m. It indicated, Purpose Statement. The purpose of this policy is to: Trilogy health Services (THS) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. THS recognizes even the most vigilant efforts may not prevent falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury. 3.1-45(a)(2)

Based on interview and record review, the facility failed to timely notify a physician of a resident with pain, timely receive scheduled pain medications from the pharmacy, and to assess pain level, location of pain, and non-pharmacological interventions attempted prior to administering prn medications for 2 of 2 residents reviewed for pain. (Residents 26 and 63) Findings include: 1. The clinical record for Resident 63 was reviewed on 1/5/26 at 1:54 p.m. The resident's diagnosis included, but were not limited to, back pain and lumbar post-laminectomy syndrome (persistent pain or neurological symptoms in the back or extremities after spinal surgery). She was admitted to the facility on [DATE]. Resident 63 had an intrathecal pain pump (device that delivers pain medication to the fluid around the spinal cord) which delivered hydromorphone (narcotic pain medication) due to chronic pain. A physician's order, dated 12/26/25, indicated she was to receive cyclobenzaprine (Flexeril muscle relaxer) 10 mg tablet three times a day. A physician's order, dated 12/26/25, indicated she was to receive Lyrica (medication to treat nerve pain) 200 milligram (mg) one tablet by mouth three times a day. The December 2025 Medication Administration Record (MAR) indicated Resident 63 did not receive Lyrica 200 mg on the following days and time: On 12/26/25 at 6:00 p.m. and at 10:00 p.m., dose not given due to being on hold pharmacy to deliver; on 12/27/25, all the three scheduled doses not administered due to being on hold; on 12/28/25 at 6:00 a.m. and 10:00 a.m., dose not administered due to being on hold. A physician's order, dated 12/26/25, indicated to monitor pain times 72 hours post admission. The December 2025 MAR indicated the resident's pain levels were as follows: 12/26/25 evening shift 0, night shift 0, 12/27/25 day shift 6 described as generalized, evening shift 4 described as generalized, night shift 5 described as generalized, 12/28/26 day shift 4 described as generalized, evening shift 10 described as generalized, night shift 0, 12/29/25 day shift 10 described as generalized, evening shift 0, and night shift 0. Pain scale of 0 to 10, 0 being no pain and 10 being severe pain. The clinical record did not include what non-pharmacological interventions were attempted to assist with pain management or that the physician had been notified of the resident's pain. On 12/27/25, Resident 63 called emergency medical services due to pain and requested to be taken to the hospital for pain management. The emergency room History and Physical, dated 12/27/25 at 9:19 a.m., indicated Resident 63 did not receive her medications last night and was informed that there would be a delay in medication administration this morning. The physical exam indicated she was not in acute distress and had diffuse pain to palpation. The Medical Decision Making indicated Resident 63 received a one time dose of oxycodone (narcotic medication) and a dose of Flexeril (muscle relaxer) and she would be discharged with a prescription for Flexeril. A Physical Therapy Evaluation and Plan of Treatment, completed 12/28/25, indicated Resident 63 had pain that interfered/ limited functional activities. Patient reports 1000/10 pain upon evaluation. She declined all functional mobility and transfers due to pain. She had pain that interfered with sleep. She verbalized pain level. A care plan, initiated 12/30/25, indicated she was at risk for pain r/t chronic low back pain, Lumbar Post-Laminectomy Syndrome, migraines, fibromyalgia, seizures, and asthma. The goal was for her pain to be at a tolerable level. The approaches were to administer medications as ordered and notify MD (physician) for any side effects observed or lack of effectiveness, attempt non-pharmacological interventions, notify MD of increased pain, observe for and record verbal and non-verbal signs of pain, and reposition as needed. A Brief Interview for Mental Status (BIMS) Assessment, dated 12/31/25, indicated Resident 63 was cognitively intact. A Physical Medicine and Rehabilitation Initial Encounter note, dated12/29/2025 at 10:11 a.m., indicated Resident 63 seen lying comfortably resting in bed. Patient reports experiencing chronic generalized pain, reporting pain most severe to low back, rating pain 10/10 on pain scale, described as aching/throbbing sensation. Patient reports since being released from hospital her pain continues to remain exacerbated, reports during hospital she felt her pain was better managed. Patient notes following with pain management provider notes that since having spinal fusion she has experience chronic pain. of note patient does have intrathecal pain pump, reports pump has not been managing pain. She reports during hospitalization she was receiving Tylenol and oxycodone which were effective for pain management. Patient does note history of constipation, reports at home taking stool softeners twice a day and is agreeable for regimen to be added at facility. Reports fair sleep and fair appetite. No acute concerns noted per nursing or therapy services. Pain management secondary to adjacent segment disease of lumbar spine with history of fusion procedure, chronic back pain, lumbar post laminectomy syndrome. Patient has intrathecal pain pump that delivers 2.5 mcg every 6 hours. Patient reporting exacerbated pain. We will start regimen that patient was on at hospital as patient reporting pain adequately managed during recent hospitalization. Start oxycodone 10 mg every 4 hours as needed, schedule acetaminophen TID. Continue Flexeril 10 mg TID and start voltaren 1% topical ointment twice a day. We will continue to monitor for increase/unmanage pain. A physician's order, dated 12/29/25, indicated Resident 63 was to receive acetaminophen (Tylenol) 500 mg tablets. 2 tablets (1000mg) three times a day. A physician's order, dated 12/29/25, indicated she was to receive oxycodone 10 mg every four hours as needed for pain. A physician's order, dated 12/29/25, indicates she was to receive voltaren 1% topical ointment (pain ointment) twice daily. The December and January MAR indicated she had received oxycodone 10 mg on the following days and times: -12/29/25 at 12:10 p.m., 5:43 p.m., 10:15 p.m. -12/30/25 at 3:00 a.m., 8:38 a.m., -12/31/25 at 12:45 a.m., 7:53 a.m., and 8:11 p.m., -1/1/26 at 9:05 a.m., 1:21 p.m., 5:40 p.m., and 9:39 p.m., -1/2/26 at 5:40 a.m., 10:06 a.m., 3:04 p.m., and 8:10 p.m., --1/3/26 at 1:16 a.m., 8:26 a.m., 12:54 p.m., 5:03 p.m., and 9:11 p.m., -1/4/26 at 2:08 a.m., 9:21 a.m., 1:44 p.m., and 1/5/25 at 2:08 a.m., 9:12 a.m., 1:26 p.m., and 9:45 p.m. The December and January MAR did not include information of pain intensity at time of administration of the oxycodone, location of pain, or non-pharmacological interventions attempted prior to administering pain medications. During an interview on 1/5/26 at 1:54 p.m., Resident 63 indicated she was admitted to the facility on [DATE]. She had chronic pain and her tolerable pain level was 6 to 7 out of 10. She had a pain pump to assist in controlling her pain and received Lyrica routinely . She had several falls prior to being hospitalized which had made her pain worse. While she was at the hospital prior to her admission to the facility, she had received Tylenol 1000 mg three times a day and oxycodone 10 mg as needed. The combination of the pain pump, Tylenol, and oxycodone had controlled her pain so that she could participate in therapy and get out of bed. When she arrived at the facility on 12/26/25, she did not receive her pain medications. The staff had told her that the pharmacy had not delivered her medications and gave her other excuses as to why her pain medications were not available. On Saturday 12/27/25, she had call 911 to go to the hospital because of her pain. The hospital had given her a one time dose of oxycodone and Flexeril, which had helped ease her pain briefly. Her pain had been 10 out of 10 from Saturday 12/27/25 until Monday 12/29/25, when she was seen by a Nurse Practitioner (NP) who had prescribed her oxycodone and Tylenol. She had been unable to participate in therapy due to the pain. During an interview on 1/7/26 at 10:31 a.m., Licensed Practical Nurse (LPN) 3 indicated he had cared for Resident 27 the weekend she was admitted . Resident 63 was in pain as soon as she got to the facility. She is in pain all of the time. Resident 63 had went to the hospital due to pain and was sent back with a prescription for Flexeril. Her concern about pain had been put in the concern book because it had not met the criteria for when to contact the on-call physicians. As soon as the physician came in on Monday she was started on oxycodone. During an interview on 1/07/2026 at 2:00 p.m., Physical Therapist (PT) 12 indicated she had performed the Physical Therapy Evaluation on 12/28/25. Resident 63 had verbalized pain during the evaluation as 1000/10. She did attempt to participate in the evaluation, but when attempting to stand or move she refused. There were no non-verbal signs or symptoms of pain. Resident 63 had asked about pain medications and was educated to talk with the Nurse Practitioner and the nursing staff. PT 12 could not recall if she had informed the nursing staff of Resident 63's pain. During an interview on 1/7/25 at 2:05 p.m., the Director of Therapy indicated she had asked the NP to see Resident 63 the morning of 12/29/25 to see if anything could be done to address her pain, since it was interfering with therapy. During an interview on 1/8/26 at 10:18 a.m., the Medical Nurse Practitioner indicated she did not recall anything of the on-call log indicating the on-call providers had been informed of Resident 63's pain from 12/26/25 through 12/28/25. She believed it was preferable to call the on-call provider about uncontrolled pain instead of a resident going to the hospital due to pain. The standing orders in the communication books were guidelines regarding acute verse's chronic and up to interpretation by the nursing staff. If non- pharmacological interventions had not worked to lessen pain, then calling the on-call provider could have been appropriate. On 1/8/26 at 10:41 a.m., the Director of Nursing Services (DNS) provided the Standing Orders and Notification Guidance which read .Pain Immediate Notification [call]: Severe joint/ hip pain associated with a fall Noticeable change in alignment ability to perform ROM [sic] in extremity Headache with altered vision, change in mental status, 'sudden onset headache' 'Worse headache of my life' Pain with change in mental status Abdominal pain with guarding/ rigidity . Routine Notification [designated folder/ clipboard/ book]: persistent mild to moderate pain in spite of interventions . 2. The clinical record for Resident 26 was reviewed on 1/5/26 at 3:30 p.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus, amputation of left toe and stroke. The Minimum Data Set (MDS) assessment, dated 12/12/25, indicated Resident 26 was cognitively intact. A pain care plan, dated 6/11/25, indicated Resident 26 was at risk for pain related to having a diagnosis of Osteomyelitis, 3rd/4th toe amputated, neuropathy, past history of a left shoulder closed fracture and chronic pain. The interventions included but were not limited to, the staff was to attempt non-pharmacological interventions for pain relief and administer pain medications with notification to the medical provider if pain medications were not effective. A physician order, dated 12/1/25, indicated the resident was to receive 500 milligrams/15 milliliters of acetaminophen every 6 hours for pain. A physician order, dated 12/1/25, indicated the resident was to receive 5-325 milligrams of hydrocodone for moderate to severe pain every 12 hours as needed. The January 2026 MAR indicated the resident had received the 15 milliliters of acetaminophen and the 5-325 milligrams of hydrocodone on the following days and times: Acetaminophen: 1/2/26 at 7:26 a.m., and 5:38 p.m. 1/3/25 at 11:18 a.m., 1/5/26 at 8:25 a.m., and 1/6/26 at 8:25 a.m. Hydrocodone: 1/2/26 at 7:26 a.m., 1/4/26 at 6:35 a.m., and 1/5/26 at 10:02 a.m. The January 2026 MAR for Resident 26 did not include nursing assessments indicating the resident's pain location, non-pharmacological interventions attempted prior to medicating nor how much pain the resident was having utilizing a pain scale. An interview was conducted with Resident 26 on 1/5/26 at 3:30 p.m. She indicated she was always in pain even after pain medication. The staff are aware her pain was not controlled. The resident was a 9 out of 10 utilizing a pain scale of 1 being the least amount of pain to 10 being the worst amount of pain. An interview was conducted with the Director of Nursing Services on 1/7/26 at 9:31 a.m. She indicated when the physician order was ordered in Resident 26's electronic record the pain scale was not clicked in error. The pain scale box was not showing up in the resident's MAR. The nursing staff should know how to assess the resident's pain when giving as needed medications. She was unsure why the nursing staff were placing an x in the box instead of indicating what non-pharmacological intervention that had been attempted prior to medicating the resident. A pain management policy was provided by the Nurse Consultant (NC) on 1/7/26 at 10:19 a.m. It indicated, .Purpose Statement. The purpose of this policy is to: To ensure each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to apply TED hose (stockings that help prevent blood clots and swelling in the legs) as ordered for 1 of 1 resident reviewed for edema and to hold blood pressure medication, as ordered by the physician, for 2 of 5 residents reviewed for unnecessary medications. (Resident 3, Resident 9, and Resident 13) Findings include: 1. The clinical record for Resident 13 was reviewed on 11/7/24 at 10:53 a.m. The diagnoses included, but were not limited to, edema. A care plan, dated 9/23/24, indicated the resident was to wear TED hose to her legs. A physician order, dated 9/17/24, indicated the staff was to apply TED hose to the resident's legs in the morning and remove them at night. Observations were made of Resident 13 on 11/7/24 at 10:53 a.m., 11/7/24 at 2:15 p.m., 11/8/24 at 9:38 a.m., and 11/8/24 at 1:21 p.m. The resident was observed wearing shoes, but she was not wearing TED hose. An observation was made of Resident 13 in her room with Certified Resident Care Associate (CRCA) 5 on 11/8/24 at 1:23 p.m. The resident was observed in her room sitting in her wheelchair. At that time, CRCA 5 had opened a drawer and located a package of TED hose. CRCA 5 indicated Resident 13 will wear the TED hose if staff applies. She normally wore them daily. 40287 2. The clinical record for Resident 3 was reviewed on 11/8/24 at 10:29 a.m. The diagnoses included, but were not limited to, hypertension and congestive heart failure. A physician's order, dated 5/2/24, indicated he was to receive carvedilol tablet (blood pressure medication) 3.125 milligram (mg) twice daily. Instructions were to hold the medication for a heart rate less than 60 beats per minute. A care plan, last reviewed 11/2/24, indicated Resident 3 had a potential for cardiovascular distress related to his diagnoses of heart failure and hypertension. The goal was for him to be free from signs and symptoms of cardiovascular distress. The interventions included, but were not limited to, administer medications as ordered and observe for and report side effects as needed, and obtain vital signs as ordered and needed. The Medication Administration Record (MAR) for October 2024 and November 2024 indicated the carvedilol 3.125 mg was administered when resident 3's heart rate was below 60 on the following day(s) and time(s): 10/3/24-evening shift, 10/4/24- evening shift, 10/10/24- evening shift, 10/14/24- evening shift, 10/19/24- day and evening shift, 10/20/24- day and evening shift, 10/21/24- evening shift, 10/29/24- evening shift, 11/1/24- evening shift, and 11/3/24- evening shift. 3. The clinical record for Resident 9 was reviewed on 11/08/24 at 2:49 p.m. The diagnosis included, but were not limited to, hypertension. A physician's order, dated 9/29/2023, indicated she was to receive metoprolol tartrate tablet (blood pressure medication) 25 mg twice daily. Instructions were to hold the medication when systolic (top number of blood pressure reading) is less than 110. A care plan, last reviewed 8/30/24, indicated Resident 9 had a potential for cardiovascular distress. The goal was for her to be free from signs and symptoms of cardiovascular distress. The interventions included, but were not limited to, obtain vital signs as ordered and administer medications as ordered. The November 2024 MAR indicated the metoprolol tartrate was administered when the systolic blood pressure reading was below 110 on the following day(s) and time(s): 11/3/24- evening shift, 11/4/24- evening shift, and 11/9/24- evening shift. During an interview on 11/08/24 at 1:27 p.m., the Nurse Consultant (NC) 4 indicated the medication should have been held, as ordered by the physician. On 11/8/24 at 2:12 p.m., the NC 4 provided the Guidelines for Medication Orders policy, last reviewed 12/31/23, which read, .Purpose To establish uniform guidelines in the receiving and recording of medication orders . A current list of orders will be maintained in the electronic clinical record of each resident . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's pain was assessed for severity of her pain for 1 of 3 residents reviewed for catheter. (Resident 25) Findings include: The clinical record for Resident 25 was reviewed on 11/6/24 at 12:20 p.m. The diagnoses included, but were not limited to, diabetes mellitus with diabetic polyneuropathy. A care plan for pain, dated 12/18/23, indicated At risk for pain r/t [related to] diabetic polyneuropathy, depression, repeated falls. The approach included, but was not limited to, observe for and record verbal and non-verbal signs of pain. A physician order, dated 10/2/24, indicated the staff was to administer five milligrams of oxycodone prior to wound care once a day as needed. A physician order, dated 11/5/24, indicated the staff was to cleanse wounds on Resident 25's right and left heels with anasept (wound cleanser); apply skin prep to peri-wounds; apply collagen to wound beds; cover with absorbent dressings; and wrap with kerlix and secure with tape. The dressing changes were scheduled for Tuesdays, Thursdays, and Saturdays. The November 2024 Medication Administration Record and Treatment Administration Record (MAR/TAR) indicated the following days the five milligrams of oxycodone was administered for pain: 11/2/24 (Saturday) at 6:45 p.m. - reason for medication use: pain and pain medication were effective, 11/3/24 (Sunday) at 12:32 p.m. - reason for medication use: pain and pain medication were effective, and 11/12/24 (Tuesday) at 8:02 a.m. - reason for medication use: leg pain and pain medication were effective. The resident's clinical record did not include the resident's severity of her pain on 11/2/24, 11/3/24, and 11/12/24. An observation was made of Resident 25 on 11/12/24 at 11:27 a.m. The resident was observed lying in bed with complaints of pain to her legs and arm. She denied pain from her wounds. She indicated the nurse had administered her pain medication early that morning, and it had not helped. At that time, her pain was rated at a nine, utilizing one being the least amount of pain to ten being the most amount of pain. An interview was conducted with the Director of Nursing on 11/12/24 at 1:28 p.m. She indicated she was unable to provide assessments of the severity of the resident's pain prior to administering the five milligrams of oxycodone. The five milligrams of oxycodone was ordered once a day as needed for pain control during Resident 25's wound treatments. A pain policy was provided by Clinical Support 4 on 11/12/24 at 1:52 p.m. It indicated, .Purpose: To ensure each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure the medication and/or supply storage rooms did not contain expired supplies for 1 of 2 medication rooms observed and 1 of 2 central supply rooms observed. Findings include: An observation was conducted of the central supply room on [NAME] unit with the Director of Nursing (DON) on 11/7/24 at 9:40 a.m. There were 16 cartons of Osmolite 1.5 (feeding solution) with an expiration date of 11/1/24. The DON indicated the facility did not have any residents currently receiving Osmolite 1.5. The Scheduler was responsible for supply storage. An observation was conducted, on 11/7/24 at 9:55 a.m., of the medication storage room on the Hinkle unit with Licensed Practical Nurse (LPN) 2. A cabinet contained ten COVID tests that had expired in 2023. A policy titled MEDICATION STORAGE IN THE FACILITY, revised 11/18, was provided by the DON on 11/7/24 at 1:48 p.m. The policy indicated the following, .E. The medication administration personnel will check the expiration date of each medication before administering it .F. No expired medication will be administered to a resident .G. All expired medications will be removed from the active supply and destroyed in the facility 3.1-25(j)

Based on interview and record review, the facility failed to ensure residents' medical records were complete and accurate with behavior monitoring and documentation of urine characteristics after insertion of a Foley catheter for 2 of 5 residents reviewed for unnecessary medications and 1 of 3 residents reviewed for catheters. (Residents' 11, 25, and 26) Findings include: 1a. The clinical record for Resident 25 was reviewed on 11/6/24 at 12:20 p.m. The diagnoses included, but were not limited to, diabetes mellitus with diabetic polyneuropathy and obstructive and reflux uropathy (blocks the flow of urine). A physician order, dated 5/8/24, indicated the staff was to change the resident's Foley catheter every 30 days. The November 2024 Treatment Administration Record indicated the resident's Foley catheter was changed on 11/8/24. A nursing progress note, dated 11/8/24, indicated the following, Anchored 16 FR [French] 10 cc [cubic centimeter] bulb catheter change for the month. Resident tolerated it well. Resident 25's clinical record did not include characteristics of the resident's urine at the time of changing the Foley catheter on 11/8/24. An interview was conducted with the Director of Nursing on 11/12/24 at 3:34 p.m. She indicated Resident 25's urine characteristics were chronic. An insertion of a Foley catheter policy was provided by the Clinical Support 4 on 11/12/24 11:53 a.m. It indicated, .3. Steps in the procedure .4. After completion of procedure .5. The following information should be recorded in the resident's medical record: a. The date and time the procedure was performed. b. All assessment date (e.g. character, color, clarity, etc.) obtained during the procedure. c. The size of the Foley catheter inserted and the amount of fluid used to inflate the balloon. d. How the resident tolerated the procedure . 1b. A physician order, dated 7/17/24, indicated order set target behavior - Resident currently has an active order of Bupropion for s/s [signs and symptoms] of depression aeb [as evidenced by] social withdrawal, being down on herself, and or feeling like a bother to others. At the end of each shift mark frequency - how often behavior occurred & Intensity - how resident responded to redirection. Intensity code: 0 = did not occur; 1 = easily altered; 2 = difficult to redirect. The staff was to document three times a day. The November 2024 Medication/Treatment Administration Record (MAR/TAR) indicated the behavior monitoring for depression was documented as NA (not applicable) on the following day(s) and time(s): 11/3/24 - 6:00 a.m. - 10:00 a.m., 11:00 a.m. - 1:30 p.m., and 11/8/24 - 6:00 a.m. - 10:00 a.m., 11:00 a.m. - 1:30 p.m. 2. The clinical record for Resident 11 was reviewed on 11/6/24 at 1:00 p.m. The diagnoses included, but were not limited to, stroke. A physician order, dated 11/6/24, indicated order set target behavior - aggressive behavior expressions. At the end of each shift mark frequency - how often behavior occurred & intensity - how resident responded to redirection. Intensity Code: 0 = did not occur; 1 = easily altered; 2 = difficult to redirect. The staff were to document three times a day. A physician order, dated 11/6/24, indicated order set target behavior - social isolation, withdrawal. At the end of each shift mark frequency - how often behavior occurred & intensity - how resident responded to redirection. Intensity Code: 0 = did not occur; 1 = easily altered; 2 = difficult to redirect. The staff were to document three times a day. The November 2024 MAR/TAR for Resident 11 indicated the behavior monitoring for aggressive, social isolation and withdrawal behaviors was documented as NA (not applicable) on the following day(s) and time(s): 11/8/24 - 6:00 a.m. - 10:00 a.m. and 11:00 a.m. - 1:30 p.m. 3. The clinical record for Resident 26 was reviewed on 11/6/24 at 2:00 p.m. The diagnoses included, but were not limited to, anxiety disorder. A physician order, dated 12/7/23, indicated order set target behavior - anxiety. At the end of each shift mark frequency - how often behavior occurred & intensity - how resident responded to redirection. Intensity Code: 0 = did not occur; 1 = easily altered; 2 = difficult to redirect. The staff were to document three times a day. A physician order, dated 7/17/24, indicated order set target behavior - Resident currently has an active order of trazadone for s/s of insomnia aeb social withdrawal, sleeping throughout the day and awoke at night, and being extremely tired. At the end of each shift mark frequency - how often behavior occurred & intensity - how resident responded to redirection. Intensity Code: 0 = did not occur; 1 = easily altered; 2 = difficult to redirect. The staff were to document three times a day. A physician order, dated 7/17/24, indicated order set target behavior - Resident currently has an active order of zoloft for s/s depression aeb social withdrawal, being down on himself, and or believing he is a failure. At the end of each shift mark frequency - how often behavior occurred & intensity - how resident responded to redirection. Intensity Code: 0 = did not occur; 1 = easily altered; 2 = difficult to redirect. The staff were to document three times a day. The November 2024 MAR/TAR for Resident 26 indicated the following day(s) and time(s) the monitoring of insomnia and depression behavior were documented as NA (not applicable): 11/3/24 - 6:00 a.m. -10:00 a.m., 11:00 a.m. - 1:30 p.m., and 11/8/24 - 6:00 a.m. -10:00 a.m., 11:00 a.m. - 1:30 p.m. An interview was conducted with Clinical Support 4 on 11/12/24 at 11:55 a.m. She indicated the staff documented NA for behavior monitoring meant the behavior was not observed during that shift. A nursing job description summary was provided by the Clinical Support 4 on 11/12/24 at 2:00 p.m. It indicated, .Role and Responsibilities .Administer and document medication and treatments per the physician's order and accurately record all care provided . 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained with hand hygiene during Foley catheter care for 1 of 3 residents reviewed for catheters. (Resident 3) Findings include: The clinical record for Resident 3 was reviewed on 11/7/24 at 11:00 a.m. The diagnoses included, but were not limited to, neuromuscular dysfunction of bladder and stage 3 kidney disease. A care plan, dated 6/10/24, indicated the Resident uses a suprapubic or Foley catheter for dx [diagnosis] of: Neurogenic Bladder. The approaches included, but were not limited to, Provide assist with catheter care and change Foley catheter per physician orders. A physician order, dated 6/10/24, indicated the staff was to provide catheter care to Resident 3 three times a day. An observation was conducted of Foley catheter care with Certified Resident Care Associate (CRCA) 3 and the Director of Nursing on 11/12/24 at 1:43 p.m. CRCA 3 was observed washing his hands and donning on gloves prior to catheter care. Then, he turned on the faucet, filled a basin of water and walked to the resident's bed side. At that time, CRCA 3 raised the resident's bed up with a bed remote. After, CRCA 3 was observed providing catheter care to Resident 3. There was no observation of doffing his gloves and utilizing hand hygiene after he touched the faucet in the sink and bed remote. An interview was conducted with Clinical Support 4 on 11/12/24 at 2:15 p.m. She indicated CRCA 3 should have set up his supplies then utilized hand hygiene and donned gloves prior to providing catheter care. An infection control policy was provided by the Clinical Support 4 on 11/12/24 at 2:25 p.m. It indicated, .Purpose. To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections . A urinary catheter care policy was provided by the Clinical Support 4 on 11/12/24 at 11:53 a.m. It indicated, .Overview. To prevent infection of the resident's urinary tract. SOP [Standard Operating Procedure] Details .18. Gather equipment and supplies to perform this procedure .20. To perform the procedure . a. Place the clean equipment on the bedside stand or over bed table. Arrange the supplies so they can be easily reached. b. Wash and dry hands thoroughly . 3.1-18(b)(1) 3.1-18(l)

