Every finding on record at Columbia Healthcare Center

Based on interview and record review, the facility failed to maintain complete and accurate medical records; the physicians orders were not entered into the EMAR (Electronic Medication Administration Record), insulin on the EMAR ordered was withheld by nursing staff, the physician was not notified for withholding medications for 1 of 3 residents reviewed for pharmaceutical services. (Resident C) Finding includes: On [DATE] at 9:30 a.m., Resident C's clinical record was reviewed. Diagnoses included but were not limited to, Type 2 diabetes mellitus with diabetic polyneuropathy, Chronic obstructive pulmonary disease, unspecified(Primary, Admission), Chronic pain syndrome, Hypertensive heart disease with heart failure, Atherosclerotic heart disease of native coronary artery without angina pectoris, Primary adrenocortical insufficiency, insomnia, mixed hyperlipidemia, anxiety disorder, Bipolar disorder, current episode depressed, mild. Resident C expired at the facility on [DATE]. The EMAR for [DATE] was reviewed and included but was not limited to: Hold diuretics, diabetes medications on [DATE], 12 a.m. to 12 p.m. Orders on hold from [DATE] to [DATE] with out physician orders included: Lantus Solostar-U-100 Insulin (insulin glargine), insulin pen, 100 unit/ml (milliliter) (3 ml) amount to administer 35 u (unit) subcutaneous twice a day, order start date [DATE]. The EMAR for the 7 -11 p.m. dose on [DATE] was left blank , the dose for [DATE] morning and evening dose was held without physician orders. The evening dose of [DATE] was documented held due to condition and did not eat supper. hydrocortisone tablet, 10 mg (milligram) amount to administer, 10 mg oral, twice a day, order start date [DATE]. The EMAR comments for the 7-11 p.m. dose on [DATE], indicated not administered due to condition. atorvastatin tablet 40 mg amount to administer 40 mg oral at bedtime, order start date [DATE]. The EMAR for the [DATE] dose at bedtime indicated not administered due to condition. melatonin tablet, 10 mg, amount to administer 10 mg oral at bedtime, order start date [DATE]. The EMAR for the [DATE] dose at bedtime indicated not administered due to condition. clonazepam -schedule IV tablet, 0. 5 mg, amount to administer 0.25 mg oral, three times a day, order start date [DATE]. The EMAR for the [DATE] 8 p.m. indicated not administered due to condition. divalproex tablet, delayed release 500 m, amount to administer 500 mg oral, order start date [DATE]. The EMAR for the [DATE] bedtime dose indicated not administered due to condition. order on hold from [DATE] to [DATE] oxycodone tablet 10 mg, amount to administer 10 mg oral , order start date [DATE]. The EMAR for the [DATE] dose at 8 p.m., indicated not administered due to condition. Progress notes were reviewed and included but were not limited to: [DATE] at 11:57 a.m., Resident has returned from surgical procedure at this time .May restart medications .Instructions for pain pump in the bagXXX[DATE] at 4:45 p.m., Resident has been having vomiting all day today. Have got new order for Clear liquid diet until Monday at Noon [[DATE]] and will reevaluate her about the vomiting issue. The EMAR did not contain the order for clear liquid diet or that insulin could be held. The clinical record did not contain information that the physician was notified of the medications that were held due to Resident C's condition.On [DATE] at 10:55 a.m, LPN 2 indicated she got a verbal order for Resident C for a clear liquid diet.On [DATE] at 12:24 p.m., the Director of Nursing (DON) indicated that LPN 2 got verbal telephone orders that Resident C's insulin could be held if she continued to vomit, but did not document the order in the clinical record. LPN 2 indicated she did not document the order to hold insulin. On [DATE] at 2:04 p.m., the Regional Nurse Consultant indicated LPN 2 should have entered the order for a clear liquid diet for Resident C. On [DATE] at 1:51 p.m., the Administrator provided the current policy on physician orders with a revision dare of 9/25. The policy included but was not limited to, All new orders will be entered into Matrixcare Physician Orders and verified by a licensed nurse. All new physician orders will also be handwritten on an appropriate order form and retained for auditing and record keeping through the next process. The MatrixCare Physician Order is to be considered the official order .This citation relates to Intake 2989322 and 3035915. 410 IAC (Indiana Administrative Code) 3.1-50(a)(1)