Based in observation, interview, and record review, the facility failed to ensure resident rooms were in good repair for 2 of 3 resident rooms reviewed for environment (Resident 15 and 29). Findings include: 1a. Resident 15's room was observed on 11/7/24 at 9:51 a.m. The drywall behind her bed had been patched. The area was unpainted and appeared bumpy and uneven. On 11/12/24 at 2:28 p.m., Resident 15's room was observed with the Executive Director (ED). The ED indicated the drywall behind Resident 15's bed had been patched. The wall had been repaired multiple times. Resident 15 utilized a trapeze to assist with bed mobility and the trapeze stand caused the drywall to become scratched. 1b. Resident 29's room was observed on 11/7/24 at 11:00 a.m. The wall behind his bed had an irregularly shaped white area present on it. On 11/12/24 at 2:40 p.m., Resident 29's room was observed with the ED and the Director of Plant Operations (DOP). The DOP indicated the white area on the wall behind the bed was from the bed scraping against the wall. The paint had been worn away. The DOP was unsure how long the area had been there. During an interview on 11/12/24 at 2:53 p.m., the DOP indicated they generally did room repairs when a room was being flipped for a new admission or when a work order was submitted for a repair. On 11/12/24 at 3:05 p.m., the ED provided a Rounding Observation form, dated 11/1/24, which indicated Resident 15's room had been found to have exposed drywall behind the bed. The area had been mudded and fixed drywall. On 11/12/24 at 3:05 p.m., the ED provided a Work Order, dated 1/3/24, which indicated Resident 29's room had been made ready for a resident and the work was completed on 1/5/24. On 11/12/24 at 3:20 p.m., Nurse Consultant 4 provided the TELS policy, last revised 2/9/2018, which read, .Trilogy utilizes the TELS program to maintain and track capital assets, aide with Life Safety compliance, and work order tracking . Work orders are maintenance issues that arise at the campus. Department heads and line staff can enter work orders at any time in TELS . 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment for 1 of 37 residents in the facility. (Resident C) Findings include: An observation of Resident C's room was conducted on 6/21/24 at 11:17 a.m. During the observation, two, small crawling insects, which appeared like ants, were crawling up the wall in between the P-[NAME] (air conditioner/heating unit) and the windowsill in Resident C's room. The two ants on the wall crawled under the windowsill and disappeared. Another small, crawling insect, which appeared like an ant, was found crawling on the floor and disappeared in between the flooring planks. An interview with Nurse Consultant (NC) conducted, on 6/21/24 at 11:03 a.m., indicated the facility did have an issue with ants in a resident's room. The facility had not called out their pest control company to spray the inside of the room, instead they decided to handle it internally and have the maintenance department spray inside the resident's room. NC stated, they (the facility) only had their pest control company treat around the exterior of the building for ants. An interview with Resident C's significant other conducted, on 6/21/24 at 11:17 a.m., indicated the debris that was on the floor in Resident C's room was the same debris that had been there all week. A Work Order, dated 6/4/24, was received, on 6/21/24 at 11:50 a.m., from Executive Director (ED). It indicated the same room that Resident C resides in previously had ants in room and in resident bed. The work order indicated; a member of the maintenance team had sprayed bug killer around the air unit in the room. No ants were observed at that time. A Pest Control policy received, on 6/21/24 at 2:54 p.m., indicated the purpose was to provide guidelines on keeping campuses pest free .maintain an ongoing pest control program to ensure the building is kept free of insects and rodents. This citation relates to Complaint IN00436179. 3.1-19(f)(4)

Based on interview and record review, the facility failed to ensure a resident's wound was maintained free of contamination by ants for 1 of 3 residents reviewed for wounds. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/21/24 at 9:55 a.m. The resident's diagnoses included, but were not limited to, traumatic brain injury and seizure disorder. He was receiving hospice care and passed away on 6/6/24. A physician's order, dated 4/5/24, indicated to cleanse the wound on his left knee with normal saline, pat dry, and apply skin prep (skin protecter) around the wound, cover the wound bed with Therahoney (wound treatment gel made of honey), and apply a dry dressing. Instructions were to change the dressing every 3 days. A CAR (Clinically at Risk) note, dated 5/24/24, indicated Resident B's left knee wound was from trauma. The wound had 70% necrotic (dead) tissue and 30 % granulation tissue (new tissue). A Hospice LPN (Licensed Practical Nurse) Visit with Wound note, dated 6/5/24, indicated the following, .SN [Skilled Nursing] routine visit this date. Pt [sic] resting in bed upon SN arrival. Facility aide reports to writer that he found ants around pts [sic] catheter line. Writer went into pts [sic] room and pulled back the blankets. Ants are in pts [sic] bed and on pt [sic]. Writer removed pts [sic] dressing to left knee and found ants on pt [sic] wound. DON, facility wound nurse and writer's CC [sic] notified. Writer and wound nurse both assessed pts [sic] left knee wound and saw the ants on the dressing. Wound care completed to knee by writer. Facility wound nurse reports that pts [sic] room was sprayed yesterday and planning to spray today. Pt [sic] has no s/s [signs and symptoms] of pain . A progress note, dated 6/6/24 at 10:59 a.m., indicated the following, .Writer contacted resident sister regarding ants found in resident [Resident B] room. Resident room has been sprayed x2 [two times] for ants. Writer noted ants to bed and bed frame during assessment on shift today. Writer to get resident up in broda chair and completely clean bed frame and mattress . During an interview, on 6/21/24 at 10:09 a.m., FM (Family Member) 10 indicated, on 6/6/24, they came to visit Resident B and found ants in his bed and crawling on him. FM 10 removed the dressing to his left knee and the dressing was full of ants. The floor to Resident B's room was filthy. The facility had told FM 10 that Resident B's roommate frequently dropped food on the floor when he ate, and that was causing the ants. FM 10 was very upset and disturbed that Resident B had to lay in a bed with ants crawling on him during his last days of life. On 6/21/24 at 1:30 p.m., the NC (Nurse Consultant) provided a copy of the investigation file for the ants in Resident B's room. The investigation file contained a Statement of Witness Form, dated 6/6/24, which indicated that the WN (Wound Nurse) had been interviewed. The WN completed wound care for Resident B on 6/4/24. While completing the wound care on that day the WN had assessed the wound and dressing to ensure that there were no ants in the dressing or on Resident B's wound bed. A Statement of Witness Form, dated 6/6/24, indicated the ADPO (Assistant Director of Plant Operations) had been interviewed. The ADPO had treated Resident B's room for ants on 6/6/24 at 3:00 p.m. The ADPO had sprayed Resident B's room every day that week for ants and had only seen one ant that week. Resident B's room was being deep cleaned by multiple staff members and Resident B's family member. The investigation file also contained work orders, dated 6/5/24 and 6/6/24. The work order, dated 6/5/24, indicated ants in Resident B's room. The priority was critical, and the category was cleaning. The comments were that a staff member had sprayed. The work order, dated 6/6/24, indicated ants in Resident B's room and that additional spray/treatment needed to be done. The priority was critical, and the category was cleaning. The comments indicated that a staff member had sprayed the room. During an interview, on 6/21/24 at 3:30 p.m., RN 4 indicated that Resident B's roommate ate breakfast in his room daily and ate snacks. The roommate often dropped food while eating. RN 4 had seen ants on the wall in Resident B's room about a week before the ants were found on Resident B and the room had been treated at that time. During an interview on, 6/21/24 at 3:26 p.m., the Director of Nursing (DON) indicated that the Hospice Nurse had informed her about the ants on 6/5/24. On 6/21/24 at 2:45 p.m., the NC provided the Guidelines for Weekly Measurements policy, last revised 5/22/18, which indicated the following, .In addition to Weekly Assessment by the licensed nurse, the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and peri-care and notify the nurse if an area is identified . On 6/21/24 at 3:31 p.m., the Executive Director provided the Guidelines for General Wound and Skin Care policy, last revised 2/23/23, which read . Reevaluate dressing and skin integrity every shift . This citation relates to Complaint IN00436179. 3.1-37(a)

Based on observation, interview, and record review the facility failed to ensure a wound treatment order was placed timely for 1 of 3 residents reviewed for wound care. (Resident C) Findings include: An observation of Licensed Practical Nurse (LPN) 2 preparing to complete wound care on Resident C was conducted on 6/21/24 at 11:17 a.m. LPN 2 began by pulling out the supplies and medications needed to complete Resident C's wound care. In doing so, LPN 2 had pulled from the medication/treatment cart three tubes of medication and dispensed a small amount from each tube into its own medication cup. Upon entering Resident C's room, Resident C was lying on his bed and was turned towards the wall. Resident C's wounds on his buttocks were visible. The wounds on his buttocks had opened areas that were red in color. The clinical record for Resident C was reviewed on 6/21/24 at 12:08 p.m. Resident C's diagnoses included, but not limited to, weakness and a contracture of right knee (inability to move). A physician's order, dated 6/13/24, indicated to apply Silvadene cream 1% (an antimicrobial topical cream used to treat a wound or burn) in conjunction with miconazole nitrate 2% cream (a cream used to treat fungal infections) and triamcinolone acetonide 0.5% cream (a cream used to relieve redness, itching, swelling of skin conditions) to Resident C's buttock wounds three times a day every day. A physician's note, dated 6/18/24, for Resident C indicated, Resident admitted to facility with shearing injuries to B/L [sic, bilateral] buttocks .Larger area to left buttock is comprised of 4 small areas that are circumferential to one another .Will start treating shearing injuries to B/L [sic] buttocks with collagen and cover with foam border dressing with changes 3x [sic, three times] weekly .Right Buttock: Apply collagen cut to size to affected area. Cover with foam border dressing. Change Tue. [sic, Tuesday], Thur [sic, Thursday], and Sunday. Left Buttock: Apply collagen cut to size to affected area. Cover with foam border dressing. Change Tue [sic], Thur [sic], and Sunday. A review of Resident C's orders was conducted again on 6/21/24 at 1:53 p.m. The order for Resident C's bilateral buttock wounds had been changed since the first review. The new physician's order for Resident C's bilateral buttock wounds were placed, on 6/21/24 at 12:35 p.m., and stated to cleanse wound with wound cleanser or normal saline, apply skin prep, apply collagen to wound bed, cover with foam dressing, and change daily and as needed. An interview with LPN 2 conducted, on 6/21/24 at 2:00 p.m., indicated he had just placed the new wound care orders for Resident C. When asked why the order had not been changed, on 6/18/24, when the order was written by the wound care Nurse Practitioner, he indicated sometimes the Scribe (a person who serves as a professional copyist or writer) places the orders into the computer system, but that time the Scribe had not and it wasn't until LPN 2 audited the orders, did he find the new order had not been placed into the computer system so he placed it in then. The new wound care orders, according to LPN 2, also needed to be updated again since the order was for the buttock wound dressings to be changed 3 times a week and not daily. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by touching the tip of a medication tube with a bare finger, not performing hand hygiene with glove use, and not wearing proper personal protective equipment (PPE) when providing incontinence care to a resident in enhanced barrier precautions (EBP) (an infection control strategy to reduce the spread of multi-drug resistant organisms during high-contact care activities) for 1 of 3 residents reviewed for wounds. (Resident C) Findings include: An observation of Licensed Practical Nurse (LPN) 2 preparing to complete wound care on Resident C was conducted, on 6/21/24 at 11:17 a.m. LPN 2 began by pulling out the supplies and medications needed to complete Resident C's wound care. LPN 2 pulled from the medication/treatment cart three tubes of medication and dispensed a small amount from each tube into its own medication cup. However, when doing so, the tube of miconazole nitrate still had the foil seal attached to the tube partially and LPN 2 moved the foil seal away from the opening with his bare finger and touching the tube opening without performing hand hygiene after touching the top of the medication/treatment cart, drawer handles, and the medication tubes. After dispensing some of the miconazole cream into the medication cup, LPN 2 then used his bare finger again to squash the foil back over the tube opening. After placing the cap back on the miconazole tube, LPN 2 donned (put on) a pair of gloves, removed the cap to the miconazole tube, removed the foil seal, replaced the cap, doffed (took off) his gloves then picked up some supplies on the cart. LPN 2 did not perform hand hygiene prior to donning or after doffing the gloves. An observation of Certified Resident Care Assistant (CRCA) 3 was made, on 6/21/24, upon entering Resident C's room at approximately 11:24 a.m. CRCA 3 was already in Resident C's room when LPN 2 had entered. CRCA 3 had just completed incontinence care for Resident C and was wearing just a pair of gloves. When asked if he, CRCA 3, knew Resident C was on enhanced barrier precautions, he indicated he did, and when asked what should staff wear when providing high-contact care activities such as providing incontinence care, he indicated, a gown and gloves. CRCA 3 was then asked where his gown was he replied, I forgot. While performing the observations with LPN 2 and CRCA 3, it was observed that Resident C's room had a sign on the door indicating that enhanced barrier precautions were needed when providing high-contact care activities. There was no PPE supply of gowns located outside of Resident C's room nor were gowns located in the room. A physician's order, dated 6/13/24, for Resident C indicated staff were to use enhanced barrier precautions wearing a gown and gloves at minimum during high-contact care activities. An Infection Control policy received, on 6/21/24 at 2:54 p.m., from Nurse Consultant (NC) indicated its purpose was To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. An Enhanced Barrier Precautions (EBP) Standard Operating Procedure received, on 6/21/24 at 2:54 p.m., from NC indicated, 1. Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO [sic, Multi-drug resistant organisms) acquisition which include: i. All Residents with chronic wounds, including but not limited to, pressure ulcers . ii. All Resident with indwelling medical devices 1. Includes but not limited to: catheters . 2. Personal Protective Equipment (PPE) should be used even if blood and bodily fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high-contact care activities . 3. High-contact care activities include but are not limited to: morning and evening ADL [sic, Activities of Daily Living] care, toileting, and showers. A Standard Precautions Guidelines policy received, on 6/21/24 at 2:54 p.m., from NC indicated, Standard precautions include but are not limited to hand hygiene .proper use of PPE (e.g., gloves, gowns, and masks) .In addition to proper hand hygiene, it is important for staff to use appropriate protective equipment as a barrier to exposure to any body fluids (whether known to be infected or not). The Centers for Diseases and Control website at https://www.cdc.gov/clean-hands/hcp/clinical-safety/; Last Reviewed: February 27, 2024, last accessed 6/24/24, titled Clinical Safety: Hand Hygiene for Healthcare Workers indicated to wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. 3.1-18(b)(1) 3.1-18(b)(2) 3.1-18(l)

Based on interview and record review, the facility failed to ensure a resident was provided timely care and/or services in accordance with professional standards of practice for a resident who experienced an unwitnessed fall within the facility for 1 of 3 residents reviewed for falls. (Resident M) Findings include: The clinical record for Resident G was reviewed on 5/3/24 at 2:39 p.m. Resident M's diagnoses included, but not limited to, cerebrovascular accident (CVA, stroke), fibromyalgia (widespread body pain), hypertension (high blood pressure) and dementia. A nursing note dated 3/20/24 at 8:25 a.m. indicated, Resident M had an unwitnessed fall and was found on the floor between her bed and the bedside table by a staff member. No injuries were noted at the time and the resident had no complaints of pain per the nursing note. A physician's note dated 3/21/24 at 9:16 a.m. and recorded as a late entry on 3/26/24 at 9:16 a.m. indicated, Resident experienced an unwitnessed fall [sic, and] was found on the floor in her room. No signs or symptoms of obvious injury. Mentation at baseline. Continue post fall neuro [sic, neurological] checks and fall precautions per facility standard. A review of Resident M's March 2024 orders indicated, a nursing intervention for post fall neurological assessments were to be completed as follows: Every 30 minutes for 4 times; Every hour for 4 hours; and every 4 hours for 5 times. Neurological assessments were to begin immediately post fall and included to monitor for level of consciousness; ability to perform certain facial movements; strength of hand grasps and bilateral lower extremity movements; pupil reactions; quality of speech; and signs and/or symptoms of dizziness, headache, nausea/vomiting or seizure activity. Resident M's March 2024 MAR (medication administration record) received on 5/3/24 at 3:08 p.m. from CS (Clinical Support) indicated, the every 30 minute neurological assessments began at 8:30 a.m. and ended at 10 a.m. on 3/20/24. The hourly neurological assessments should have begun at 11 a.m. and ended at 2 p.m. However, Resident M's March 2024 MAR did not indicate the 11 a.m. neurological assessment had been completed. The every four hour neuro assessments should have started at 6 p.m. on 3/20/24 and ended at 6 a.m. on 3/21/24. However, Resident M's March 2024 MAR indicated the following: On 3/20/24, the first of the every 4 hour neuro assessments was completed on 3/20/24 at 11 p.m. which was late as it should have been done at 6 p.m. then again at 10 p.m., 2 a.m. on 3/21/24 and finally at 6 a.m. on 3/21/24. Additionally, on 3/21/24 the only neuro assessment completed was at 3 a.m. The 7 a.m. assessment only documented the vitals but did not indicate the neurological assessment had been completed. An interview with CS conducted on 5/3/24 at 4:19 p.m. indicated, when a resident has an unwitnessed fall, neurological assessments should have been completed to minimize and/or prevent injury. A Falls Management Program Guidelines policy received on 5/3/24 at 10:42 a.m. from ED (Executive Director) 3 indicated, the purpose of the policy was to maintain a hazard free environment, mitigate fall risk factors and implement preventive measures however, not all falls are prevented and at those times intensive efforts will be directed toward minimizing or preventing injury. This tag relates to Complaint IN00429359. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a gait belt was utilized for transferring a resident who lost their balance and fell on to the bathroom floor for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/12/23 at 3:25 p.m. The diagnoses included, but were not limited to, chronic lung disease, depression, hypertension, macular degeneration, and osteopenia. A Quarterly Minimum Data Set (MDS) assessment, dated 8/31/23, indicated severe cognitive impairment, extensive assistance with two staff for transfer, and extensive assistance with one staff for toilet use. Resident B was listed as not steady with moving on and/or off the toilet. A fall risk care plan, start date of 7/19/23, indicated Resident B was at risk for falling related to impaired mobility due to generalized weakness, asthma with shortness of breath, impaired vision related to macular degeneration and glaucoma. The approaches listed included, but were not limited to, encourage resident to assume standing position slowly and staff to assist resident with transfers as needed. A progress note, dated 10/30/23 at 11:26 a.m., indicated the following, .Resident had assisted fall while assisting with RR [restroom] needs on 10/30/23. Resident was assisted to standing position and right leg buckles [sic] causing resident to fall forward to left side and staff lost grip. Nursing staff assessed and noted hematoma to left side of forehead/skin tear/right foot turned inward. Staff assisted with positioning for comfort and called 911. Noted dx: Other specified disorders of bone density and structure, unspecified site Note: Osteopenia. Intervention: Hoyer lift for all transfers [sic] An interview conducted with Licensed Practical Nurse (LPN) 2, on 12/12/23 at 4:08 p.m., indicated she assisted Resident B to stand after toileting. LPN 2 pulled up Resident B's incontinent product and noticed her right leg was giving out on her. LPN 2 went to try and get a better grip of Resident B and she fell forward towards her left side, by the shower. LPN 2 was trying to hold onto Resident B's clothing while LPN 2 went towards Resident B's left side in attempt to prevent her from falling. LPN 2 indicated she had transferred Resident B in the past, and observed staff, certified nursing assistants (CNAs), transfer Resident B to where she moves well and had not utilized a gait belt. No gait belt was utilized while transferring Resident B on and/or off the toilet during the fall event on 10/30/23. An interview conducted with Regional Nurse 4, on 12/12/23 at 4:45 p.m., indicated Resident B's care plans did not reflect the utilization of a gait belt. So, a gait belt would not have been utilized for Resident B. A policy titled Guidelines for Gait Belt Use, review date of 12/31/22, was provided by Regional Nurse 4 on 12/12/23 at 5:00 p.m. The policy indicated the following, .Procedures .3. If a resident requires more than limited assists and does not require a lift a gait belt may be used with transfers A policy titled Fall Management Program Guidelines, review date of 3/16/22, was provided by Regional Nurse 4 on 12/12/23 at 3:30 p.m. The policy indicated the following, .Purpose .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. [Name of Corporation] recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury The Indiana State Department of Health Nurse Aide Curriculum, revised November 19, 2015, indicated the following, .PROCEDURE #24: USING A GAIT BELT TO ASSIST WITH AMBULATION .3. Place belt around resident's waist with the buckle in front and adjust to a snug fit ensuring that you can get your hands under the belt .4. Assist the resident to stand on count of three .6. Stand to side and slightly behind resident while continuing to hold onto belt .PROCEDURE #26: TRANSFER TO WHEELCHAIR .2. Place wheelchair on resident's unaffected side .4. Stand in front of resident and apply gait belt around the resident's abdomen This citation relates to Complaint IN00423364. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to timely assist in arranging emergency dental services for a resident with an abscessed tooth resulting in a delay of dental services for the abscessed tooth which was painful and infected 1 of 1 Resident reviewed for Dental (Resident 2). Findings include: The clinical record for Resident 2 was reviewed on 8/16/23 at 1:30 p.m. The Resident's diagnosis included, but were not limited to, dementia and dysphagia (difficulty swallowing). She was admitted from an acute care hospital to the facility on [DATE]. Resident 2 resided in the facilities attached memory care assisted living prior to her hospitalization . A nursing progress note, dated 7/9/23 at 6:17 p.m., indicated a family member informed staff member that Resident 2 was to have oral surgery prior to her hospitalization . Resident 2 had multiple teeth which needed extracted. A follow up appointment needed to be scheduled as soon as possible. An assessment of Resident 2 revealed pain to mouth and throat and a large, abscess-like area along the gum line on the bottom left side of her mouth. A physician's progress note, dated 7/10/23 at 11:29 a.m., indicated Resident 2 had a possible dental abscess. Her right jaw showed as to be painful and mildly swollen. Augmentin (antibiotic) was started and an order for urgent outpatient dental appointment was written. A physician's order, dated 7/10/23, read as written URGENT: DENTIST TO EVAL AND TREAT FOR POTENTIAL ABSCESS. The order was discontinued on 7/14/23. There was no documentation in the clinical record that a dental appointment had been scheduled or that the Resident 2's POA (Power of Attorney) had been contacted about dental services. A physician's order, dated 7/10/23, read amoxicillin-pot[sic] clavulanate [Augmentin] tablet; 875-125 mg[milligram]; 1 tablet; oral DX [sic] periapical [dental] abscess without sinus] Twice a Day . The order was discontinued on 7/17/23. An Admission MDS (Minimum Data Set) Assessment, completed 7/13/23, indicated Resident 2 was severely cognitively impaired, needed extensive assistance of 2 staff members to transfer, and had no dental concerns present. A physician's order, dated 7/14/23, read as written SCHEDULE A DENTIST TO EVAL[SIC] AND TREAT FOR POTENTIAL ABCESS. Special Instructions: may d/c[sic] order when completed . The order was discontinued on 7/18/23. A social services note, dated 7/15/23 at 1:44 p.m., indicated that a Resident 1st meeting was held and that hospice services were discussed. The POA (Power of Attorney) wanted to continue therapy for a few more weeks and see progress before making a decision about hospice. Plan of care is in place with no changes made. The meeting notes did not indicate that Resident 2's tooth pain was addressed during the meeting. A nursing progress note, dated 7/18/23 at 1:07 p.m., read writer notified family in regards of setting up dental appt[sic] family made aware will schedule appt [sic] will continue to monitor. A nurse practitioner progress note, dated 7/18/23 at 1:20 p.m., indicated Resident 2 was being seen to evaluate condition after antibiotic therapy. No record of dental appointment. Resident 2 was an unreliable historian. When she was asked, she denied jaw pain. A nursing progress note, dated 7/24/23 at 1:46 a.m., indicated that Resident 2's appetite and oral intake remained poor. Resident 2 periodically complained of mouth and tooth pain. Resident 2's family stated that she is to be seen by the facility dentist in preparation for a potential tooth extraction. Resident 2 is unable to use a straw for liquids due to cognition deficit and potential tooth pain. A physician's progress noted, written by NP (Nurse Practitioner) 30 on 7/24/23 at 12:26 p.m., indicated that Resident 2 was being seen as a follow up to the acute log report of mouth pain. There was still no word on outpatient dental appointment. A second round of Augmentin was started. A care plan, initiated 7/25/23, indicated Resident 2 had the potential for mouth pain related to abscess and tooth decay per daughter's report. The goal was for her not to exhibit mouth pain or infection. The interventions, initiated 7/25/23, included but were not limited to, encourage fluids, offer and provide mouth care as needed, administer medications as ordered, and dental evaluation and interventions as needed. A physician's order, dated 7/25/23, indicated she was to receive tramadol (pain medication) 25 mg twice daily for pain and every 4 hours as needed for pain. A nursing progress note, written by the DON (Director of Nursing) on 7/25/23 at 12:35 p.m., indicated the Nurse Practitioner was aware of mouth and tooth pain with a new order for tramadol (pain medication) 25 mg twice daily. and every 4 hours as needed for pain. The family member was at the facility for a meeting and was aware of the new order. A physician's progress note, written by NP 30 on 7/25/23 at 1:37 p.m., indicated Resident 2 was on the acute log again due to mouth pain. Augmentin restarted yesterday. Resident 2 was on the list to be seen by in-house dentist. The Dental Provider Note, dated 7/25/23, indicated Resident 2 had a limited exam for pain on the left upper side. X-rays were taken to confirm. The recommendation is extraction of this tooth. The dental provider could try to extract in house, if approved by the resident representative, the tooth could be extracted in the facility. The dental provider also sent a referral for her to be sent out for extraction, so that Resident 2 would be covered for either scenario. A physician's progress note, written by NP 30 on 7/31/23 at 10:53 a.m., indicated Resident 2 was being seen as a follow up for the end of antibiotic therapy. The staff reports that resident is on the list to be seen by the in-house dentist this week. We will continue to monitor closely. The July MAR (Medication Administration Record) indicated that the Augmentin, ordered on 7/10/23, had been administered as ordered, with the exception of refused evening dose on 7/10/23. The July 2023 MAR did not contain documentation that Augmentin, ordered on 7/24/23, was given at all. A social services progress note, dated 8/1/23 at 9:03 a.m., indicated that had Resident 2 had expressed mouth pain. Antibiotics had been started by the physician to help eliminate any signs or symptoms of infection and to reduce pain. The POA (Power of Attorney) was offered an opportunity for resident to be sent out to dental services within the community for a prompt resolution. The POA expressed that due to Resident 2's physical and mental decline, an in-house dentist was preferred. The dental group provided an emergency visit on 7/25/23. Consents for in house services were signed and sent back to the dental group on 7/28/23. Awaiting confirmation of upcoming appointment. A nursing progress note, dated 8/4/23 at 5:06 p.m., indicated Resident 2 now on routine pain medication as she is unable to express discomfort. She has flaccid facial expressions with no indicator of pain. A Physicians order, dated 8/4/23, indicated Resident 2 was to receive tramadol 25 mg at 8 a.m., 12 p.m., 4 p.m., and 8 p.m. for pain and may receive tramadol 25 mg as needed twice daily for pain. A nursing progress note, dated 8/5/23 at 9:14 p.m., indicated Resident 2 had very poor oral intake during the shift. A Family Member at bedside earlier in the shift had expressed concerns regarding teeth extractions. A social services progress note dated 8/7/23 at 12:04 p.m. read Writer contacted in house dental group, regarding emergency scheduling of extractions for resident. Upon last contact made, appointment would be scheduled, and writer was to be made aware of date/[sic] time. As of today, writer had received no updated information. Upon contact with clinical support manager, next available appointment is 8/22/23. Writer requested that clinical support manager supervisor make contact in efforts to find opportunities of an earlier visit date as resident is exhibiting pain and discomfort related to tooth. Writer currently awaiting return call/[sic] email from supervisor related to scheduling. POA [sic] made aware. Pain medications have been reviewed and ATB [sic] treatment ordered and in place to provide resident with comport and relief. A physician's order, dated 8/7/23, indicates Resident 2 was to receive amoxicillin- pot clavulanate (Augmentin) 875-125 mg tablet twice daily for pain. A physician's progress note, written by NP 30 on 8/15/23 at 12:37 p.m., indicated that on 8/7/23, Resident 2 continued to complain of mouth pain. Has been decreasing oral intake due to pain. The social worker to get dentist here as soon as possible. Will restart Augmentin while awaiting dental intervention. On 8/15/23, complaints of pain today. Will begin oral saline rinse in the morning, after food intake, and at bedtime. She is on the list to be seen by in-house dentist. On 8/17/23 at 1:30 p.m., Resident 2 was observed sitting in the common area with a staff member. Her teeth were noted to be dark brown in color. During an interview on 8/18/23 at 12:30 p.m., FM (Family Member) 31 indicated that Resident 2's dental issues had been going on for a long time. Resident 2 had complained that her teeth were bothering her and she was scheduled to have some teeth extracted prior to leaving the Assisted Living part of the facility but had been hospitalized prior to having it done. When she was admitted to the facility on [DATE] she was complaining of tooth pain. FM 31 was not offered the option of having Resident 2 see an inside dentist when she was admitted to the facility on [DATE] and had not declined in house services for dental care upon admission. FM 31 was unable to transfer Resident 2 to a dental chair and was not sure how she would get Resident 2 to the oral surgeon because it took two people to transfer her. FM 31 did not know what else to do about getting a dental appointment. FM 31 had made the facility aware of the need for a dental visit on several occasions and had received no direction, which was frustrating. The facility started her on an antibiotic and Tylenol and the pain got better. On around 7/22/23 Resident 2 started to say that her teeth hurt again. The antibiotic course was over. During a meeting on 7/25/23, FM 31 had told SSD that Resident 2's teeth were hurting again, and the DON came into the meeting to discuss pain medication options. The facility ordered some pain medication for her to help with the tooth pain. The facility offered an inside dentist to see Resident 2 and she was seen on 7/25/23. FM 31 had given verbal permission to the dental provider for them to provide treatment in house, over the phone on 7/27/23 and had signed a consent for dental treatment on 7/28/23. During an interview on 8/18/23 at 1:50 p.m., the SSD indicated that in house dental services are normally offered upon admission and at the Resident First meeting. The consent would be signed and faxed to the provider. On 8/18/23 at 3:40 p.m. NP 30 and NP Compliance Officer 33 were interviewed. NP 30 indicated she had written the 7/10/23 order for Resident 2 to be seen by the dentist. She had written another order on 7/14/23 for Resident 2 to have a dental consult because she had not heard any updates from the facility on if the appointment was scheduled and NP 30 had been aware the family had wanted in house dental services. NP 30 had intended for Resident 2 to receive a second round of Augmentin on 7/24/23 to treat her oral abscess and for a possible urinary tract infection. She was unaware it had not been given. NP Compliance Officer 33 indicated that the 7/24/23 Augmentin order had been written in Resident 2's Assist Living chart in error. During an interview on 8/21/23 at 1:25 p.m., Pharmacist 20 indicated that the 7/24/23 order for Augmentin had been filled. There had been 14 tablets of Augmentin delivered to the 200 hall of the facility on 7/24/23. Seven of the Augmentin tablets had been returned to the pharmacy. Resident 2 had resided on the 200-hall portion of the facilities Assisted Living, which was connected to the health center unit Resident 2 was admitted to on 7/7/23. Resident 2's tooth was extracted at the facility on 8/22/23. During an interview on 8/24/23 at 1:13 p.m., Dental Provider Scheduler 38 indicated that the first time the facility contacted the in-house dental provider to arrange a dental exam was 7/21/23. The Dental Provider had a Dentist in the facility on 7/21/23, but the triage form had been received by the dental provider after the dentist had already left the facility. If the facility had reached out sooner, Resident 2 could have been seen for her initial triage appointment on 7/21/23, and a treatment plan could have been started. Resident 2 was seen by a Dentist for a triage appointment on 7/25/23 and a treatment plan was set up at that time. When a tooth is abcessed it is normally very uncomfortable for the patient due to the pain and pressure from the infection. During an interview on 8/18/23 at 2:06 p.m., the Executive Director indicated the facility did not have a specific dental policy, the facility followed the regulation. 3.1-24(a)(2)

Based on observation, interview, and record review, the facility failed to prime an insulin flex pen prior to administering insulin for 1 of 5 residents observed during administration of medications, ensure monitoring of bowel and bladder outputs for 1 of 2 residents reviewed for hospitalization and 1 of 1 residents reviewed for constipation, and to administer antibiotics, as ordered by a physician, for 1 of 1 resident reviewed for dental (Residents' 2, 9, 35 and 142) Findings include: 1. The clinical record for Resident 35 was reviewed on 8/21/23 at 9:00 a.m. The diagnosis for Resident 35 included, but was not limited to, diabetes mellitus type 2. A physician order indicated the resident was to receive a sliding scale of insulin aspart. The sliding scale was the following: blood sugar reading of 151 to 200 = 3 units, blood sugar reading of 201 to 250 = 5 units, blood sugar reading of 251 to 300 = 8 units, blood sugar reading of 301 to 350 = 10 units, and blood sugar reading of 351 to 400 = 12 units, An observation was made of a medication administration with License Practical Nurse (LPN) 6 on 8/21/23 at 11:22 p.m. LPN 6 was observed preparing to administer insulin utilizing a flexpen to Resident 35. LPN 6 pulled an aspart insulin flexpen and placed a needle on it. LPN 6 then administered 3 units of aspart insulin to the resident. There was no observation of priming the flexpen prior to administration of the 3 units. An interview was conducted with Pharmacist 20 on 8/21/23 at 1:22 p.m. He indicated the flex pens should be primed 2 units of insulin prior to dial up the insulin amount to be given. Novolog (insulin aspart injection) flextouch manufacture instructions at website www.novologpro.com dated 2/2023, was retrieved on 8/22/23. It indicated Prescribing information .Priming your novolog flextouch pen: Step 7: Turn the dose selector to select 2 units .Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip . If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times If you still do not see a drop of insulin, change the needle and repeat steps 7 to 9 . 2. The clinical record for Resident 9 was reviewed on 8/16/23 at 2:00 p.m. The diagnosis for Resident 9 included, but was not limited to, kidney disease. A medical provider progress note dated 5/24/23 indicated Chronic kidney disease .monitor renal function closely. A medical provider progress note dated 6/8/23 indicated the resident was being seen that day due to recent hospitalization for acute respiratory failure with hypoxia, hypertensive urgency, and new onset volume overload Stage III chronic kidney disease, Monitor urinary output . A June 2023 urine output report was provided by the Director of Nursing on 8/21/23 at 10:54 a.m. It indicated the following days urine output was not recorded for Resident 9: 6/1/23, 6/8/23, 6/9/23, 6/10/23, 6/11/23, 6/12/23, 6/13/23, 6/14/23, 6/15/23, 6/16/23, 6/19/23, 6/20/23, 6/21/23 and 6/23/23. An interview was conducted with Nurse Consultant (NC) 2 on 8/21/23 at 2:45 p.m. She indicated she was unable to provide any additional urine outputs for the missing days from the June 2023 urine output report. 3. The clinical record for Resident 142 was reviewed on 8/16/23 at 2:00 p.m. The diagnoses for Resident 142 included, but were not limited to, constipation and cerebral palsy. The resident was admitted on [DATE]. The discharge paperwork dated 8/11/23 indicated the resident was receiving daily fleet enemas due to constipation. A baseline care plan dated 8/11/23 indicated the Resident will maintain or improve present bowel and bladder . The bowel report for Resident 142 indicated the resident had not had bowel movement on 8/12/23, 8/13/23, 8/14/23, 8/15/23, 8/16/23 and 8/17/23. A physician order dated 8/11/23 indicated Resident 142 was to receive a fleet enema once a day. A physician order dated 8/11/23 indicated Resident 142 was to receive 8.6 milligrams of senna. A physician order dated 8/11/23 indicated if resident had not a bowel movement within 72 hours 2 tablespoons of natural laxative would be provided. The August 2023 Medication/Treatment (MAR/TAR) record for Resident 142 indicated the resident was to receive a fleet enema once a day between 6:00 a.m. - 10:00 a.m. The resident did not receive the fleet enema on 8/15/23, because of availability of medication and 8/17/23 between 6:00 a.m. -10:00 a.m., because resident was unavailable. The resident's clinical record did not indicate the staff was providing additional monitoring of the resident's lack of bowel movements since admission of 8/11/23. An interview was conducted with Nurse Consultant (NC) 1 on 8/17/23 at 2:03 p.m. She indicated Resident 142's food consumption was minimal, and he was admitted with receiving fleet enemas daily with senna. A KUB would be ordered. An Registered Dietcian note dated 8/16/23 indicated Resident 142's meal consumption ranging from refusal to 51-100%. An interview was conducted with NC 2 on 8/18/23 on 8/18/23 at 3:13 p.m. She indicated the resident's scheduled fleet enema was moved to be provided in the evenings from 6:00 p.m. - 10:00 p.m. as of 8/17/23. The resident had received a fleet enema that evening. A bowel protocol guidelines policy was provided on 8/18/23 at 2:57 p.m. It indicated .Purpose. To provide guidance for the use of bowel stimulants for residents with constipation. Procedures. 1. Upon admission, an order may be obtained to 'utilize bowel protocol as needed.' 2. If the resident needs to utilize the bowel protocol, the 'Bowel Protocol' order set may be opened and orders entered from order set. 3. The ineffective bowel pattern event should be initiated for any resident not having a BM [bowel movement] within 72 hours (unless this has been determined to be a usual bowel pattern for the individual). a. A progress note associated to the ineffective bowel event, should be completed until the resident has a BM or the bowel pattern returns to normal for the resident. The progress note should include abdominal distention, pain and bowel sounds. 4. Nursing staff shall assess for effectiveness, orders may be written as follows; a. if no bowel movement within 72 hours, 2 tablespoons .of 'Natural Laxative' b. If no results within 24 hours, after 'natural laxative' give 30 cc [cubic centimeters/milliliters] of Milk of Magnesia c. If no results within approximately 12 hours after MOM administer Dulcolax suppository. d. If results of suppository are not satisfactory within 2 hours give Fleet enema. 5. IF at any time there are indications of a bowel blockage the physician should be notified to receive instructions to proceed with the protocol or to intervene with further testing . 40287 4. The clinical record for Resident 2 was reviewed on 8/16/23 at 1:30 p.m. The Resident's diagnosis included, but were not limited to, dementia and dysphagia (difficulty swallowing). She was admitted from an acute care hospital to the facility on [DATE]. Resident 2 resided in the facilities attached memory care assisted living prior to her hospitalization . A nursing progress note, dated 7/24/23 at 1:46 a.m., indicated that Resident 2's appetite and oral intake remained poor. Resident 2 periodically complained of mouth and tooth pain. Resident 2 is unable to use a straw for liquids due to cognition deficit and potential tooth pain. A physician's progress noted, written by NP (Nurse Practitioner) 30 on 7/24/23 at 12:26 p.m., indicated that Resident 2 was being seen as a follow up to the acute log report of mouth pain. A second round of Augmentin was started. A care plan, initiated 7/25/23, indicated Resident 2 had the potential for mouth pain related to abscess and tooth decay per daughter's report. The goal was for her not to exhibit mouth pain or infection. The interventions, initiated 7/25/23, included but were not limited to, encourage fluids, offer and provide mouth care as needed, administer medications as ordered, and dental evaluation and interventions as needed The July 2023 MAR did not contain documentation that Augmentin, ordered on 7/24/23, was given at all. On 8/18/23 at 3:40 p.m. NP 30 and NP Compliance Officer 33 were interviewed. NP 30 indicated she had intended for Resident 2 to receive a second round of Augmentin on 7/24/23 to treat her oral abscess and for a possible urinary tract infection. She was unaware it had not been given. NP Compliance Officer 33 indicated that the 7/24/23 Augmentin order had been written in Resident 2's Assist Living chart in error. During an interview on 8/21/23 at 1:25 p.m., Pharmacist 20 indicated that the 7/24/23 order for Augmentin had been filled. There had been 14 tablets of Augmentin delivered to the 200 hall of the facility on 7/24/23. Seven of the Augmentin tablets had been returned to the pharmacy. 3.1-37

Based on observation, interview, and record review the facility failed to serve pureed food at appropriate temperatures with the potential to affect 7 of 37 residents residing at the facility. Findings include: The lunch service was observed with the Dietary Manager on 8/18/23 at 11:42 a.m. The pureed food temperatures were obtained while the food was on the steam table for service. The pureed ham was 102 degrees Fahrenheit, the pureed sweet potatoes were 100 degrees Fahrenheit, and the pureed greens were 100 degrees Fahrenheit. During an interview at 11:50 a.m., the Dietary Manager indicated the temperature at serving should be at least 145 degrees Fahrenheit. The pureed meal had already been served to a couple of residents. It would be reheated. The pureed meal had been 171 degrees Fahrenheit when it was removed from the oven. There should have been a cover over the food to assist in maintaining the temperatures. During an interview on 8/21/23 at 11:36 a.m., Nurse Consultant 2 indicated there were 7 residents of the health center who received a pureed diet. 3.1-21(a)(2)

Based on observation, interview and record review the facility failed to timely address a resident's change of condition which resulted in a delay in treatment to the resident's fractured left hand and failed to timely apply dressings, as ordered by the physician, for 1 of 1 resident reviewed for skin conditions and to administer a resident's medication, as ordered, and collaborate with hospice regarding an ordered medication and Broda chair for 1 of 1 resident reviewed for hospice and 1 of 2 residents reviewed for hospitalization . (Resident L, O, W) Findings include: 1. The clinical record for Resident O was reviewed on 3/9/22 at 12:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident O was cognitively impaired. She was extensive assistance with 1 staff person for bed mobility, transfer and dressing. A care plan dated 12/27/20 indicated .Resident is at risk for falling r/t [related to]: decreased mobility, need for assistance with toileting, transfers, bed mobility, Alzheimer's disease, dementia, [CONDITION(S)] [hypertension]. Goal .Resident will remain free of falls with major injury .Interventions: .provide non-skid footwear . An interview was conducted with Resident O's Representative on 3/9/22 at 12:40 p.m. He indicated the resident had fallen out of bed and had broken something in her wrist. An observation was made of Resident O on 3/10/22 at 9:32 a.m. Resident was observed sitting in her wheelchair with a brace on her left arm. A nursing progress note written by License Practical Nurse (LPN) 10 dated 1/29/22, indicated Writer notified by the CRCA [Certified Resident Care Assistant] 12 that resident [O] was on the floor. Writer entered [Resident O's room number] and noted resident lying on L [left] side of the floor next to bed, (+) [had] ROM [range of motion] x [times] 4 extremities, no in/outward or length difference of BLE [bilateral lower extremities], no visual injuries, up with assist x 2 [staff members]. Resident A&O [alert and oriented] x 1, unable to tell what happened. Resident was laying in bed before incident. Writer notified MD [medical doctor] and [family], will cont. [continue] to monitor. A fall event dated 1/29/22 at 3:30 p.m., indicated Resident O had an unwitnessed fall in her room. She was observed and assessed by LPN 10 at that time. The resident was observed not wearing appropriate footwear, she had range of motion to all extremities and was not in any pain. It indicated physician and family notified. A bruise event written by LPN 10 dated 1/29/22 at 6:39 p.m., indicated Resident O's left hand and distal forearm was blue in color and her hand had swelling. The resident was experiencing pain at level of 3 using the following pain scale: 0-no pain, 1-mild pain, 2, 3, 4-moderate pain distressing/miserable, 5, 6, 7-severe pain-horrible/intense, 8, 9, 10-Excruciating pain - worst possible -interferes with ability to carry on with daily routines, socialization or sleep. The event indicated a progress note dated 1/29/22 at 6:45 p.m., after putting resident to bed the CRCA [12] noted L hand and distal forearm was bruise (blue) and nursing swollen. Writer noted bruises and applied ice, bruising from previous fall today-resident rolling out of low bed, will cont. to monitor . The physician and family was notified. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note written by LPN 11 dated 1/30/22 indicated Resident L hand and distal forearm bruising, swelling, and severe pain indicated by Nursing extreme guarding of area; assessment revealed need for x-ray ordered by NP [Nurse Practitioner] on call. X-ray completed this day at 11am (sic) that confirmed an acute fracture of the distal radius of left extremity. Nurse notified on-call NP of findings and new orders given to send resident to ER [emergency room ] for further evaluation and treatment. Resident [family] notified. Resident being transported to [name of hospital] via ambulance. A lab report dated 1/30/22 indicated an acute fracture to Resident O's left wrist was reported to the facility at 12:30 p.m. The Hospital Records was provided by the Nurse Manager on 3/10/22 at 3:14 p.m. It indicated Resident O was brought in to the emergency room and seen on 1/30/22 at 4:30 p.m.Chief complaint: Patient presents with arm injury. left arm fracture from fall out of bed yesterday evening .X-ray today showed radial fx [fracture]. Splinted by medics . An interview was conducted with Nurse Practitioner 22 on 3/11/22 at 9:24 a.m. He indicated Resident O's fall occurred over a weekend. The staff can either write in a medical provider book if a fall occurs with no injury, and it would be reviewed the following business day. If a fall occurred with injury the staff would need to notify by phone utilizing the on-call medical provider service. The order was given to obtain an x-ray for Resident O's hand on 1/30/22. An interview was conducted with LPN 10 on 3/11/22 at 11:18 a.m. She indicated she was the nurse that had taken care of Resident O at that time of her fall. After the fall, she had assessed the resident with no injuries that she had observed. LPN 10 had then written the fall incident in the medical provider book due to the resident did not have an injury. She had not notified the medical provider via phone about the fall. Later on in the evening, the CRCA 12 had reported to her the resident's left hand was bruised, swollen, and she had complaints of pain. LPN 10 at that time applied ice to the resident's left hand, but did not notify the medical provider. She believed at that time, the resident did not have any major injury to her left wrist. The resident had landed on her left side, and she believed the hand was just bruised from the fall. LPN 10 had administered scheduled pain medication, but had not provided any additional pain medication that evening. She had worked on the unit until 10:00 p.m. LPN 13 was the night shift nurse that took over Resident O's care at 10:00 p.m., that night. LPN 13 was going to notify the medical doctor to have an x-ray ordered for the resident's left hand. An interview was conducted with LPN 13 on 3/11/22 at 3:33 p.m. She indicated she had taken over Resident O's care after LPN 10 at 10:00 p.m. to 6:00 a.m. She had also been working that evening on a different hallway, and was aware Resident O had fallen that evening. After assessing the resident's hand when she had taken over her care, the resident's left hand was observed to be visibly swollen, bruised, and the resident had complaints of pain if the extremity was touched. The resident would draw up her arm and verbalize an ow if the left extremity was touched. The resident's verbal and physical reactions were apparent to LPN 13 the resident's arm was causing her pain. She believed she had administered pain medication that night to Resident O. She had notified the medical provider about the resident's condition. It was not the end of her shift, but it was later on in her shift when she notified the medical provider. After notification, an x-ray was ordered by the provider. An interview was conducted with CRCA 12 on 3/11/22 at 3:20 p.m. She indicated she had worked on the evening of 1/29/22 and was providing care to Resident O until 10:00 p.m. She had notified LPN 10 Resident O had fallen on the floor in her room. Later on in the evening, she had reported to LPN 10 she had noticed the resident's left hand was blue, swollen and she was hollering out in pain. The resident does normally yell out when the staff turn her, but it was different that time. She was in real pain. She had taken care of Resident O all evening and kept checking on the resident in bed through out her shift due to concerns of the resident's hand. She had not observed any ice that had been applied to the resident's hand that evening. CRCA 12 then had notified LPN 13, the night nurse that took over the resident's care that the resident had fallen and something was wrong with her left hand. LPN 13 had stated she agreed with CRCA 12 something was wrong with the resident's hand. An interview was conducted with LPN 11 on 3/11/22 at 11:34 a.m. She had indicated she had taken over the care of Resident O on the morning of 1/30/22. She had observed the resident in the hallway prior to getting report and had already observed the resident's hand was bruised and swollen twice the size of her other hand. She had indicated to the night staff Resident O's hand does not look right. LPN 13 had reported she had called the doctor and received an order to get an x-ray. The lab would be coming out to obtain. The lab team was late getting to the facility and had come around lunch time to obtain the x-ray. The resident was unable to voice her pain utilizing a numeric pain scale due to her cognitive status. The resident would verbalize a no if the staff tried to touch her arm during care and/or she would guard her arm bringing it close to her body. The x-ray was challenging to obtain due to the resident did not like her hand to be touched due to pain. She could tell the resident was in pain, because she grimaced or verbalize Oh, Ow, and No if anyone touched her arm. After receiving the x-ray results the medical provider was notified. LPN 11 had received an order to send the resident to the emergency room due to the results indicated a fracture. The resident was then sent out approximately around 2:00 p.m. - 3:00 p.m. A nursing progress note dated 1/31/22 indicated Resident O returned from hospital.Resident has fractured L wrist with splint and elevated on a pillow. Resident to have follow up appointment with ortho in one week . A fall management policy was provided by the Executive Director on 3/10/22 at 10:15 a.m. It indicated Procedure: 2. Should the resident experience a fall the attending nurse shall complete the 'Fall Event' .3. The attending physician or medical director in the absence of the attending physician and the responsible party should be notified . 2. The clinical record for Resident L was reviewed on 3/9/22 at 11:30 a.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated on 6/6/21, indicated she was at risk for skin breakdown related to decreased mobility, history of falls, history of incontinence, [CONDITION(S)], and diabetes. The goal was for her skin to remain intact. A Quarterly MDS (Minimum Data Set) Assessment, completed 12/20/21, indicated she was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A dry dressing was to be applied to the skin tear and changed daily and as needed for soiling or dislodgement. On 3/9/22 at 11:38 a.m., she was observed in her room sitting in a wheelchair. She had a skin tear on her left arm which had steri strips applied to it. There was no dressing over the skin tear. During an interview on 3/9/22 at 11:39 a.m., Resident L indicated the skin tear had happened a couple of days ago and they put a bandage over it sometimes. On 3/14/22 at 10:15 a.m., she was observed in her room sitting in her chair. The skin tear on her left arm was visible. There was no dressing over the skin tear. During an interview on 3/14/22 at 10:30 a.m., LPN (Licensed Practical Nurse) 6 indicated she needed to put a new dressing on her skin tear. It frequently did not have a dressing on it in the morning. She did the dressing each day. On 3/14/22 at 2:17 p.m., the Nurse Manager provided the Dressing Changes Procedure, revised 5/11/16, which read . To ensure measures that will promote and maintain good skin integrity while maintaining standard measures that will minimize/ control contamination .11. Follow doctors[sic] recommendations for treatments . 3. a) The clinical record for Resident W was reviewed on 3/9/22 at 2:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was discharged to the hospital on 2/20/22 after a fall and readmitted to the facility from the hospital on 2/24/22. The 2/20/22 to 2/24/22 hospital notes read, SIRS [systemic [CONDITION(S)] response syndrome] criteria/Leukocytosis/[CONDITION(S)]. Unclear source. BP [Blood pressure] stable [CONDITION(S)] with HR [heart rate] up to 130s. Fever of 103.1 in ED [emergency department.] WBC [white blood cell] of 15.1, lactic acid 2.3 Started on [CONDITION(S)] protocol with broad spectrum antibiotics with vanc [[MEDICATION(S)]]/[MEDICATION(S)], given fluids Continue on antibiotics and IV [intravenous] fluids. The discharge medication list indicated to start taking [MEDICATION(S)] 75 mg/5 mL solution, 10 mLs by mouth, 3 times daily for 5 days. The 2/25/22 IDT (Interdisciplinary Team) note read, IDT review of infection event. Resident admitted to campus with new orders for antibiotic therapy related to dx [diagnosis] of [CONDITION(S)]. Resident to continue with antibiotic per orders. The February, 2022 and March, 2022 MARs (medication administration records) indicated Resident W never received the ordered antibiotic medication after returning from the hospital. The 2/27/22 nurse's note read, Called pharmacy to follow up on why ABX [antibiotic] [MEDICATION(S)] has not yet been received .they are unable to fill the script [prescription] written as is. Recommended change is to 150 mg capsules (which can be opened). Will place in triage book for MD/NP [nurse practitioner] reorder. The 2/28/22 nurse's note read, Still awaiting ABT [antibiotic] order clarification. The 3/1/22 nurse's note read, Awaiting ABT order clarification. NP/MD aware. The 3/2/22 nurse's note read, Awaiting order clarification for ABT. The 3/7/22 nurse's note read, Still awaiting clarification on ABT orders. The 3/8/22 nurse's note read, Awaiting clarification on ABT orders. An interview was conducted with the NM (Nurse Manager) on 3/10/22 at 2:39 p.m. She indicated Resident W never received the [MEDICATION(S)] ([MEDICATION(S)]) antibiotic she was ordered when discharged from the hospital. It appeared the pharmacy was not able fill the prescription as written. Nursing attempted to contact the physician about it. They put it in the triage book and sent the order to hospice. The pharmacy was unable to fill it in liquid form and suggested the pill form instead, but have been unable to get the order from anyone. They have NP 22, their medical director, and hospice available to them, and between those 3, I still cannot get an order. She stated, I saw [name of NP 22] on Tuesday. I said I need you to give me an order, please, and he said, 'We'll take a look at it,' and I still don't have one. An interview was conducted with NP 22 on 3/11/22 at 9:45 a.m. He indicated he gave permission to start the antibiotic yesterday, 3/10/22. He stated, I think I was first notified yesterday that she had the order. Resident W was on hospice, so he was not the primary provider. He stated, Obviously it would have been optimal for it to have started sooner. Whenever you don't start an order there's always a risk for further progression of why it wasn't started. An interview was conducted with Hospice Nurse 14 on 3/11/22 at 12:21 p.m. She indicated she was made aware yesterday, 3/10/22, about the [MEDICATION(S)] order from the hospital. When their admission nurse, Hospice Nurse 16, came to the facility upon Resident W's readmission, she would have been the one made aware of the order. An interview was conducted with Hospice Nurse 16 on 3/11/22 at 5:25 p.m. She indicated she was the admitting hospice nurse when Resident W was readmitted to the facility on [DATE]. She asked the facility for her current orders, not the hospital orders. She just assumed all medications she was on when discharged from the hospital would have been included. She was unaware she did not receive the [MEDICATION(S)] as ordered. 3. b) The clinical record for Resident W was reviewed on 3/9/22 at 2:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/2/21 hospice care plan, last revised 1/17/22, indicated approaches were to communicate with hospice when any changes were indicated to the plan of care; to coordinate care with the provider; and to collaborate with all team members including Medical NP, hospice NP, family and staff. An interview was conducted with the NM on 3/11/22 at 12:44 p.m. She indicated they did not have access to Resident W's hospice notes at the facility and had to request them to be sent. An interview was conducted with the NM on 3/14/22 at 10:30 a.m. She indicated their preferred communication method with hospice was to call them. There was a hospice binder with hospice information like names, phone numbers, etc. at the nurse's station, but they did not include notes. If hospice came in and wrote a new order, they would have to verbalize it to the nurse, because hospice did not have access to their electronic health record. Resident W had a fall the evening of 2/14/22 and the morning of 2/15/22. The 2/15/22, 3:45 p.m. IDT (interdisciplinary team) note read, Review of fall on 2/15/22. Resident noted with witnessed fall onto hallway floor by nurses station while trying to reach for something. Resident noted with increased restlessness observed. No other injuries noted at this time per staff nurse assessment. Resident assisted to bed et [and] resting. Family/MD made aware. Hospice called & notified. New intervention noted for hospice to evaluate anti-anxiety medication. The 2/16/22, 12:20 p.m. nurse's note, written by the NM (Nurse Manager) read, Spoke with [name of Resident W's hospice company] regarding most recent falls and interventions. Hospice nurse to evaluate anti-anxiety medication upon next scheduled visit. An interview was conducted with the NM on 3/14/22 at 10:14 a.m. She indicated she remembered discussing having hospice evaluate Resident W's anti-anxiety medications and writing it in the 2/16/22 note, but didn't see any verification it was done. An interview was conducted with Hospice Nurse 14 on 3/11/22 at 12:21 p.m. She indicated she didn't remember if she was asked to evaluate Resident W's anti-anxiety medications after her 2/15/22 fall. Perhaps the on call hospice nurse, Hospice Nurse 16, would know, as she was the nurse who spoke with the facility after her 2/14/22 and 2/15/22 falls. After reviewing the notes, there was no information about an anti-anxiety medication review. Hospice Nurse 14 came to the facility later on 2/15/22 to visit Resident W. An interview was conducted with Hospice Nurse 16 on 3/11/22 at 5:25 p.m. She indicated she was the on call nurse when Resident W fell . When they called her, Resident W had already been monitored since the fall. Her vital signs were stable, and there were no signs or symptoms of injury. The facility informed her they would call, if they had any other concerns. She was not notified of any other concerns and was never informed of any intervention of reviewing her anti-anxiety medications. She was uncertain if Hospice Nurse 14 was made aware of the intervention, but I definitely wasn't made aware of it by the facility. The 2/15/22 Hospice Staff Collaboration Log indicated Hospice Nurse 14 visited on 2/15/22 as a follow up for 2 falls. The section entitled Was The Care Plan Changed? read, Will order Broda Chair. The 2/15/22 hospice note, written by Hospice Nurse 14, read, Late entry for PRN [as needed] visit today at 3:34 p.m Writer spoke with staff nurse, [name of CRMA 20,] who confirmed that patient fell last night. [Name of CRMA 20] also reports that patient fell from her wheel chair this morning. Nurse stated that perhaps patient was attempting to pick something up off the floor and lost her balance Broda Chair requested by facility nurse. An interview was conducted with the NM on 3/14/22 at 11:12 a.m. She indicated she wrote the order for the Broda chair on 3/3/22, so that was when she got it. There was a care plan meeting on 2/25/22, where they discussed the Broda chair, positioning, and what would be most comfortable for her. Hospice was there via phone. She was unaware of the 2/15/22 hospice note about the Broda chair and did not recall discussing it prior to the 2/25/22 care plan. She thought the family chose Resident W's hospice company. She let families know which companies were available, but encouraged them to do their own research and make the decision. She stated, I guess I'm going to have to read this binder everyday. Clearly, this collaboration with [name of hospice company] is not working. Resident W had another fall on 2/20/22 and was sent to the hospital. She returned to the facility on [DATE]. The hospice contract between the facility and Resident W's hospice company was provided by the NM on 3/14/22 at 12:00 p.m. It read, Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. 3.1-37

Based on interview and record review, the facility failed to provide a resident with adequate assistance of 2 staff members for bed mobility. This resulted in a fall with a fractured rib for 1 of 4 residents reviewed for accidents and failed to ensure fall interventions were implemented per the plan of care for 2 of 4 residents reviewed for falls. (Resident H, Q, W). Findings include: 1. The clinical record for Resident H was reviewed on 3/9/22 at 12:40 p.m. The Resident's diagnosis included, but were not limited to, polyosteoarthritis (arthritis in multiple joints) and contracture of her r knee. A Quarterly MDS (Minimum Data Set) Assessment, completed 10/25/21, indicated that she required extensive assistance of 2 staff members for bed mobility and total assistance of 2 staff members for toileting care. Her cognitive status was intact. A physical therapy discharge summary, dated 11/23/21, indicated that she continued to require maximum assistance of 2 staff members for side rolling in bed. The care givers had been provided education on positioning she was laying supine (laying on her back), proper body mechanics and on safety with bed mobility. A Quarterly MDS Assessment, completed 1/25/22, indicated that she required extensive assistance of 2 staff members for bed mobility and total assistance of 2 staff members for toileting care. Her cognitive status was intact. A care plan, last reviewed on 1/28/22, indicated she verbalized discomfort and or pain during ADL (Activities of Daily Living) care. The goal was for her ADL care to be completed successfully without discomfort or pain. The approaches, initiated 1/28/2019, were to evaluate effectiveness of pain medications as needed and utilized 2 care givers for ADL care. A fall event, dated 2/7/22, indicated that on 2/7/22 at 7:53 p.m., she was being turned in bed and had a witnessed fall. She experienced moderate pain (distressing or miserable) and a suspected fracture. She was transferred to an acute care hospital for evaluation. The IDT (Interdisciplinary Team) had reviewed the fall on 2/8/22 at 11:38 a.m., as she had been being changed in bed, the air bed had fluctuated, and she had rolled out of bed. She had complaints of pain all over and wanted to go the emergency room . She had voiced it was an accident and that the girl was just attempting to help clean her up when she fell . An Emergency Department Providers noted, dated 2/7/22 at 10:41 p.m., indicated she had been brought to the emergency department after a fall. She was having her brief changed when she fell to the ground. She was complaining of right hip and knee pain. A chest x-ray, completed at the emergency department on 2/7/22 at 11:20 p.m., indicated there was at least 1 rib lower left rib fracture. A care plan, revised on 2/8/22, indicated that she had a history of falls related to weakness, paralytic (abnormal) gait, and dizziness. The goal was that she would remain free from injuries. The approaches included to provide her with toileting assistance, initiated 1/28/19, to transfer her using a mechanical lift and assist of 2 staff members, initiated 1/28/19, and to use a 2-person approach to care, initiated 2/8/22. During an interview on 3/9/22 at 12:17 p.m., Resident H indicated she had rolled out of bed and had a fall. She went to the hospital and had a fracture. During an interview on 3/10/22 at 2:20 p.m., CRCA (Certified Resident Care Assistant) 1 indicated she used 2 staff members to assist with Resident H's bed mobility. She had always used 2 staff members, even prior to the fall, for safety. During an interview on 3/10/22 at 2:21 p.m., CRCA 2 indicated prior to the fall on 2/7/22, she had turned her in bed by herself. Since the fall she had been instructed to always use 2 staff members when turning her. During an interview on 3/11/22 at 12:46 p.m., CRCA 4 indicated she was present when Resident H fell on [DATE]. She was attempting to turn her to while providing incontinent care and she slid out of the bed. She normally turned and repositioned her in bed or during incontinent care by herself. She had not been told to use 2 staff members for bed mobility or incontinent care until after the fall. During an interview on 3/14/22 at 9:54 a.m., PTA (Physical Therapy Assistant) 5 indicated she had provided treatments for Resident H. She had needed maximum assistance of 2 staff members for turning in bed throughout most of her time residing at the community. Upon discharge from therapy 11/23/21, she had required maximum assistance of 2 staff members for turning side to side in bed and for providing brief changes. On 3/10/22 at 10:15 a.m., the Executive Director provided the Falls Management Program Guidelines Policy, reviewed 5/22/18, which read .to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures intensive efforts will be directed toward minimizing or preventing injury Care plan interventions should be implemented that address the resident's risk factors 2. The clinical record for Resident W was reviewed on 3/9/22 at 2:00 p.m. The diagnoses included, but were not limited to, [CONDITION(S)]. The fall care plan, last revised 3/11/22, indicated the goal was for her to remain free from falls with major injury. An approach was for hospice to evaluate anti-anxiety medication, with a start date of 2/15/22. The 2/14/22, 9:48 p.m. nursing note read, fell out of wheel chair at 9:20 p.m. 2/14/22 nurse notified. Minor knot on back of head. The 2/14/22, 10:43 p.m. nurse's note read, Unwitnessed fall in [NAME] hallway. Resident was sitting in WC [wheel chair] and fell to floor and hit head on side of WC on wheel. Noted a small hematoma on the left side. No bruising noted, skin is closed. No dizziness, h/a [head ache,] or nausea seen. Unable to determine pupil size, but both are sluggishly reactive and equal. ROM [range of motion] intact and normal for resident's baseline. VSS [vital signs stable.] .Resident kept awake for monitoring in a 1:1 with aide or nurse. Will continue to monitor and observe. The 2/15/22, 4:48 a.m. nurse's note read, Resident was given 1 dose of PRN [as needed] ordered [MEDICATION(S)] [anti-anxiety medication] for restlessness once placed in bed The 2/15/22, 9:45 a.m. nurse's note read, Witnessed fall observed & reported. Res [Resident fell out of w/c onto hallway floor by nurses station while trying to reach for something. Res laying on her left side, with BLE [bilateral lower extremity] flexed at the knees. [CONDITION(S)] [Hypertension] noted. Increased restlessness observed. No other injuries noted at this time. Res laid down in bed & is sleeping at this time . On 3/15/22 at 2:25 p.m., an interview was conducted with CRMA (Certified Resident Medication Aide) 20, who witnessed Resident W's fall on 2/15/22. She indicated Resident W was reaching for something and fell by the medication cart in front of the nurse's station. CRMA 20 was behind the desk at the time and was unaware Resident W was placed on 1:1 monitoring for a fall the previous night. The 2/15/22, 3:45 p.m. IDT (interdisciplinary team) note read, Review of fall on 2/15/22. Resident noted with witnessed fall onto hallway floor by nurses station while trying to reach for something. Resident noted with increased restlessness observed. No other injuries noted at this time per staff nurse assessment. Resident assisted to bed et [and] resting. Family/MD made aware. Hospice called & notified. New intervention noted for hospice to evaluate anti-anxiety medication. The 2/16/22, 12:20 p.m. nurse's note, written by the NM (Nurse Manager) read, Spoke with [name of Resident W's hospice company] regarding most recent falls and interventions. Hospice nurse to evaluate anti-anxiety medication upon next scheduled visit. An interview was conducted with the NM on 3/14/22 at 10:14 a.m. She indicated she remembered discussing having hospice evaluate Resident W's anti-anxiety medications and writing it in the 2/16/22 note, but didn't see any verification it was done. An interview was conducted with Hospice Nurse 14 on 3/11/22 at 12:21 p.m. She indicated she didn't remember if she was asked to evaluate Resident W's anti-anxiety medications after her 2/15/22 fall. Perhaps the on call hospice nurse, Hospice Nurse 16, would know, as she was the nurse who spoke with the facility after her 2/14/22 and 2/15/22 falls. After reviewing the notes, there was no information about an anti-anxiety medication review. Hospice Nurse 14 came to the facility later on 2/15/22 to visit Resident W. An interview was conducted with Hospice Nurse 16 on 3/11/22 at 5:25 p.m. She indicated she was the on call nurse when Resident W fell . When they called her, Resident W had already been monitored since the fall. Her vital signs were stable, and there were no signs or symptoms of injury. The facility informed her they would call, if they had any other concerns. She was not notified of any other concerns and was never informed of any intervention of reviewing her anti-anxiety medications. She was uncertain if Hospice Nurse 14 was made aware of the intervention, but I definitely wasn't made aware of it by the facility. The 2/15/22 Hospice Staff Collaboration Log indicated Hospice Nurse 14 visited on 2/15/22 as a follow up for 2 falls. The section entitled Was The Care Plan Changed? read, Will order Broda Chair. The 2/15/22 hospice note, written by Hospice Nurse 14, read, Late entry for PRN [as needed] visit today at 3:34 p.m Writer woke with staff nurse, [name of CRMA 20,] who confirmed that patient fell last night. [Name of CRMA 20] also reports that patient fell from her wheel chair this morning. Nurse stated that perhaps patient was attempting to pick something up off the floor and lost her balance Broda Chair requested by facility nurse. There was no information in the clinical record to indicate Resident 20 was provided with a Broda chair until 3/3/22. An interview was conducted with the NM on 3/14/22 at 11:12 a.m. She indicated she wrote the order for the Broda chair on 3/3/22, so that was when she got it. There was a care plan meeting on 2/25/22, where they discussed the Broda chair, positioning, and what would be most comfortable for her. Hospice was there via phone. She was unaware of the 2/15/22 hospice note about the Broda chair and did not recall discussing it prior to the 2/25/22 care plan. The 2/20/22, 5:28 p.m. nursing note read, Writer was alerted by CRCA [Certified Resident Care Assistant] that resident fell at the nurses station. Res [Resident] has laceration to left eye and a hematoma forming over left eyebrow. Res in pain, speech mumbled, pupils react slowly. Vitals 157/107 T [Temperature] 98.2 P [Pulse] 71 02 [Oxygen saturation] 95%. Laceration to left eye cleansed and dry dressing applied. Res given prn pain meds. Daughter notified. NP [Nurse Practitioner] notified. Res sent out to ER for further eval [evaluation.] 3. The clinical record for Resident Q was reviewed on 3/9/22 at 2:00 p.m. The diagnoses for Resident Q included, but were not limited to, dementia, difficulty in walking, unsteadiness on feet, lack of coordination and repeated falls. A care plan dated 1/23/19 indicated .Resident is at risk for falling. Requires assist of staff with transfers/mobility. Has dx [diagnosis] of dementia .Approach: remind resident of asking for assistance. antirollbacks to wheelchair. place non-skid strips in bathroom in front of toilet. add non skid strips to bathroom floor . A fall event dated 12/29/21 indicated Resident Q had unwitnessed fall in her room. The resident had transferred herself. A nursing progress note dated 12/31/21 indicated IDT [interdisciplinary team] Review: Resident was found on floor next to bed. Had attempted to transfer self from wheelchair to bed without proper footwear and slipped and fell . Resident interventions in place of que signs, non skid strips and bed in lowest position. Resident is supposed to keep her shoes on for transfers. Due to dx resident is non compliant with interventions and continues to do transfers and toileting by herself and non compliant with asking staff for assistance .No injuries noted from fall. IDT recommends to place anti-rollbacks on resident wheelchair. MD and family notified and care plan updated. A fall event dated 1/8/22 indicated Resident Q had an unwitnessed fall in her bathroom. The resident was transferring herself to toilet. An IDT Review dated 1/10/22 indicated .Resident was found on floor in bathroom. Resident stated that she was transferring back to wheelchair and forgot to lock her brakes .Resident reminded to ask for assistance from staff for safety. Resident recently initiated therapy for strength training. Will continue to remind resident of asking for assistance. An observation was made of Resident Q in her room with Nurse Support 10 on 3/10/22 at 3:10 p.m. There was no observation of anti-tippers on her wheelchair nor non-skid strips on her bathroom floor per the plan of care. An interview was conducted with the Nurse Manager on 3/11/22 at 2:30 p.m. She indicated the anti-tippers were missed and had not been placed on Resident Q's wheelchair. The facility no longer places non-skid strips on the flooring. The resident's care plan will need to be revised. This Federal Tag relates to complaint IN 313. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure residents' pain were adequately assessed, monitored and addressed for 1 of 1 residents reviewed for pain management, 1 of 1 residents reviewed for tube feeding and 1 of 4 residents reviewed for falls. This resulted in a resident transferred to hospital with a fracture in pain. (Resident H, O and P) Findings include: 1. The clinical record for Resident O was reviewed on 3/9/22 at 12:00 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident O was cognitively impaired. She was extensive assistance with 1 staff person for bed mobility, transfer and dressing. A care plan dated 12/27/20 indicated At risk for pain r/t [related to]: decreased mobility, need for staff assistance with bed mobility, transfers and toileting, dx [diagnosis] of Alzheimer's disease and dementia. Goal: Resident's pain will be at a tolerable level with interventions. Interventions: Administer medications as ordered and notify MD [Medical doctor] for any side effects observed or lack of effectiveness. Attempt non-pharmacological interventions. notify MD of increased pain. Observe for and record verbal and non-verbal signs of pain. Reposition as needed . An observation was made of Resident O on 3/10/22 at 9:32 a.m. Resident O was observed sitting in her wheelchair with a brace on her left arm. A fall event dated 1/29/22 at 3:30 p.m., indicated Resident O had an unwitnessed fall in her room. She was observed and assessed by LPN 10 at that time. The resident was observed not wearing appropriate footwear, range of motion to all extremities and was not in any pain. A nursing progress note written by License Practical Nurse (LPN) 10 dated 1/29/22, indicated Writer notified by the CRCA [Certified Resident Care Assistant]12 that resident (O) was on the floor. Writer entered [Resident O's room number] and noted resident lying on L [left] side the floor next to bed, (+) [had] ROM [range of motion] x [times] 4 extremities, no in/outward or length difference of BLE [bilateral lower extremities], no visual injuries, up with assist x 2 [staff members]. Resident A&O [alert and oriented] x 1, unable to tell what happened. Resident was laying in bed before incident . A bruise event written by LPN 10 dated 1/29/22 at 6:39 p.m., indicated Resident O's left hand and distal forearm was blue in color and her hand had swelling. The resident was experiencing pain at level of 3 using the following pain scale: 0-no pain, 1-mild pain, 2, 3, 4-moderate pain distressing/miserable, 5, 6, 7-severe pain-horrible/intense, 8, 9, 10-Excruciating pain - worst possible -interferes with ability to carry on with daily routines, socialization or sleep. The event indicated a progress note dated 1/29/22 at 6:45 p.m., after putting resident to bed the CRCA [12] noted L hand and distal forearm was bruise (blue) and nursing swollen. Writer noted bruises and applied ice, bruising from previous fall today-resident rolling out of low bed, will cont. to monitor . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The January 2022 Medication Administration Record (MAR) indicated Resident O's pain was assessed on the following days, shifts, pain location and pain level: 1/29/22 = 2:00 p.m. - 10:00 p.m., resident had no pain assessed by LPN 10, 1/29/22 = 10:00 p.m.- 6:00 a.m., location of the pain was left wrist and the pain level was 4 out of 10 assessed by LPN 13, and 1/30/22 = 6:00 a.m. - 2:00 p.m., location of pain was left wrist and hand and pain level was 5 out of 10 assessed by LPN 11. The MAR indicated 500 milligrams of scheduled Tylenol was administered on 1/29/22 between 6:00 a.m. - 10:00 a.m., by LPN 11, 1/29/22 between 6:00 p.m. -10:00 p.m. by LPN 10, and 1/30/22 between 6:00 a.m. - 10:00 a.m. by LPN 11. The MAR did not indicate any as needed pain medication was administered on 1/29/22 nor 1/30/22. The clinical record did not indicate Resident O's pain was addressed nor continued monitoring of the resident's pain was conducted by staff after the fall; that included non-pharmacological interventions, as needed pain medication administrations, or assessing effectiveness of the scheduled pain medications. A nursing progress note written by LPN 11 dated 1/30/22 indicated Resident L hand and distal forearm bruising, swelling, and severe pain indicated by Nursing extreme guarding of area; assessment revealed need for x-ray ordered by NP (Nurse Practitioner) on call. X-ray completed this day at 11am (sic) that confirmed an acute fracture of the distal radius of left extremity. Nurse notified on-call NP of findings and new orders given to send resident to ER (emergency room ) for further evaluation and treatment. Resident [family] notified. Resident being transported to [name of hospital] via ambulance. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A lab report dated 1/30/22 indicated an acute fracture to Resident O's left wrist was reported to the facility at 12:30 p.m. An interview was conducted with LPN 10 on 3/11/22 at 11:18 a.m. She indicated she was the nurse that had taken care of Resident O at that time of her fall. After the fall, she had assessed the resident with no injuries that she had observed. LPN 10 had then written the fall incident in the medical provider book due to the resident did not have an injury. She had not notified the medical provider via phone about the fall. Later on in the evening, the CRCA 12 had reported to her the resident's left hand was bruised, swollen, and she had complaints of pain. LPN 10 at that time applied ice to the resident's left hand, but did not notify the medical provider. She believed at that time, the resident did not have any major injury to her left wrist. The resident had landed on her left side, and she believed the hand was just bruised from the fall. LPN 10 had administered scheduled pain medication, but had not provided any additional pain medication that night. She had worked on the unit until 10:00 p.m. An interview was conducted with LPN 13 on 3/11/22 at 3:33 p.m. She indicated she had taken over Resident O's care after LPN 10 at 10:00 p.m. to 6:00 a.m. She had also been working that evening on a different hallway, and was aware Resident O had fallen that evening. After assessing the resident's hand when she had taken over her care, the resident's left hand was observed to be visibly swollen, bruised, and the resident had complaints of pain if the extremity was touched. The resident would draw up her arm and verbalize an ow if the left extremity was touched. The resident's verbal and physical reactions were apparent to LPN 13 the resident's arm was causing her pain. She believed she had administered Tylenol that night to Resident O. She had notified the medical provider about the resident's condition. It was not the end of her shift, but it was later on in her shift when she notified the medical provider. An interview was conducted with CRCA 12 on 3/11/22 at 3:20 p.m. She indicated she had worked on the evening of 1/29/22 and was providing care to Resident O until 10:00 p.m. She had notified LPN 10 Resident O had fallen on the floor in her room. Later on in the evening, she had reported to LPN 10 she had noticed the resident's left hand was blue, swollen and she was hollering out in pain. The resident does normally yell out when the staff turn her, but it was different that time. She was in real pain. She had taken care of Resident O all evening and kept checking on the resident in bed through out her shift due to concerns of the resident's hand. She had not observed any ice that had been applied to the resident's hand that evening. An interview was conducted with LPN 11 on 3/11/22 at 11:34 a.m. She had indicated she had taken over the care of Resident O on the morning of 1/30/22. She had observed the resident in the hallway prior to getting report and had already observed the resident's hand was bruised and swollen twice the size of her other hand. She had indicated to the night staff Resident O's hand does not look right. LPN 13 had reported she had called the doctor and received an order to get an x-ray. The lab would be coming out to obtain. The lab team was late getting to the facility and had come around lunch time to obtain the x-ray. The resident was unable to voice her pain utilizing a numeric pain scale due to her cognitive status. The resident would verbalize a no if the staff tried to touch her arm during care and/or she would guard her arm bringing in close to her body. The x-ray was challenging to obtain due to the resident did not like her hand to be touched due to pain. She could tell the resident was in pain, because she grimaced or verbalize Oh, Ow, and No if anyone touched her arm. LPN 11 indicated she had administered Tylenol to Resident O that day, but can not recall if it was scheduled or as needed. The Hospital Records was provided by the Nurse Manager on 3/10/22 at 3:14 p.m. It indicated Resident O was brought in to the emergency room and seen on 1/30/22 at 4:30 p.m.Chief complaint: Patient presents with arm injury. left arm fracture from fall out of bed yesterday evening .X-ray today showed radial fx [fracture]. Splinted by medics . The records indicated the resident had pain in arm and hip. A physician note dated 1/31/22 indicated .Chief Complaint/Nature of Presenting Problem: 1/31: Resident is being seen today for follow up rounds for recent hospital leave Resident [P] was found on the floor lying on her side. L hand and distal forearm bruising, swelling and severe pain. X ray ordered showing acute fx of the distal radius of the left extremity. Pt [patient] sent to ED [emergency department] for further evaluation .Plan: .left forearm/radius fracture: 1/31/22: Splint in place .Pain management. ortho follow up . 2. The clinical record for Resident P was reviewed on 3/9/22 at 11:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for Resident P dated 9/17/20 indicated Risk for pain r/t: terminal dx of breast cancer, decreased mobility, dx of malnutrition, GERD [gastroesopheal reflux disease], presence of pressure ulcers .Goal: Resident's pain will be at a tolerable level with interventions .Approach: Administer medications as ordered and notify MD for side effects observed or lack of effectiveness. Attempt non-pharmacological interventions. notify MD of increased pain. Observe for and record verbal and non-verbal signs of pain. Reposition as needed. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident P was moderately cognitively impaired. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . apply thin layer of [MEDICATION(S)] ointment and cover with split gauze twice a day . This order was discontinued on 3/9/22. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply [MEDICATION(S)] ointment. Cover with split sponge and secure. Change daily and as needed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A March 2022 [MEDICATION(S)] Narcotic count sheet indicated on 3/11/22 at 7:45 a.m., LPN 7 had administered 10 milligrams of [MEDICATION(S)] to Resident P. The resident received another dose of [MEDICATION(S)] on 3/11/22 at 7:50 p.m. A Narcotic [MEDICATION(S)] count sheet indicated Resident P had not received any dosages of [MEDICATION(S)] on 3/11/22. A nursing progress notes dated 3/3/22 indicated .PEG [gtube] site cleaned with NS [normal saline]. Noted to be unchanged from this nurse previous assessment. Brown purulent drainage noted. Very painful to palpation, though now to the superior of the PEG tube insertion site. [CONDITION(S)] and [CONDITION(S)] around insertion site. Also noted bloody drainage with cleaning of site. Resident reports it is painful. NP aware. Will continue to monitor, clean and observe. An observation was made of Resident P's gtube site with LPN 7 on 3/11/22 at 11:00 a.m. LPN 7 had indicated the resident's gtube site has been very aggravated. The resident was scheduled to have removal, because she had been eating. At that time, the resident's site was observed with a brown substance around the site. LPN 7 asked Resident P at that time if she was in any pain. She utilized a scale of 1 being the least amount of pain and 10 being the most amount of pain. Resident P responded her pain was an 8. LPN 7 then continued to provide care to the resident's gtube site. An interview was conducted with Resident P on 3/11/22 at 2:15 p.m. She indicated her pain level was still an 8 out of 10. She had not received any additional pain medication nor any care was provided for pain relief. The gtube site was tender by touching it. An interview was conducted with LPN 7 at 3/11/22 at 2:25 p.m. LPN 7 indicated she had given Resident P her scheduled [MEDICATION(S)] around 10:00 a.m., that morning. The resident had to wait 4 hours before she was able to give her anything else for pain. She had delivered the resident's lunch earlier, and she had not reported to her any other concerns about pain. The scheduled pain medication she had given her earlier that day had probably wore off, and she was able at that time to have something else. A nursing progress note written by LPN 7 dated 3/11/22 at 11:14 a.m., indicated Res [resident] seen for wound/irritation around g-tube site this a.m. Res c/o [complaints] pain around site on a scale of 8/10. Res was given scheduled pain meds this morning, pain meds were somewhat effective, Nurse made aware that site was starting to bother res again around 2:30 pm (sic) after report, nurse made QMA [qualified medication aide] assisting aware to continue with PRN [as needed] med orders. Res also c/o of sore irritate throat and was given PRN throat drops . An interview was conducted with CRCA 9 (Certified Resident Care Assistant) on 3/14/22 at 10:00 a.m. CRCA 9 indicated Resident P has had complaints of stomach pain for weeks. An interview was conducted with the Nurse Manager on 3/14/22 at 10:10 a.m. She indicated if staff recognized by facial expressions or verbal responses that the residents' are in pain, the nursing staff will then proceed to treat by utilizing his or her pain orders or call the doctor for pain medication orders. 3. The clinical record for Resident H was reviewed on 3/9/22 at 12:40 p.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed 10/25/21, indicated that she required extensive assistance of 2 staff members for bed mobility and total assistance of 2 staff members for toileting care. Her cognitive status was intact. She had frequent pain, which limited her daily activities. The pain was a 5 on a pain scale of 1 through 10 and she had received scheduled pain medications. She had also received as needed pain medications and non-pharmacological interventions to help with pain. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS Assessment, completed 1/25/22, indicated that she required extensive assistance of 2 staff members for bed mobility and total assistance of 2 staff members for toileting care. Her cognitive status was intact. She had frequent pain, which limited her daily activities. She described the pain as moderate and received scheduled pain medications. She had not received as needed pain medications or non-pharmacological intervention to help with pain. A care plan, last revised on 1/28/22, indicated she was at risk for pain related to arthritis and [CONDITION(S)]. She had a bone spur in her right ankle. The goal was for her to voice pain relief within 1 hour of any intervention that had been provided. The approaches, with start dates of 1/28/19, were to administer medications as ordered. To monitor and record effectiveness and report adverse side effects to the physician. Encourage support of family and significant others. To evaluate effectiveness of pain management interventions and adjust if ineffective or adverse side effects emerge. Monitor and record any complaints of pain, including location, frequency, effect on function, intensity, alleviating factors, and aggravating factors. To monitor for any non-verbal signs of pain such as crying, guarding, moaning, restlessness, grimacing, diaphoresis (sweating), withdrawal. To offer non-medicated pain relief measures such as biofeedback, application of heat or cold, massage, physical therapy, stretching and strengthening exercises, acupuncture, excreta, and monitor effectiveness. A fall event, dated 2/7/22, indicated that on 2/7/22 at 7:53 p.m., she was being turned in bed and had a witnessed fall. She experienced moderate pain (distressing or miserable) and a suspected fracture. She was transferred to an acute care hospital for evaluation. An Emergency Department Providers noted, dated 2/7/22 at 10:41 p.m., indicated she had been brought to the emergency department after a fall. She was complaining of right hip and knee pain. A chest x-ray, completed at the emergency department on 2/7/22 at 11:20 p.m., indicated there was at least 1 rib lower left rib fracture. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The February 2022 MAR (Medication Administration Record) indicated she received her scheduled dose of [MEDICATION(S)]- acetaminophen as ordered for the month of February and her PRN dose on the following days, with the effectiveness of the medication for pain relief as documented: 2/17/22 at 8:20 p.m. for pain with somewhat effective results, 2/18/22 at 1:49 p.m. for pain, which was not effective, 2/20/22 at 1:38 p.m. for pain, which was effective, and 2/24/22 at 1:54 p.m. for pain which was effective. The Controlled Drug Use Record for her [MEDICATION(S)]- acetaminophen 5-325 mg indicated that she had also received a PRN dose on the following days, which were not recorded on the February MAR and did not indicate the effectiveness of the medication: 2/21/22 at 3 p.m., 2/22/22 at 12:30 p.m., 2/23/22 at 3 p.m., and 2/26/22 at 3:30 p.m. The PRN dose of [MEDICATION(S)]- acetaminophen was discontinued on 2/26/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated 3/4/22 at 11:29 p.m., indicated the right knee x-ray results showed she had a fracture of the distal femur (lower end of thigh bone) and proximal tibia (upper end of shin bone). NP (Nurse Practitioner) 22 had been notified and had given an order to send her to the ED (Emergency Department). She had refused to go the ED and NP 22 was informed of her refusal. A pain event IDT (Interdisciplinary Team) note, dated 3/7/22 at 10:58 a.m., indicated she had 2 fractures noted on the right knee x-ray. She had refused treatment at any hospital and that treatment options were being discussed with her family. She continued to receive scheduled pain medication and had PRN pain medication available. On 3/10/22 at 3:24 p.m., the NM (Nurse Manager) provided the March MAR, which indicated she had received her scheduled [MEDICATION(S)]- acetaminophen, as ordered, and her PRN dose on the following days, with the effectiveness of the medication for pain relief as documented: 3/3/22 at 1:04 p.m. for pain, which was effective, 3/4/22 at 11:02 a.m. for pain, which was effective, 3/8/22 at 12:57 p.m. for pain, which was effective, and 3/9/22 at 2:00 p.m. for pain which was effective. The Controlled Drug Use Record for her [MEDICATION(S)]- acetaminophen 5-325 mg indicated that she had also received a PRN dose on the following days, which were not recorded on the March MAR and did not indicate the effectiveness of the medication: 3/3/22 at 1:30 p.m., 3/5/22 at 2:00 p.m., 3/6/22 at 2:00 p.m., and 3/7/22 at 3:00 p.m. On 3/9/22 at 12:14 p.m., Resident H was observed laying in her bed. She was grimacing and moaning. She indicated that she sometimes had to wait for pain medication. During an interview on 3/10/22 at 2:20 p.m., CRCA (Certified Resident Care Assistant) 1 indicated Resident H had started complaining about her right leg hurting after the fall she had in February. She complained about the pain each time she was turned in bed. She had let the nurses know about the increased pain when she turned her. During an interview on 3/11/22 at 9:11 a.m., NP 22 indicated that he had ordered the PRN [MEDICATION(S)]- acetaminophen on 2/17/22 due to Resident H complaining to him about rib pain. She was usually vocal about her pain and let him know if there was any new pain or issues. He had ordered the right knee x-ray due to her complaining of increased pain and he had noted some redness when he examined her right knee. He would expect to be notified if a resident's pain was disproportional to their normal status. During an interview on 3/11/22 at 2:31 p.m., LPN (Licensed Practical Nurse) 7 indicated that when she administered a PRN pain medications, she would usually wait around 30 to 40 minutes, and then check to see how effective it was, and then document the effectiveness on the MAR. She did not document the effectiveness of the routine pain medications she gave. If a CRCA informed her that a resident was in pain, she would do a pain assessment on the resident to determine where the pain was and the pain level. She would then administer a PRN pain medication, if the resident had one, or she would inform the physician about the pain. Resident H usually had a pain level of about 8 of 10 when she received PRN pain medications and her pain level would generally be decreased to around a 4 of 10. The 2 [MEDICATION(S)]- acetaminophen she received routinely were more effective for her pain than the PRN medication was. She verbally informed the physician or the nurse practitioner of how the pain medication were doing. On 3/10/22 at 10:15 a.m., the Executive Director provided the Guidelines for Pain Observation and Management Policy, revised 5/23/17, which read .Purpose To ensue each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual . 3. Initiate a Plan of care related to chronic, acute or breakthrough pain .4. If there is a change in pain indicators or verbalizations from resident, a pain event form will be completed to indicate changes and care plan updated. a. Observe the resident for a condition that would indicate that pain might be expected (injury, surgery, procedure) 5. Educate the resident /[sic] family/[sic]/ care givers on the pain management interventions and importance of notifying staff of changes in pain status. 6. Implement the care plan approaches to assist with pain management. 7. Evaluate the effectiveness of pain management interventions and modify as indicated . 3.1-37(a)

Based on observation, interview and record review the facility failed to promote the prevention of a pressure ulcer resulting in the development of an unstageable pressure ulcer, provide monitoring, and assure treatment for [REDACTED]. Findings include: The clinical record for Resident T was reviewed on 6/25/2019 at 2:23 p.m. The [DIAGNOSES REDACTED]. The clinical record contained an Annual Minimum Data Set Assessment, completed 3/14/2019, indicating Resident T was at risk for pressure ulcers. There were no pressure or arterial ulcers present during the assessment. A Significant Change Minimum Data Set Assessment was completed on 6/03/2019, which indicated Resident T had 2 unstageable pressure ulcers and 2 arterial ulcers present. On 6/24/2019 at 7:24 p.m., Resident T was observed sitting in a wheel chair, in the hallway next to the medication cart. She had dressings on both of her feet and was wearing pressure relief boots to her feet. The clinical record contained a care plan, dated 10/01/2015, indicating Resident T was a risk for pressure and stasis areas due to decreased mobility and incontinence. The goal of the care plan was for her skin to remain intact. The approaches for the care plan, with start dates of 10/01/2015, included a pressure reducing cushion to the wheel chair, provide incontinent care as needed, keep linens clean and dry, low air loss mattress to bed, and report any signs of skin breakdown to physician. The wound management documentation contained an assessment of Resident T's left heel pressure ulcer on 4/23/2019, indicating the size of the wound was 3.5 cm (centimeters) in length and 3 cm in width, with the appearance being dark purple in color and the area around the wound was red, soft and mushy to touch. The clinical record did not contain a care plan addressing the left heel pressure ulcer and no new interventions were added to the existing 10/01/2015 care plan to address the change in skin condition or prevention of further pressure ulcers. A care plan, with a start date of 4/26/2019, indicated Resident T refused to lay down for pressure relief throughout the day, with a goal of her preferences being honored to the extent that non- compliance with physicians orders will not result in injury to self or others. The approaches indicated to educate her regarding physician's orders [REDACTED]. The clinical record contained no assessment or documentation for the reason for Resident T's refusals to lay down, or alternates that were offered to Resident T for pressure relief. A Registered Dietician progress noted dated 4/26/2019 indicated Resident T was noted to have new pressure area to her left heel. She receives a mechanical soft diet with her choice of either Boost Breeze or Ensure. She had experienced gradual weight loss. A recommendation of prostat 30 ml (milliliters) 3 times daily to aid in protein intake and encourage wound healing. The MAR (Medication Administration Record) for (MONTH) 2019 was reviewed. It indicated Resident T had refused at least one dose of prostat on 5/2/2019, 5/3/2019, 5/4/2019, 5/8/2019, 5/9/2019, 5/10/2019, 5/12/2019, 5/13/2019, and 5/14/2019. A Registered Dietician progress note dated 05/17/2019 indicated the sized of her left heel wound appears to have increased. She was having a hard time with the prostat. A recommendation to decrease frequency of prostat to 2 times daily to encourage better intake. The MAR for (MONTH) and (MONTH) were reviewed. They indicated that she had refused at least one dose of prostat on 5//18/2019, 5/19/2019, 5/20/2019, 6/5/2019, 6/8/2019, 6/11/2019, 6/12/2019, 6/13/2019, 6/14/2019, 6/18/2019, 6/19/2019, 6/20/2019, 6/21/2019, 6/22/2019, 6/24/2019, 6/25/2019 and 6/26/2019. The clinical record did not contain any alternatives to prostat that were offered for increased protein intake or a care plan addressing prostat refusals or the need for increased protein intake to aid in wound healing and prevention. A physician's orders [REDACTED]. A nursing progress note dated 5/20/2019 at 10:00 a.m., indicated that resident had a low air loss mattress and heel float boots in place. A nursing progress note dated 5/21/2019 at 3:32 p.m., indicated Resident T presented with a new pressure wound to her coccyx. Education was provided to resident regarding importance of turning from side to side when in bed as she has a preference of sleeping on her back. A Roho (pressure relief) cushion continues in her wheel chair and resident had refused to have a low air loss mattress to her bed. A nursing progress note dated 5/22/2019 at 3:24 p.m., indicates Resident T and her daughter were educated on risks of refusal of treatments and medication. Resident T had cultural beliefs and values pertaining to end of life care and holistic approaches to medical interventions. She was agreeable to topical treatment for [REDACTED]. Resident T had declined a low air loss mattress for her bed, but was now agreeable to have her mattress changed. The clinical record contained a care plan dated 5/22/2019 indicating Resident T had a pressure area to her left ankle, coccyx and an arterial ulcer on the bottom of her left foot right ankle, left big toe and left heel. The goal of the care plan was that areas will remain free of complications and approaches included, but were not limited, to administer pain medication as ordered, assess and record the condition of the skin surrounding the pressure and stasis areas, observe and report signs of infection such as localized pain, redness, swelling, tenderness, drainage, odor and fever, obtain a dietary consult as needed. The clinical record did not contain a care plan addressing cultural preference or beliefs which may affect her medical care. The wound management documentation contained an assessment of Resident T's coccyx wound dated 5/21/2019 at 4:00 p.m., indicating the length of the wound was 3 cm, width was 2.5 c.m. and depth of .1 c.m. The wound had a light amount of drainage which was pale red to pink in color and thin and watery in consistency. The wound had no tunneling present. It had 20 % granulation (red) tissue, 40% slough (yellow dead) tissue, and 40 % eschar (black dead) tissue present in the wound bed. The skin surrounding the wound was red and blanchable (turned white when pressure applied and then returned to red). The next recorded assessment of the coccyx wound was on 5/29/2019 at 2:00 p.m. The length was 3.3 c.m, width was 2.5 c.m, and the depth was unmeasurable. The drainage amount was light with a pale red, pink color. There was 80% eschar tissue present in the wound bed and the skin surrounding the skin was dark purple to rusty in color. The coccyx wound was assessed in wound management on 6/5/2019 at 8:30 a.m. The length was 3.6 c.m, width 3 c.m, and the depth was unmeasurable. There was no tunneling present and the wound had a light amount of pale red to pink drainage. There was 80% eschar tissue present in the wound bed and the skin surrounding the wound was dark purple to rusty in color. The coccyx wound was assessed in wound management on 6/12/2019 at 2:00 p.m. The length was 5 c.m., width 3.2 c.m., and depth was 2.4 c.m. There was tunneling present at the top of the wound (12 o'clock) which measured 2.2 c.m. There was addition tunneling noted to be present at 2 o'clock and at 6 o'clock. The drainage presented with a mild odor and pale red to pink in color. The skin surrounding the wound noted to be dark purple. The next assessment recorded in the wound management record was 6/17/2019. The wound presented with a length of 4.1 c.m, width of 2.7 c.m., and depth of 1.5 c.m. The drainage was noted to be heavy and purulent (milky white indicating presence of puss) and odor was noted to be present. The tunneling at the top of the wound (12 o'clock) was noted to be 5.5 c.m. The area around the wound was noted to have [DIAGNOSES REDACTED]. The wound bed was noted to have 67% to 100 % slough and eschar tissue. The wound assessment dated [DATE] at 2:00 p.m., indicated the coccyx wound was 4.7 cm in length, 2.3 cm in width, and 3 cm in depth. Heavy drainage was present which was malodorous and purulent in appearance. Tunneling was noted to be 5.5 cm in depth and located at the top of the wound (12 o'clock). The wound bed had 30 % granulation tissue, 50% slough tissue, and 20 % eschar tissue. The area around the wound presented with [DIAGNOSES REDACTED]. There was no documentation in the nursing notes of daily assessment of the skin surrounding the pressure ulcer, the condition of the wound bed, amount of drainage present, type of drainage present, or signs and symptoms of infection. There were no new care plan interventions addressing changes to the wound. During an interview on 6/27/2019 at 10:57 a.m., LPN (Licensed Practical Nurse) 5 indicated if changes in appearance of the wound occur or if the wound appears to be worsening it is the nurse's judgement on informing the physician or documenting the changes. Daily documentation on wound appearance was not required. The clinical record contained a progress note from a from a consult with a wound healing center, dated 6/24/2019, indicating a culture of the wound had been obtained and a bone biopsy had been performed . Resident T had been referred to an infectious disease physician. During an interview on 6/27/2019 at 3:03 p.m., Wound Center Nurse 27 indicated the wound culture and bone biopsy had been done due to signs of infection of the coccyx wound and that osteomylitis ( a bone infection) was present at the coccyx wound. The clinical record contained a physician's orders [REDACTED]. The physician's orders [REDACTED]. Apply Dakin's solution (a disinfective) to gauze. Wring out excess. Apply Dakin's moistened gauze to wound bed. Place ABD pad over primary dressing. Secure with tape. Change BID (twice daily) and PRN (as needed). On 6/27/2019 at 10:18 a.m., LPN 4 and LPN 5 were observed providing wound care to the coccyx. Resident T was lying in bed on her left side. LPN 4 and LPN 5 performed hand hygiene prior to beginning the dressing change. LPN 4 assisted Resident T to lay on her left side. LPN 5 removed a foam dressing from the coccyx wound. She then performed hand hygiene and applied a clean pair of disposable gloves. She cleansed the coccyx wound as ordered. The area around the wound had a dark purple appearance. LPN 4 applied the moistened gauze to the wound bed. Resident T made a soft moaning sound and displayed a grimace on her face. She talked softly with LPN 5. LPN 4 continued the dressing change, covering the wound with an ABD pad and securing the dressing with tape. During an interview on 6/27/2019 at 10:25 a.m., LPN 4 indicated Resident T has expressed that her wound was sore. Resident T had been given pain medication prior to the dressing change, but only took half the dose due to her not liking the new liquid pain medication that was ordered. She had also received scheduled Tylenol. During an interview on 6/27/2019 at 10:35 a.m., LPN 5 indicated a foam dressing was removed from the wound. The current order was for the wound to be covered with an ABD pad and secured with tape. She was unsure why a foam dressing had been used. During an interview on 6/28/19 at 12:16 p.m., the Nurse Consultant indicated a foam dressing was not what was ordered for the coccyx wound dressing. During an interview on 6/27/2019 at 12:45 p.m., the Executive Director and the Nurse Consultant indicated the facility was unable to provide a policy for pressure ulcer care or dressing changes. The Prevention and treatment of [REDACTED]. Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014, was retrieved from the National Pressure Ulcer Advisory Panel Website on 7/2/2019. The guidance includes guidelines for assessment of pressure ulcers and monitoring of healing. Guidance indicates assessment of the individual, his or her ability to heal, the risk for development of additional pressure ulcers, and the ulcer itself are important. An assessment of the individual should include any co-morbid health problems, including combination(s) of problems; medications; nutritional status; risk factors, including immobility and incontinence; diagnostic test results; psychosocial implications; and wishes, goals and concerns of the individual and significant others. Guidance further indicates that with each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications). Wound status can change rapidly. Wound improvement or deterioration indicated by change in wound dimensions, change in tissue quality, an increase or decrease in wound exudate, signs of infection or other complications all provide indications of the effectiveness of the current management plan. Address signs of deterioration immediately. This recommendation is based on expert opinion. Signs of deterioration include increase in wound dimensions, change in tissue quality, and increase in wound exudate or other signs of clinical infection. Assess and document physical characteristics including: location, category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Use the findings of a pressure ulcer assessment to plan and document interventions that will best promote healing. This Federal Tag relates to complaint IN 738. 3.1-40

Based on observation, interview, and record review, the facility failed to implement, modify, and communicate fall interventions to address a resident's planting of her feet while being assisted in her wheel chair, resulting in an emergency room visit requiring sutures, for 1 of 1 residents reviewed for accidents. (Resident C) Findings include: The clinical record for Resident C was reviewed on 6/25/19 at 12:36 p.m. The [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. An interview was conducted with LPN (Licensed Practical Nurse) 13 on 6/28/19 at 10:04 a.m. She indicated when she assisted Resident C down the hall in her wheel chair, she would ask her to put her feet up, but she would put them down while she was pushing her. LPN 13 indicated she would stop, ask Resident C to lift them up, and Resident C would oblige. LPN 13 indicated Resident C did not use foot pedals on her wheel chair, because they considered it to restrict her movement, since she can ambulate herself. LPN 13 indicated Resident C would make sudden jerking movements, and if you weren't paying attention, or quick enough, she could fall forward. An interview was conducted with CNA (Certified Nursing Assistant) 10 and CNA 11 on 6/28/19 at 10:26 a.m. CNA 10 indicated Resident C would plant her feet while assisting her down the hallway in her wheel chair, and had been doing so since at least January, 2019. CNA 10 stated, Oh honey, so dangerous. She puts them down all the time. CNA 11 indicated Resident C would put her feet down a lot, and had been doing so as long as she'd worked there for the past year. An interview was conducted with CNA 12 on 6/28/19 at 10:49 a.m. She indicated, when assisting Resident C down the hallway in her wheel chair, she would put her feet down a lot, and had been doing so for at least a few months. The 10/8/18 at risk for falls care plan for Resident C indicated the goal was for her to remain free from falls with major injury. There were no approaches to monitor Resident C for unexpected/unsafe movements during wheel chair transports until 6/12/19. The 6/12/19 IDT (Interdisciplinary Team) note read, Resident was participating in an activity group, once the activity was completed the activity assistant was pushing her w/c (wheel chair) to assist her back to the common area close to the nurses station. The activity assistant states that the resident abruptly planted her feet to the floor then resident fell forward and fell to the ground hitting her head, blood loss noted, charge nurse immediately assessed resident. Resident laying on her right side and blood loss noted to her right eyebrow and right upper lip. N.O. (New order) to send resident out via 911 to the ER (emergency room ) for eval (evaluation) and tx (treatment.) POA (Power of Attorney) notified of event and resident being transferred to (name of hospital) ER. Updated Intervention once resident returns from ER - Staff educated to monitor resident closely for unexpected/unsafe movements during w/c transports. The 6/12/19 hospital ER notes read, Diagnoses: [REDACTED]. Injury of head, initial encounter. Contusion of right shoulder, initial encounter HPI (History of Present Illness) .presents to the Emergency Department, was (sic) fell while walking with the staff at ECF (extended care facility.) She has a prior history of a stroke, nonverbal, has dementia as well. She has rightsided facial injuries, bruising to her right eye, and the lack on top of her right eyebrow and upper lip. There is no active bleeding at all. There was no report of being loss of consciousness. The patient does have contractures of the upper extremities bilaterally. She is moving her lower extremities. She has a history of spastic movement post stroke. She will respond and answer some questions by what sounds like yes. The patient points to her right shoulder with her left upper extremity Procedure Note: Laceration repair. Indication: Laceration. The 2 cm and 1 cm right upper lip and right eyebrow lacerations were prepped and draped in the usual sterile fashion. The wound was anesthetized with 1 percent [MEDICATION NAME] with good wound anesthesia. The wound was then copious (sic) irrigated with NS (normal saline) irrigation. Inspection demonstrated no tendon, vessel, or bony abnormality, and no foreign bodies were identified. The wound edges were then closely approximated with 5-0 [MEDICATION NAME] simple interrupted sutures with good wound approximation and hemostasis. The pt (patient) underwent the procedure with no complications. Sterile dressing was applied. An observation of Resident C was made on 6/28/19 at 10:00 a.m. She had sutures above her right eye, near her eye brow. An interview was conducted with the DNS on 6/28/19 at 10:35 a.m. The DNS was informed of LPN 13's, CNA 10's, CNA 11's, and CNA 12's statements about the frequency of Resident C putting her feet down during transport. He indicated, to his knowledge, Resident C did not put her feet down during transport a lot, and her doing it on 6/12/19, when she fell , was an isolated incident. An interview was conducted with the TD (Therapy Director) on 6/28/19 at 10:17 a.m. The TD indicated, if Resident C regularly put her feet down, foot pedals could be used, but no one had ever reported to her she put her feet down on a regular basis. She stated, If she's doing it all the time, I would still say not putting foot pedals on while self propelling, but on while pushing. An interview was conducted with AA (Activity Assistant) 9 on 6/28/19 at 11:40 a.m. She stated, I've worked here a couple months and she's always put her feet down while assisting her in her wheel chair. AA 9 indicated she was assisting Resident C down the hallway on 6/12/19, asked her to put her feet up, but halfway down the hall, Resident C planted her feet and fell forward. AA 9 indicated there was nothing she could do to stop it, and no one at the facility ever discussed the use of foot pedals with her, when assisting Resident C in her wheel chair, prior to or after Resident C's 6/12/19 fall. An interview was conducted with CNA 12 on 6/28/19 at 10:49 a.m. She indicated she personally, would use foot pedals with Resident C, if she planted her feet while assisting her in her wheel chair, but no one at the facility had ever discussed the use of foot pedals with her. An interview was conducted with CNA (Certified Nursing Assistant) 10 and CNA 11 on 6/28/19 at 10:26 a.m. CNA 11 indicated the facility did not start using foot pedals until after Resident C fell on [DATE], and since then, Resident C had not refused the use of foot pedals when she assisted her. The Falls Management policy was provided by the DNS on 6/28/19 at 11:50 a.m. It read, (Name of facility) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure appropriate foot care was provided for a diabetic resident, resulting in an amputation of a toe and to ensure a resident who used oxygen had an order to do so, per facility policy, for 1 of 1 resident reviewed for foot care and 1 of 1 resident reviewed for respiratory care. (Resident #98 and #L) Findings include: 1. The clinical record for Resident #L was reviewed on [DATE] at 11:30 a.m. The [DIAGNOSES REDACTED]. Resident #L's BIMS (Brief Interview for Mental Status) score was 15 out of 15 which indicated the resident scored the highest possible for cognitive function. Resident #L's admitted was [DATE], and he was discharged on the evening of [DATE]. The Minimum Data Set (MDS) assessment dated , [DATE], indicated Resident #L needed physical help in part of bathing activity times 1 staff member and extensive assist times 1 staff member for dressing. A physician order [REDACTED].#L was to be weighed daily. The physician orders [REDACTED].#L. An interview was conducted with the Clinical Support #14 on [DATE] at 12:11 p.m. She indicated there were no weekly skin assessments completed for Resident #L, and all residents in the facility should have a weekly head to toe skin assessment. The Clinical Support #14 indicated if a resident has had a fall in the facility a skin assessment is also completed. A progress note dated, [DATE], indicated Resident #L was found on the floor in his room with an abrasion to his right wrist. A progress note dated, [DATE], indicated Resident #L was found on the floor. There was no injuries noted. A progress note dated, [DATE], indicated Resident #L was found on the floor next to the bed. There was no injuries noted. A progress note dated, [DATE], indicated Resident #L was found sitting on the floor. There was no injuries noted. Resident #L's shower sheets were provided by the Clinical Support #14 on [DATE] at 1:00 p.m. It indicated Resident #L received partial bed baths from [DATE] thru [DATE] except for the following days Resident #L was bathed from head to toe: [DATE] - Shower [DATE] - Shower [DATE] - Shower [DATE] - Shower [DATE] - Complete Bed Bath An interview was conducted with the Clinical Support #14 on [DATE] at 1:15 p.m. She indicated partial bed baths included: bathing of the face, underarms and privates. She indicated bathing is individualized by the resident's preference. The Clinical Support #14 indicated the facility does not have a system in placed to acquire preferences for bathing. The Clinical Support #14 indicated she also could not locate the weekly scheduled shower days for Resident #L. An interview was conducted with Resident #L's family member on [DATE] at 3:17 p.m. He indicated Resident #L was discharged from the facility on the evening of [DATE]. Resident #L's family member indicated during discharge, he had assisted Resident #L with putting his shoes on and noticed a bad odor coming from Resident #L's foot that was covered with his sock. Resident #L's family member brought the odor to the attention of the staff and was ensured Resident #L was showered that day. The following morning, his mother removed the sock from Resident #L's foot and noticed his toenail was no longer attached to his toe. The toenail was found attached to the inside of the sock, and Resident #L's toe appeared to be black in color. Resident #L indicated to his wife at that time his toe had been bumped on the scales when he had been weighed a few weeks ago. The Certified Resident Care Assistant (CRCA) indicated at the time of the incident she would have notified the nurse and have his toe looked at. Resident #L's family member indicated nursing staff did not come to look at Resident #L's foot after the incident. Resident #L's family member indicated Resident #L had a hard time feeling his feet due to having diabetes. At the time of the incident Resident #L had indicated his toe had stung, but after the occurrence he did not experience any pain. Resident #L's family member indicated staffing changed frequently at the facility, and Resident #L could not determine who was the CRCA at the time of incident. Resident #L's family member indicated an appointment was made for Resident #L to be seen by a physician to look at his toe. Resident #L was seen on [DATE], and it was determined at that time the toe would need to be amputated. Resident #L's family member indicated Resident #L did not want to lose his entire toe, so a portion of the toe was removed on [DATE]. Resident #L's toe could not be saved, and the remaining portion of the toe was amputated in January. An interview was conducted with Resident #L on [DATE] at 4:30 p.m. He indicated the staff at the facility had to weigh him every day. The CRCA wheeled him to the scales and did not shift the wheels on the wheelchair correctly and bumped his toe on the scales. The CRCA indicated she would notify the nurse, and the nurse would look at his toe. Resident #L indicated the nurse never came in to look at his toe. Resident #L indicated he went to the doctor after his toenail was found in his sock. The doctor indicated he had to have his toe amputated. Resident #L could not remember what day the incident occurred in the facility, or what staff member it was that was present at the time of the incident. He indicated he was a diabetic and his feet are numb. Resident #L indicated he does not usually feel pain on his feet. Resident #L indicated staff in the facility did not look at his injured toe nor was given any medication to treat his toe. The physician documentation was provided on [DATE] at 3:30 p.m. The podiatrist progress notes dated, [DATE], indicated Integument lower extremities: Right distal (away from point of attachment) 2nd digit (toe) full thickness ulceration (1.5cm (centimeters) x 1.5 cm x 0.6 cm deep) which exposed bone of distal phalanx (toe bone) with overlying necrotic (dead) tissue and mild [DIAGNOSES REDACTED] (redness). Sausage toe appearance. Assessment/Plan: Amputation right hallux and partial hallux amputation left hallux. Discussed the exposed bone 2nd digit right foot and the high likelihood of osteo[DIAGNOSES REDACTED] due to visible necrosis of bone and the implications it has on healing and limb loss. I stressed the need to treat the problem aggressively. Recommended excision (removal) of the infected bone with culture and biopsy of the area . The Surgery Center progress notes dated, [DATE], indicated Preprocedure Diagnosis: [REDACTED].Procedure performed: partial amputation, second digit, right foot Indications: This patient presented to my office yesterday with a distal second digit ulceration with exposed bone of distal phalanx. On x-ray there was no changed noted, however, the bone visualized was necrotic. I explained to the patient that he has osteo[DIAGNOSES REDACTED] and needs a partial second digit amputation . The physician progress notes [REDACTED].#L presents for first post-op exam .Objective: Examination of the surgery site reveals: Incision well coated with no gapping or drainage but with black ischemic (insufficient of blood supply) appearing edges. There is mild surrounding [DIAGNOSES REDACTED]. There is mild, localized [MEDICAL CONDITION]. There is mild ecchymosis (bruising). Neurovascular status intact to all toes. Good position of the surgical site. The physician progress notes [REDACTED].#L presents 2 week post-op exam .Objective: Examination of the surgery site reveals: Incision appears necrotic with malodor and fluctuance. I debrided skin and soft tissues down to necrotic appearing bone of proximal (near point of attachment) phalanx 2nd digit right foot. There is mild surrounding [DIAGNOSES REDACTED]. There is mild, localized [MEDICAL CONDITION]. There is mild ecchymosis. Neurovascular status intact to all toes. Good position of the surgical site. Discussed the exposed bone through 2nd digit incision right foot and the high likelihood of osteomelitis due to visible necrosis of bone and the implications it has on healing and the limb loss. I stressed the need to treat the problem aggressively. Recommended excision (removal) of the remaining 2nd digit. The Surgery Center dated, [DATE], indicated Preprocedure Diagnosis: [REDACTED]. Postprocedure Diagnosis: [REDACTED]. Procedure performed: 2nd digit amputation, right foot .Indications: This patient is who had a partial 2nd digit amputation approximately three weeks ago. The incision went on to necrose and dehisce and on his last visit the toe appeared necrotic. It was decided at that time to remove the rest of the digit. The Clinical Support #14 was interviewed on [DATE] at 1:00 p.m. She could not locate any documentation the incident regarding Resident #L's toe had occurred. A policy titled, Weekly skin assessment guideline was provided by the Clinical Support #14 on [DATE] at 3:48 p.m. It indicated To monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures as indicated. 1. A full body assessment shall be completed weekly by the licensed nurse. 2. Upon admission the admitting nurse shall include as part of the admission orders [REDACTED]. 0 = no areas of skin impairment 1= new area of skin impairment 2= existing area of impairment (see wound sheet). 3. The date the assessment should be completed shall be assigned by the DHS or designee and indicated by the corresponding date on the treatment administration record (TAR). 4. The nurse completing the weekly skin check shall indicate the appropriate number (0,1,2) medication note. 5. Initiate applicable Wound Event if a new area of impairment is identified. (Pressure/Statis/Arterial/Diabetic or Other). This may not include incidental bruises, hemosiderin staining, petechiae, and senile purpura. 6. In addition to the Weekly Assessment by the license nurse, the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified. 2. The clinical record for Resident #98 was reviewed on [DATE] at 9:28 a.m. The [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. The [DATE] Discharge Continuity of Care forms from Resident #98's previous facility indicated she used 5 liters of oxygen per nasal cannula. The Vitals Report for Resident #98 indicated oxygen was in use on the following dates: [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] The [DATE], 1:06 p.m., nurses note indicated, Resident began experiencing difficulty breathing at approx (approximately) 1130pm. Oxygen concentrator checked and was noted to have low air flow. Oxygen concentrator switched, resident continued to c/o (complain of) not getting any air. Nasal cannula checked and was functioning. Oxygen turned up to 5 liters per resident request. O2 (oxygen) sat (saturations) at this time 67%. [MEDICATION NAME] neb (nebulizer) treatment given and on call NP (nurse practitioner) called. After neb treatment complete, O2 sat ,[DATE]%. Per NP, (name of nurse practitioner), resident to be sent to ER (emergency room ). Writer told resident that she was going to ER, resident stated she would be fine and did not want to go out. O2 sat remained in low 70s with oxygen at 6 liters on portable oxygen tank via face mask. Resident agreed to be transported to ER at approx. 12am. (Name of ambulance company) called to transport. Writer in room waiting with resident. Mottling noted to bilateral upper and lower extremities. Oxygen remains in place at 6 liters via face mask. Writer exited room to open door for EMTs (emergency medical technicians) and returned, resident noted to be unresponsive, with no pulse and no respirations. Remained unresponsive after sternal rub preformed. CPR (cardio [MEDICAL CONDITION] resuscitation) started. ON call paged due to resident being own responsible party, order given to stop CPR. Time of death called at 1224am. Emergency contacts called. There was no information in the clinical record to indicate Resident #98 had an order for [REDACTED]. An interview was conducted with LPN #18 on [DATE] at 11:07 a.m. She indicated it didn't look like Resident #98 had an order for [REDACTED].>An interview was conducted with Clinical Support #14 on [DATE] at 12:38 p.m. She indicated Resident #98 did not have orders for oxygen, but acknowledged Resident #98's use of oxygen while in the facility. Clinical Support #14 indicated, typically, there would be an order to keep saturations above 90%, perhaps a titration order, but an order of some sort. She indicated the facility could do a 24 hour order for oxygen in the case of emergencies, but afterwards, would need an order. Clinical Support #14 indicated her transfer paperwork from her previous facility indicated Resident #98 was on 5 liters of oxygen per nasal cannula, but the information was never transferred to their orders, nor was it clarified. Clinical Support #14 indicated if Resident #98's saturations were low, staff probably bumped it up until it was above 90. The Guidelines for Administration of Oxygen policy was provided by the Clinical Support #14 on [DATE] at 2:50 p.m. It indicated the purpose of the policy was, To provide guidelines for safe oxygen administration when insufficient oxygen is being carried by the blood to the tissues. The policy indicated, Verify physician's orders [REDACTED]. This Federal tag relates to complaint IN 746. 3XXX,[DATE] (a)(6) 3XXX,[DATE](a)(7)

Based on record review and interview, the facility failed to ensure necessary services, including assessments, observations, and safety interventions, were implemented for a resident (Resident #B) with a venous access fistula (an implanted device to allow access for [MEDICAL TREATMENT]) who was identified as at risk for bleeding from the fistula and who suffered a fatal loss of blood from the fistula site. One of two residents reviewed for venous access fistula care and one of four residents reviewed for assessment of risk. The Immediate Jeopardy began on [DATE] at 9:30 P.M., when Resident #B returned from [MEDICAL TREATMENT], and L.P.N. #1 identified bleeding from the resident's [MEDICAL TREATMENT] venous access fistula in her left arm, cleaned the area, and applied a reinforcement to the dressing. The Executive Director, Director of Health Care Services,and Assistant Director of Health Care Services were notified of the Immediate Jeopardy at 4:30 P.M., on [DATE]. Findings include: On [DATE] at 2:03 P.M., the facility reported through the Indiana State Department of Health Survey Reporting System an initial report regarding an incident involving Resident #B. The report indicated that on [DATE] at 4:50 A.M., Resident #B was .found by Aide in supine position on floor next to bed at (room number for Resident B). Nurse notified. CPR started immediately. Emergency services (911) called immediately .EMT's arrived on scene 0459 (4:59 A.M.) . A follow up to the above report filed with the State Agency on [DATE] at 9:28 A.M., added At the time of the incident, the CNA (CRCA #1; Certified Resident Care Assistant) was walking down the hallway and looked in the resident's (Resident B) room as she was passing by. Noted resident to be laying on the floor. Called for nurse. Resident was laying on her left side. Approximately a 2 inch laceration to left eyebrow noted and bleeding. Left arm shunt (fistula) area for [MEDICAL TREATMENT] also noted to be bleeding. No respirations or pulse noted. Code status checked and resident was a Full Code. CPR initiated 911 was called and Paramedics arrived and at this time they took over performing CPR. Unable to resuscitate resident. Per the nurse assessment and paramedics report, the blood appeared to be from the renal shunt in her left arm, that had been 'displaced'. Per interview with the Medical Director and [MEDICAL TREATMENT] MD, both stated that if the resident manipulate the renal shunt and removed the 'scab' portion over the opening, there would be significant bleeding. The record of Resident #B was reviewed on [DATE] at 10:30 A.M., and indicated Resident #B was admitted most recently on [DATE]. Diagnoses, obtained from the current electronic medical records [DIAGNOSES REDACTED]. An admission Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident #B was cognitively impaired, with a Basic Interview for Mental Status score of 7 of a possible 15. The remainder of the M.D.S. was incomplete. The staff member responsible for completing Resident #B's M.D.S. was interviewed on [DATE] at 12:05 P.M., with the Executive Director (E.D.) and Director of Health Services (D.H.S.) present. She indicated she was aware Resident #B's M.D.S. was incomplete, and past due. She indicated the M.D.S should have been completed by 14 days after admission, which would correspond to [DATE]. She stated the reason it was not done was I'm behind. The admission M.D.S. was completed on the afternoon of [DATE]. It indicated Resident #B had mood concerns of feeling down or depressed, sleep troubles, and little energy; had no behavior issues; required staff assistance of 1 person for bed mobility and transfers; was able to walk in her room with the assist of 1 person; and required staff assistance for toileting and personal hygiene. She was continent of bowel and bladder. Care plans for documented for Resident #B were limited to one for code status initiated [DATE] indicated Resident #B was a Full Code status, and one initiated [DATE] indicating a potential for weight fluctuation and alterations in labs due to receiving [MEDICAL TREATMENT] treatments. There were no care plans related to diagnoses, treatments, assistance with activities of daily living, appropriate care and assessment of the resident's [MEDICAL TREATMENT] fistula, communication with the [MEDICAL TREATMENT] center, or any other issues. The resident's family member and Power of Attorney was interviewed by phone on [DATE] at 11:00 A.M. She indicated that on the evening of [DATE] she brought the resident back to the facility from [MEDICAL TREATMENT], and brought dinner as was her custom. She noted seeing a small amount of blood on the resident's sweater, and observing while the nurse cleaned and reinforced the dressing. She did not note any problems after the dressing was reinforced. She indicated she had been called to the facility on the early morning of [DATE]. When she arrived at the facility at 6:15 A.M., she indicated she was told the resident had bled to death in her room and that due to the amount of blood in the room the police advised her that it would not be good for her to see it. She indicated she was not allowed to see the resident until after the room and the resident's body had been cleaned. She indicated she had regularly transported the resident to [MEDICAL TREATMENT], and the facility had never sent any paperwork with her to give to the [MEDICAL TREATMENT] center. She also indicated the facility had never asked for any report of the resident's status or condition at [MEDICAL TREATMENT], and the [MEDICAL TREATMENT] facility had never provided any documentation for her to present to the facility. An Investigation Interviews form completed by the Assistant Director of Health Services (A.D.H.S.) indicated: Resident Name: (Resident B) Date of Occurrence: [DATE] Description of Occurrence: Resident found unresponsive on floor. 'This writer notified at 0522 (5:22 A.M.) .that resident was found on the floor .This writer was notified that police were notified by EMS (Emergency Medical Services) because of the amount of blood in resident's room .This writer entered room .Resident was lying on her back covered by a blanket. Blood stretched from head of resident's bed to the opposite wall .this writer walked to (symbol for left) side of bed and found kerlix dressing covered in blood .Large pile of vomit noted in pile of blood next to wall along (symbol for right) side of bed. Multiple pools of blood noted on bed and sheets .large cut noted above resident's (symbol for left) eyebrow. Also noted was a bloody hand print on wall . A written statement by the Director of Health Services (D.H.S.) dated [DATE] indicated: I cleaned up/post mortem care given to resident, a large amount of blood was noted all around the resident, while cleaning her up there were numerous blood clots from the shoulder to the wrist were noted .she had a cut on her left eyebrow, approximately 1 inch .(we) transferred to the bed, we washed her hair, a moderate amount of bright red blood was noted on the bottom sheet under her head. I steri stripped (a bandage dressing) her left eye and it stopped bleeding. The family then viewed her. A progress note recorded by L.P.N. #2 with a date and time of [DATE] at 9:40 P.M., entered as a Late Entry on [DATE] at 4:51 P.M., indicated Resident (Resident# B) arrived back to facility in w/c (wheelchair) with (family member) at this time. Resident has no c/o fatigue. When (family member) took residents jacket off blood was noted to left sweater sleeve. Sweater removed and drsg (dressing) to fistula site was bloody. Area cleansed and wrapped with kerlix and secured with tape. Resident had no further bleeding noted at this time. (Family member) stated that resident was anxious to leave [MEDICAL TREATMENT] this evening. No paperwork from [MEDICAL TREATMENT] returned. (Family member) brought resident dinner to facility. Aided resident into bed. No c/o (complaint of) pain or discomfort. Skin is warm, dry, and pink. No SOB (shortness of breath) noted. Resident's (family member) left the facility aroun (sic) 10:,[DATE] (P.M.) A written statement from L.P.N. #2 dated [DATE] included, but was not limited to, .(symbol for at) 11 P.M. report given to night shift nurse (nurse #3) the drsg applied to fistula site and no further bleeding had been noted (symbol for after) drsg applied . L.P.N. #2 was interviewed in person on [DATE] at 1:45 P.M. She indicated she provided care for Resident #B when she returned from [MEDICAL TREATMENT] on [DATE] at approximately 9:00 P.M. During care she noted blood on the resident's fistula dressing, which she noted as about the size of a fifty cent piece. She indicated she had taken care of [MEDICAL TREATMENT] patients before, and did not consider this to be an unusual occurrence. She indicated she cleaned the area and reinforced the dressing, and saw no more bleeding. She assisted the resident to prepare for and get into bed. She indicated the resident was pleasant and happy and gave her a hug before she left. She indicated she did tell the oncoming nurse about the bleeding and dressing reinforcement at shift change, but did not write it down anywhere. Progress notes entered by L.P.N. #3 included: [DATE] 4:40 A.M., Nursing called to resident's room by CRCA. Resident found lying on right side and facing the doorway. Blood and emesis of partially digested food noted on floor to left of bed. Blood also noted on sheets. [DATE] 4:55 A.M., Resident's code status confirmed as full code. NRSG (nursing) directed CRCA to call 911 and additional CRCA to get crash cart and notify another nurse for assist. CPR initiated. Resident positioned on back and sternal rub given with no response. Chest compressions started. Additional nurse on scene and assisting. CRCA at building entrance to assist medics to resident room. AED (automatic electronic defibrillator) applied and it instructed to continue with chest compressions. Ambu bag (a hand held device used to provide ventilation for a person who is not breathing) utilized by assisting nurse. [DATE] 4:59 A.M., Medics have arrived at facility and to resident's room. Chest compressions in progress. Medics taking over CPR at this time. [DATE] 5:37 A.M., Medics have ceased cardiac code process at this time following a 30 minute attempt to revive resident. A written statement from L.P.N. #3 indicated to be for events of [DATE] included, but was not limited to, On [DATE] I took report from (L.P.N. #2) evening shift nurse. This statement is concerning (Resident #B). I was told in report that (Resident #B) had come back from [MEDICAL TREATMENT] around 9 P.M. and to pass on that she wanted her legs shaved. That is the only information I received about this patient in report .(Resident #B's family member) returned my call at 5:25 A.M. I told her of the events taking place. (She) told me at that time that (Resident #B's) fistula was bleeding when she brought her back from [MEDICAL TREATMENT]. (She) stated that the evening shift nurse (L.P.N. #2) had put a dressing on the fistula site. I was not told any of this information in report . L.P.N. #3 was interviewed in person on [DATE] at 11:30 A.M. She indicated that information noted above in her progress notes and her written statement were accurate. She indicated that when she was called into Resident #B's room, Resident #B's upper body was completely covered in blood. She indicated that she saw no active bleeding. She also indicated she saw no significant bleeding from the cut over the resident's eyebrow. She reiterated that she had never been told of any bleeding or concerns about the dressing over the fistula. She provided a shift report sheet for [DATE], which she indicated she used to document information obtained in report at shift change. The box for Resident #B contained the notes [MEDICAL TREATMENT] and Wants legs shaved. There was nothing noted on the form about bleeding or concerns with the fistula dressing. Employee Counseling Record forms provided by the D.H.S. and dated [DATE] indicated both LPN #2 and LPN #3 had received written counseling, with a Reason for Employee Counseling noted as Did not use 24 hour log to communicate bleeding to shunt site on [DATE]. CRCA #1 was interviewed by phone on [DATE] at 4:30 P.M. She indicated that on [DATE] at 4:50 A.M. she passed Resident #B's room and observed her on the floor in a huge pool of blood. She indicated she did not enter the room, but immediately called nursing who came to the room, and directed her to call 911, which she did. She indicated she did not participate in the code in any way other than directing E.M.S. to the room. A physician's orders [REDACTED].#B to assess the fistula site for bruit and thrill (used to assess the condition of a fistula or graft; bruit is a whooshing sound detected by listening with a stethoscope, and thrill is a vibration that is felt). The A.D.H.S. indicated this order was obtained following a chart review, and that this order should have been in place since admission. A Treatment Administration History document indicates these checks were performed on day, evening, and night night shifts on [DATE], all noted to have been done by L.P.N. #2. Resident #B's record, including progress notes and 24 hour reports, contain no other documentation of any assessment or observation of Resident #B, including the condition of her fistula site, other than as noted above, for the period following her return from [MEDICAL TREATMENT] on [DATE] until being found on the floor in her room at 4:50 A.M., on [DATE]. During an interview on [DATE] at 11:30 A.M., the Director of Health Services indicated there was no additional documentation of observation or assessment of Resident #B other than as noted above. During the above interview, and confirmed by interview on [DATE] at 10:10 A.M., the D.H.S. indicated that [MEDICAL TREATMENT] Communication Forms were sent with Resident #B to each [MEDICAL TREATMENT] appointment. The facility was responsible for completing the top section , Communication From Campus to [MEDICAL TREATMENT] Center, prior to sending the resident for treatment. The middle section, Communication From [MEDICAL TREATMENT] to Campus, was the responsibility of the [MEDICAL TREATMENT] center to complete before returning the resident to the facility. The bottom section, Assessment Upon Return From [MEDICAL TREATMENT] was to be completed by the facility. [MEDICAL TREATMENT] Communication Forms, as initiated by the facility, were received from the facility for the dates [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Each had the top and bottom sections completed. None contained any documentation in the center section from the [MEDICAL TREATMENT] center. The D.H.S. indicated a facility nurse should have contacted the [MEDICAL TREATMENT] center to obtain the missing information, and did not. The [MEDICAL TREATMENT] center that treated Resident #B was visited on [DATE] and the [MEDICAL TREATMENT] clinic's treatment sheets for the dates [DATE] through [DATE] were reviewed. During the review, the [MEDICAL TREATMENT] clinic director indicated that all communication had been with the resident's family, and no information was communicated directly to the facility. The clinic director indicated a section on the clinic's reports called notes was used to document any unusual issues. None of the reports mentioned any issues with bleeding. Notes related to the resident's mood and behavior included: [DATE] pt (patient) unable to sit in chair, wanted to stand up .making it unsafe for the pt to continue tx .family called to make them aware . [DATE] .needed continual verbal cueing to stay in chair .(family member) .made aware . [DATE] .pt had to have a sitter at chairside to run tx (treatment)., continues to want to get out of chair and go home, needs continual cueing for safety . [DATE] .needing verbal cueing to stay in chair .family made aware that pt may need a sitter with tx. During the phone interview with the resident's family member [DATE] at 11:00 A.M., she indicated the [MEDICAL TREATMENT] facility had discussed with the family about the possible future need for a sitter during treatment to ensure safety, but no decision had been made. She also indicated that the only time the resident was anxious or agitated was during the actual [MEDICAL TREATMENT] treatment, indicating she has trouble sitting still that long. A written statement dated [DATE] and signed by the [MEDICAL TREATMENT] center manager indicated To whom it may concern: To the best knowledge of the staff employed at (name of [MEDICAL TREATMENT] center) no communication from Clearvista Lake nursing facility was presented with (name of Resident B) prior to treatments. A facility document received from the Executive Director on [DATE] at 9:10 A.M., titled SNF Outpatient [MEDICAL TREATMENT] Services Agreement dated [DATE] and signed by representatives from the facility and the [MEDICAL TREATMENT] service provider indicated: Transport and Referral of [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) Residents: .The facility shall be responsible for arranging for suitable and timely transportation .including .qualified personnel to accompany the [MEDICAL CONDITION] Residents . Obligations of the [MEDICAL CONDITION] [MEDICAL TREATMENT] and/or Company .To provide to the Nursing Facility information on all aspects of the management of the [MEDICAL CONDITION] Resident's care .including, but not limited to, bleeding, infection, and care of [MEDICAL TREATMENT]. Mutual Obligations: Collaboration of Care: Both parties shall ensure that there is documented evidence of collaboration of care and communication .Documentation shall include, but not be limited to, participation in care conferences . During an interview on [DATE] at 11:30 A.M., the Executive Director indicated he was uncertain of the definition of qualified personnel as required in the Transport and Referral' section of the [MEDICAL TREATMENT] Service Agreement above. A facility document titled Guidelines for Monitoring Shunt: [MEDICAL TREATMENT] Arteriovascular Access (AV) (Fistula, Graft, or Central Venous Catheter) dated ,[DATE] received form the Campus Clinical Support person on [DATE] indicated: Purpose: To effectively provide monitoring of vascular access utilized for [MEDICAL TREATMENT]. Procedure: 1. Monitor AV shunt daily for: redness; swelling; signs and symptoms of infections . 2. Monitor the AV shunt daily for bruit and thrill . 3. Area of AV shunt dressing, is to be kept clean and dry. [MEDICAL TREATMENT] will typically change the dressing . 5. Notify attending physician, [MEDICAL TREATMENT] center and responsible party of adverse findings . 6. Document assessment findings in medical record nursing notes and or in designated area on treatment record . 7. If abnormal bleeding is noted apply pressure to area and call 911 for transfer to the hospital. An undated facility document titled Guidelines for [MEDICAL TREATMENT] Provider Communication received form the Campus Clinical Support person on [DATE] indicated: Purpose: To provide guidelines for communication and partnership of [MEDICAL TREATMENT] Providers and the campus. Procedure: 1. The campus shall have the information regarding the [MEDICAL TREATMENT] Provider schedule and requirements such as but not limited to: C. Required documentation from campus. 2. The campus shall be responsible for arranging or providing transportation to and from the [MEDICAL TREATMENT] Provider . 4. A report (may be written ot verbal) shall be requested from the [MEDICAL TREATMENT] Provider that will alert the the campus regarding: a. tolerance to procedure, b. vital signs, c. medications administered, d. other information deemed necessary for the ongoing provision of care. 5. Upon return from the [MEDICAL TREATMENT] Provider the campus shall: a. Provide ongoing monitoring of the shunt site for signs of complication. b. Review the [MEDICAL TREATMENT] Provider paperwork for any necessary follow up requirements. 6. A care plan shall be developed containing the necessary information for ongoing care interventions and approaches regarding [MEDICAL TREATMENT] services. The Immediate Jeopardy that began on [DATE] was removed on [DATE] at 3:30 P.M., when the facility provided documentation of re-education of staff members on [MEDICAL TREATMENT] fistula assessment and care, communication and documentation in report and on appropriate facility forms, and timeliness of resident observations. Staff were interviewed to ensure knowledge of assessment, observation, communication, and documentation; and a plan was initiated to ensure ongoing staff training and compliance with identified issues. Facility records were reviewed to ensure compliance with identified corrections. The noncompliance remained at the lower level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced. This Federal tag relates to complaint IN 464. 3XXX,[DATE](a)

Based on record review and interview the facility failed to ensure a resident who was without pressure sores did not develop pressure sores, as evidenced by a resident who was admitted without pressure sores, and while in the facility developed pressure sores of the coccyx, right buttocks, left buttocks, left outer foot, left ankle, and right heel. 1 resident (Resident #H) of 3 reviewed for pressure sores in a population of 6. Findings include: The record of Resident H was reviewed on 8/10/15 at 9:15 A.M. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident H was severely cognitively impaired, required extensive staff assistance for bed mobility, transfers, and all activities of daily living, did not ambulate, had no pressure sores, and was at risk for developing pressure sores. admission orders [REDACTED]. An admission Nutrition Assessment and Data Collection form dated 4/30/15 indicated Skin: red area (symbol for right) knee. This was noted to be related to the resident's habit of sitting with her legs crossed. The form contained no other indications of skin concerns. A Resident First Conference Notes form dated 5/05/15 indicated Resident H had no pressure areas, arterial/venous ulcers, or other areas of skin impairment. C.N.A. daily shower sheets for 5/05/15, 5/07/15, 5/11/15, 5/14/15, 5/18/15, 5/21/15, 5/25/15, 5/28/15, 6/01/15, 6/04/15, 6/08/15, 6/11/15, 6/15/15, 6/18/15, 6/22/15, 6/25/15, 6/29/15, and 7/02/15 all indicated Resident H had no skin concerns, including open areas. During an interview on 8/10/15 at 11;10 A.M. the Director of Health Services (DHS) indicated Resident H had no pressure sores on admission to the facility. The DHS also indicated that Resident H had been seen twice by an outside wound consultant on 6/17/15 and 7/15/15, but otherwise the nursing unit manager was responsible for wound management. A Pressure/Stasis/Arterial/Diabetic Ulcer Assessment form dated 6/08/15 indicated: Initial Identification: Date 6/08/15. Location: Lt (left) ankle. Present on admission: No. Pressure Stage/Thickness: l. Length: 1.0 Width 2.0 (centimeters). A Skin Impairment Circumstance, Assessment and Intervention form dated 6/08/15 indicated: Date of Impairment Discovery: 6/8/15 Location of Impairment: Lt. ankle. Stage: l A nurse's progress note dated 6/13/15 at 7:00 P.M. indicated Daughter came to nurse (sic) desk to show new area on resident's heel hard black area noted 4 1/2 X 1 cm (centimeter) Skin prep applied (symbol for with) (unreadable) and Kerlix. A Pressure/Stasis/Arterial/Diabetic Ulcer Assessment form dated 6/13/15 indicated: Initial Identification: Date 6/13/15. Location: Rt. (right) heel. Present on admission: No. Pressure. Stage/Thickness: (Not noted). Length: 4.1/2 Width 1.0 (centimeters). A Skin Impairment Circumstance, Assessment and Intervention form dated 6/13/15 indicated: Date of Impairment Discovery: 6/13/15. Location of Impairment: Rt. heel. Stage: (Not noted.) A physician's office visit form, noted to be from an outside wound care practice, dated 6/17/15, indicated: Location: (symbol for right) heel. Length .4 Width .3 (centimeters) 100% red min (minimal) serous drainage. Cause: Friction/pressure. A Clinically At Risk Individual Monitoring Sheet dated 6/20/15 indicated: Reason for discussion: Wound/skin issues. Current status: Friction wound to (right) heel measuring 0.4 x 0.3. A Skin Impairment Circumstance, Assessment and Intervention form dated 7/03/15 indicated: Date of Impairment Discovery: 7/03/15. Location of Impairment: (symbol for left) buttocks. Type of impairment: Pressure. Stage: ll. A Clinically At Risk Individual Monitoring Sheet dated 7/09/15 indicated: Reason for discussion: Wound/skin issues. Current status: Stage ll pressure wound to (symbol for left) buttocks measuring 1.3 cm x 1.4 cm. A physician's office visit form, noted to be from an outside wound care practice, dated 7/15/15, contained documentation of 2 wound sites, and indicated: Location: (symbol for right) heel Stage l. Length .(not noted) Width .(not noted). Cause: (Not noted). Location: (symbol for left) isch (ischium). Length .7 Width .5 (centimeters) 100% red. A nurse's progress note dated 7/21/15 at 2:00 P.M. indicated (Name of doctor) called (symbol for with) N.O. (new order) for [MEDICATION NAME] to coccyx (symbol for and) (symbol for right) buttock Stage ll- 100% granulated- recurring pressure ulcers noted. A Skin Impairment Circumstance, Assessment and Intervention form dated 7/21/15 indicated: Date of Impairment Discovery: 7/21/15. Location of Impairment: coccyx/ right buttocks. Type of impairment: P (Pressure). Stage: ll. A Pressure/Stasis/Arterial/Diabetic Ulcer Assessment form dated 8/05/15 indicated: Initial Identification: Date 8/05/15. Location: L (left) heel. Present on admission: No. Pressure. Stage/Thickness: U (unstageable). Length: 1.5 Width 1.5 (centimeters). A Pressure/Stasis/Arterial/Diabetic Ulcer Assessment form dated 8/05/15 indicated: Initial Identification: Date 8/05/15. Location: L. (left) ankle. Present on admission: No. Pressure. Stage/Thickness: l. Length: .5 Width .5 (centimeters). A Pressure/Stasis/Arterial/Diabetic Ulcer Assessment form dated 8/05/15 indicated: Initial Identification: Date 8/05/15. Location: L. (left) outer foot. Present on admission: No. Pressure. Stage/Thickness: U (unstageable). Length: 3 Width 2.7 (centimeters). Tunneling: Necrotic. A nurse's progress note dated 8/05/15 indicated Skin assessment: (symbol for right) buttock /ishium (sic) 6 x 4.5.area (symbol for with) necrotic center.coccyx 5.5 cm x 3 cm x 2 cm (deep) black center (symbol for with) macerated edges unstageable.(symbol for left) outer foot 2 x 2.7 x 0- unstageable. Hard and black (symbol for left) heel.(symbol for left) outer ankle 0.5 x 0.5 x 0- Stage l.notified (daughter) of wounds extremely upset. An untimed nurse's progress note dated 8/05/15 indicated (Name of doctor) called (symbol for with) N.O. (new order) for promod (a dietary supplement); Keflex (an antibiotic) for wound healing. physician's orders [REDACTED]. On 8/10/15 at 11:10 A.M. the Director of Health Services indicated that Resident H left the facility before these orders could be fulfilled, that no therapy evaluation for position had been performed, and that Resident H had been on the facility's standard pressure reducing mattress throughout her stay. A nurse's progress note dated 8/06/15 at 12:00 P.M. indicated (Daughter) here- very upset-.(Doctor) called with N.O. to send to ER (emergency room at (acute care hospital.(daughter) concerned resident may be septic. A nurse's progress note dated 8/06/15 at 7:30 P.M. indicated Resident left via ambulance to (acute care hospital. A hospital Physician's History and Physical dictation for Resident H indicated: admitted : 8/06/15 Chief complaint: Urinary tract infection, fever, and decubitus ulcers. History of Present Illness: (Resident H) is an (age) female with advanced dementia, who has been a resident of (name of facility).The patient is wheelchair bound, and was noted to have some skin breakdown on the feet and buttock regions approximately 1 month ago. The patient's daughter continued to check in, assuming that the wounds had continually been managed; however, noted today that she has worsening skin breakdown and fever, which prompted her admission here to the emergency room . Skin: The patient has a large sacral wound, approximately 5 x 5 cm, which is unstageable due to it's size, as well as an additional wound on the anterior aspect of the left buttock region, which is, again, also unstageable. On the feet, the patient has areas both laterally and medially with pressure ulceration due to her immobility of the feet bilaterally. These are approximately stage ll ulcerations. She also has some redness to the heels bilaterally. Plan: The patient is admitted to the (acute care hospital) team.given the extent of her sacral and foot wounds, she will need wound care and debridement during her hospitalization . An acute care hospital Nursing Physical Assessment- Admission IP Status documentation dated 10/06/15 at 10:30 P.M. indicated: Skin: Bil (bilateral) heels chafed; left lateral metatarsal necrotic area; left outer ankle decub (decubitis ulcer); left foot small scar present; left inner foot bruising noted; left ischial spine 4x4 (dressing) present (dressed in ER); sacral wound dressing present. An acute care hospital Nursing Physical Assessment- Shift IP Status documentation dated 10/07/15 at 6:00 A.M. indicated: Wound assess (assessment):. Location: Sacrum, sacral. Type: Pressure ulcer. Bed: unobserved. Location: left fifth lateral metatarsal. Type: Pressure ulcer. Size: length 2 cm x width 1.5 cm x depth 0 cm. Bed: Black, necrotic. Location: Left ischial spine. Type: pressure ulcer. Size: length 6 cm x width 4 cm x depth 0cm Bed: darkened skin surrounding pink soft wound. An acute care hospital wound care physician's documentation dated 10/09/15 at 4:15 P.M. indicated: WOC (wound care) here to see patient for open wound to coccyx.Noted coccyx with 2.5Lcm (length, centimeters) x 2.5Wcm (wide, centimeters) x 2.0 Dcm (deep, centimeters).The right buttock adjacent to coccyx wound has a 6.0Lcm x 5.0Wcm x 0.2Dcm open wound.To the patients left foot there are two wounds: 1) L 5th metatarsal has a 1.5 diameter dark purplish black area. There is no open area.2) L ankle medial 0.5cm in diameter x 0.1cmD.A. The coccyx is consistent with an unstageable pressure ulcer.the right buttock wound is consistent with a shearing wound with a moisture component.the ankle is consistent with Stage ll pressure ulcer.We will follow up for reevaluation of need for surgical debridement to the coccyx wound. An undated facility document titled Wound Round Guidelines received from the Director of Health Services on 8/10/15 at 9: 10 A.M. indicated: Purpose: To ensure treatment approaches and interventions are being followed through by resident care givers. Policy: The Director of Health Services or designee should make periodic walking rounds to visualize implementation and follow nthrough of individual resident care plan interventions, approaches and physician orders. Rounds should include inspection of the wound to ensure proper treatment is in place, applied properly, signed and dated. Discrepencies in implementing of care approaches and interventions should be corrected immediately by teaching, training and/or disciplinary action when warrented. This Federal tag relates to Complaint IN 746. 3.1-40(a)(1) 3.1-40 (a)(2)

Based on record review and interview, the facility failed to provide adequate supervision and training to ensure a resident was protected from harm, including a fall from bed during care resulting in a hospital visit with identified injuries, and 2 instances of the use of an inappropriate lifting device resulting in injury and psychosocial distress. 1 resident of 3 reviewed for harm in a sample of 3. (Resident #B) Findings include: The record of Resident #B was reviewed on 6/22/15 at 1:30 P.M. [DIAGNOSES REDACTED]. An admission Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident #B had no cognitive deficits, had no mood or behavior disorders, did not ambulate, required extensive assistance for bed mobility, required extensive assistance of 2 persons for transfers, and required extensive assistance for activities of daily living. He was noted to be frequently incontinent of bowel and bladder, and plans were to discharge him back to the community when clinically appropriate. A nurse's progress note dated 6/01/15 at 11:00A.M., indicated: Resident was being transferred to wheel chair (sic) when his leg brushed against the lift. (Symbol for no) pain (Symbol for no) bleeding. Skin tear is 2cm (centimeters) by 1.5cm. A nurse's progress note dated 6/02/15 at 9:00A.M., indicated: Clarification: Skin tear is on top of (Symbol for right) foot. A Skin Impairment Circumstance, Assessment and Intervention form dated 6/01/15 indicated: Date of Impairment Discovery: 6/01/15. Location of Impairment: Top of (Symbol for right) foot. Type of Impairment: Skin tear, full thickness. MD notified? Yes. Prevention Update: Reinforce safety with *****(Brand name of mechanical transfer assistive device) lift (symbol for with) caregivers. During an interview with Resident #B on 6/23/15 at 3:10P.M., he indicated that the above incident Hurt like crazy. They had my foot trapped under the machine (a ****(Brand name) stand up lift). My trainer (therapist) told me they used the wrong kind of lift and they should never have done that. He rated the pain at the time of the incident as a 10 on a scale of 1 to 10. During an interview on 6/23/15 at 3:10P.M., Resident #B indicated he had a second occurrence of injury involving the use of the ****(Brand name) stand up lift on 6/15/15. He stated They got me up in it and couldn't get me out. They forgot to strap my legs in again. I was just hanging there for 15 or 20 minutes while a bunch of people tried to get me out. I felt like I was choking and couldn't breath. I hung there so long my arms got bruised. I kept telling them just put me back to bed but they wouldn't do it. An OT (Occupational Therapy) Treatment Note dated 6/15/15 indicated: Upon entering the patient's room this morning, CRCA (C.N.A.) and Nsing (sic; nursing) attempting to complete bed.w/c (wheelchair) transfer using stand lift. This OT informed Nsing staff that this is not the appropriate lift to use 2/2 (secondary to) Pt's (patient's) BLE (bilateral lower extremity) [MEDICAL CONDITION] (weakness), as previously explained at earlier date by PT (physical therapist).This OT educated Nsging and patient on importance of using *****(brand name) lift (mechanical sling lift) at this time.Nsging verbalized understanding. CNA #3 was interviewed on 6/25/15 at 11:40A.M. She indicated she initiated the transfer of resident #B, and that Resident #B told her he preferred the stand up lift to the *****(brand name) lift, and that is what she used. She indicated she forgot to put the strap around the resident's lower legs and that when she initiated the transfer his legs came off and she could not complete the transfer. She called for help, and ultimately 3 additional staff assisted her and they were able to physically move Resident #B from the lift to his wheelchair. She estimated that Resident #B had been in the lift for approximately 10 minutes. LPN #2 was interviewed on 6/25/15 at 11:30 A.M. She indicated she responded to CNA #3's call for assistance. She indicated Resident #B's legs were not strapped in and they wouldn't bend. She indicated that 2 people lifted his upper body and 2 lifted his legs and placed him in his wheelchair. She indicated she was aware the Resident #B's assessment called for use of a *****(brand name) lift. RN #4 was interviewed on 6/25/15 at 11:55 A.M. She indicated she came to help get Resident #B out of the Sara lift. She indicated Resident B had told CNA #3 he wanted to use the ****(Brand name) lift, but that the CNA should have checked the book to determine Resident #B's appropriate transfer status. She indicated the lower leg strap had not been fastened, and his legs had fallen off the lift, making it impossible to complete the transfer. She indicated they could not put him back to bed because of the positioning of his legs. She stated we could have broken his legs. A Resident Lift Assessment Profile dated 5/19/15 Resident #B was assessed to require a mechanical sling type lift, such as a ****(Brand name #1 of mechanical transfer assistive device) or ********(brand name #2 mechanical transfer assistive device) and was not appropriate for a ****(Brand name #3 transfer assistive device) type standing lift. A Resident Preferences sheet dated 6/23/15 indicated Resident #B was a ****(Brand name mechanical transfer assitive device) lift. A manufacturer's instruction book for the ****(Brand name #3 Mechanical transfer assistve device) stand up lift received from the Director of Health Services indicated: Warning: An assessment must be made for each individual resident being raised by the ****(Brand name #3 mechanical transfer assistive device)-by a medically qualified person-as to whether the resident requires the lower leg straps when using the standing sling. Use if necessary.with residents with spasms.that were assessed as suitable to be raised with the ****(Brand name). An untimed physician's progress note dated 6/03/15 Reportedly pt (patient) rolled OOB (out of bed) early this AM. Now at ER (emergency room ). A Fall Circumstance, Assessment and Intervention form dated 6/03/15 indicated: Time of fall: 12:45 A.M. Witnessed: Yes. Injury: None. Treatment required: No. C/O Pain: 5 on a scale of 1 to 10. Location: Knees aching. Activity at time of fall: Turning in bed. Fall Risk Re-Assessment included, but was not limited to, that Resident B required assistance to transfer and ambulate safely, was unable to maintain balance without assistance, required the use of an assistive device, and was unable to maintain postural positioning in bed or chair. A Change in Condition Form dated 6/03/15 indicated: Condition change that prompted request for physician order: Fall or other injury. Describe signs and symptoms of condition change: Resident rolled off side of bed during care. Did not use side rails. Has requested a larger bed and overhead trapeze. (symbol for no) injuries or open areas noted. A hospital discharge note for Resident #B dated 6/03/15 indicated You have a contusion to your lower extremity (leg, knee, ankle, foot or toes). This causes local pain, swelling and sometimes bruising. There are no broken bones. This injury may take from a few days to a few weeks to heel. A nurse's progress note dated 6/03/15 at 1:00 P.M. indicated: Resident returned to facility by (name of ambulance company). (Symbol for no) new orders.Resident still c/o (complaining of) pain upon return. Resident #B was interviewed on 6/23/15 at 10:20 A.M. He indicated there were 2 staff members in the room when he fell from bed, and they were on the same side of the bed. He stated I just did what they told me to do. They said turn to the other side of the bed, and when I did my leg flopped over and pulled me out of bed. I can't control my legs. They should have known that was going to happen. It hurt and I asked to go to the hospital and they said no. I kept complaining and finally the next morning they sent me to the hospital. An undated facility policy titled Guidelines for SWAT-We've Got Your Back Program received from the Director of Health Services on 6/24/15 at 8:55A.M., indicated: Purpose: To ensure the safety of residents and staff when performing mobility/transfer tasks. Procedure: Upon admission the admitting nurse shall determine the type of transfer device required to assist with safe mobility.4. The type of equipment to be used for the resident should be reflected on the individual care plan and on the nursing assistant assignment sheet. 7. As a general guideline: The Dependant Mechanical Lift shall be used for individuals who cannot bear weight, have poor trunk stability and require extensive assistance or total dependence with transfers. This Federal tag relates to Complaint IN 557. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident who did not have a pressure sore did not develop a Stage lll pressure sore requiring continuing treatment. (Resident C). 1 resident of 3 reviewed for pressure sores in a sample of 5. Findings include: The record of Resident C was reviewed on 10/28/14 at 9:20 A.M. [DIAGNOSES REDACTED]. A "Resident First Conference Notes" form dated 4/29/14 at 4:00 P.M., indicated "Pressure Area: No." "CNA Skin Assessment Detail Reports" documenting skin assessments done on an every shift basis for the dates 3/17/14 through 5/23/14, inclusive; 5/25/14 through 6/09/14, inclusive; 6/10/14 through 6/29/14, inclusive; 6/30/14 through 7/27/14, inclusive; and 7/28/14 through 8/12/14, inclusive, all indicated "Did you see a new skin problem? No." A "CNA Skin Assessment Detail Reports" entry dated 5/24/14 at 9:09 P.M., indicated "Did you see a new skin problem? Yes. Did you notify the nurse of skin problem? Yes. Where is the skin problem located? On her entire buttocks." A "CNA Skin Assessment Detail Reports" entry dated 6/09/14 at 11:35 A.M., indicated "Did you see a new skin problem? Yes. Did you notify the nurse of skin problem? Yes." A "CNA Skin Assessment Detail Reports" entry dated 6/29/14 at 3:41 A.M., indicated "Did you see a new skin problem? Yes. Did you notify the nurse of skin problem? Yes." A "CNA Skin Assessment Detail Reports" entry dated 7/27/14 at 8:01 P.M., indicated "Did you see a new skin problem? Yes. Did you notify the nurse of skin problem? Yes." During an interview on 10/30/14 at 11:30 A.M., with the Executive Director and the Director of Health Services present, the Corporate Nurse Consultant indicated there was no additional documentation related to the above "CNA Skin Assessment Detail Reports" entries, and that she could not identify what type of skin concerns had been observed, and could not say if there was any action taken in response to the concerns. A physician's orders [REDACTED]. (incontinence.)" Documentation does not indicate [MEDICATION NAME] protective paste was applied as ordered on: 6/05/14, 11 to 7 6/06/14, 11 to 7 6/08/14, 7 to 3 6/09/14, 11 to 7 6/11/14, 11 to 7 6/13/14, 11 to 7 6/17/14, 7 to 3 6/22/14, 3 to 11 6/26/14, 3 to 11 6/27/14, 11 to 7 and 3 to 11 7/07/14, 3 to 11 7/29/14, 11 to 7 7/30/14, 3 to 11 and 11 to 7 8/01/14, 11 to 7 8/04/14, 3 to 11 8/06/14, 3 to 11 A "Wound Tracking" form dated 7/15/14 for Resident C indicated: "Wound Location: Butt (Buttocks). In-House Acquired: Yes. Stage/Type: P/1 (pressure, stage 1) Treatment: [MEDICATION NAME]. Comments: Red butt." A "Wound Tracking" form dated 7/23/14 for Resident C indicated: "Wound Location: Butt (Buttocks). In-House Acquired: Yes. Stage/Type: P/1 (pressure, stage 1) Treatment: [MEDICATION NAME]. Comments: Remains red." A "Wound Tracking" form dated 7/29/14 for Resident C indicated: "Wound Location: Butt (Buttocks). In-House Acquired: Yes. Stage/Type: P/1 (pressure, stage 1) Treatment: [MEDICATION NAME]. Comments: Blanches." A "Wound Tracking" form dated 8/08/14 for Resident C indicated: "Wound Location: Butt (Buttocks). In-House Acquired: Yes. Stage/Type: P/1 (pressure, stage 1) Treatment: [MEDICATION NAME]. Comments: Blanches." During an interview on 10/30/14 at 11:30 A.M., with the Executive Director and the Director of Health Services present, the Corporate Nurse Consultant indicated there was no additional documentation related to the above "Wound Tracking" form entries, including but not limited to additional assessments, treatments, communication with the physician, or physician's orders [REDACTED]. A nurse's note dated 8/12/14 at 6:00 P.M., indicated "...ordered by (name of treating physician)...to start [MEDICATION NAME] (an antibiotic) PO (by mouth) 500mg (milligrams) for res. (resident) open area on coccyx." A physician's orders [REDACTED]. Indication: Wound healing." A physician's orders [REDACTED].M., indicated "Send to (name of acute care hospital) for eval (evaluation) and treat." A hospital "Transfer Summary Report [REDACTED]...5. Sacral wound, likely stage ll: Wound consult." A facility "Nursing Admission and Data Collection" form dated 8/27/14, the day of her return from the hospital, had a drawing identifying a wound to Resident C's coccyx, and indicated wound measurements of 7 by 41/2cm (centimeters) and 0.5cm dept (sic) (depth). A "Wound Tracking" form dated 8/29/14 for Resident C indicated: "Wound Location: Butt (Buttocks). In-House Acquired: Yes. Stage/Type: P/lll (pressure, stage 3) Length: 6.1 Width: 4.9 Depth: 0.2 Treatment: Collagen (symbol for "plus") [MEDICATION NAME] island." Comments: ...no lying flat on back..." A "Wound Tracking" form dated 10/24/14 (the most recent available) for Resident C indicated: "Wound Location: Coccyx In-House Acquired: Yes. Stage/Type: ll (pressure, stage 2) Length: 4.1 Width: 0.9 Depth: 0.7 Treatment: CaAlginate (calcium alginate) (symbol for "with") Allevan foam top..." Comments: None noted. Resident C was seen by the facility's contracted Wound Care physician on 8/29/14, 9/05/14, 9/26/1410/03/14, 10/10/14, 10/17/14, and 10/24/14. Wound measurements were taken, the wound was described, and treatment was ordered. Documentation indicates Resident C will continue to be seen by the Wound Care physician. Resident C's sacral wound was observed on 10/30/14 at 2:30 P.M. The wound was consistent in size and description of the "Wound Tracking" form of 10/24/14. The resident was unable to be interviewed due to confusion. During an interview on 10/30/14 at 1:30 P.M., the Clinical Nurse Consultant indicated the facility had no additional information or documentation to provide related to Resident C's pressure sore. This Federal tag relates to complaint IN 889. 3.1-40(a)(1) 3.1-40 (a)(2)