Based on observation, interview, and record review, the facility failed to ensure food was stored and labeled appropriately in 1 of 1 kitchen tours. Food packages were not dated with an open date and use by date, and expired food was not disposed of. (Kitchen)Finding includes:During a tour of the kitchen on 4/1/26 at 8:49 A.M., the following was observed:Reach-in refrigerator:1 bottle of mayonnaise with an expiration date of 3/27/261 bottle of grape jelly with no open date or use by date with an expiration date of 2/11/26 1 bottle of caramel syrup with no open date or use by date1 bottle of chocolate syrup with no open date or use by date1 bottle of ketchup with an open date of 9/11/25 and expiration date of 3/11/261 container of Worcestershire sauce with an open date of 1/26/26 and a use by date of 3/10/26Food preparation area:1 box of baking soda with an open date of 1/6/25 and use by date of 1/6/261 bag of mini marshmallows with use by date of 2/28/262 bags of pudding mix wrapped with plastic wrap with no open date or use by date 1 bag of yellow cornmeal with a use by date of 3/1/26Dry storage area:3 bottles of orange juice with a use by date of 3/27/26During an interview on 4/1/26 at 9:05 A.M., the Dietary Manager indicated that once food was opened it should have an open date and a use by or expiration date on the label.On 4/1/26 at 12:53 P.M., the Administrator provided a Kitchen Operations policy dated 5/2025. The policy indicated .refrigerated, ready-to-eat food. shall be clearly marked when the container is opened and the date which the food will be consumed or discarded . This opened food can be held at 41 degrees F (Fahrenheit) or less for no more than 7 days and the date marked may not exceed the manufacturer's use-by-date. The day the original container is opened shall be counted as Day 1 . Food items that are not considered potentially hazardous including commercially prepared mayonnaise, salad dressing, mustard, ketchup, BBQ sauce, pickles, and pickle relish will be labeled when opened and, to ensure quality, used or disposed of within 90 days of opening or per the use-by-date, whichever comes first. Follow manufacturer's directions regarding the need to refrigerate after opening to preserve quality .Food items that are considered shelf stable are to be used within 1 year of delivery. These items include non-perishable liquids as well as dry goods. All foods shall be covered or wrapped tightly, labeled, and dated. This citation relates to Intake 2792113.410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(2)410 IAC 16.2-3.1-21(i)(3)

Based on interview, and record review, the facility failed to follow Physicians Orders. A resident with a pressure ulcer did not receive antibiotics and treatment as ordered for 1 of 4 residents reviewed for quality of care. (Resident C)Finding includes:On 11/12/25 at 11:40 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, type 2 diabetes mellitus and gout.The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 9/29/25, indicated Resident C had moderate cognitive impairment, 1 unstageable pressure ulcer, and was not on a turning and repositioning program. Resident C required substantial to maximal assistance of staff (staff performs more than half the effort) for transfers and toileting.Care plans included, but were not limited to, the following:Impaired mobility related to right foot osteomyelitis with an intervention to turn and reposition Resident C every 2 hours, dated 10/21/25.The resident had a right heel infection with an intervention to administer antibiotics as ordered by the physician, dated 10/16/25.Physicians' Orders included, but were not limited to, the following:Clindamycin (antibiotic) 300 milligrams (mg) oral every 6 hours for wounds started on 8/27/25 and discontinued on 9/1/25.Resident C's medication administration record (MAR) lacked documentation that the dose on 9/1/25 at 4:00 A.M. was administered.Right lateral heel: cleanse with wound cleanser, pat dry, apply skin prep to peri-wound, apply medi-honey to wound bed, then calcium alginate, cover with foam dressing. Change every day and as needed if soiled or dislodged. Started on 9/26/25 and discontinued on 10/1/25.Resident C's clinical record and treatment administration record (TAR) lacked documentation that the wound treatment was completed on 9/26/25 from 6:00 A.M. to 6:00 P.M.Cephalexin (antibiotic) 500 mg oral every 8 hours started on 10/6/25 and discontinued on 10/13/25.Resident C's MAR lacked documentation that cephalexin was administered on 10/10/25 at 8:00 P.M. and on 10/11/25 at 12:00 P.M.Right lateral heel: cleanse with wound cleanser, pat dry, apply gauze with wound cleanser to wound bed, cover with an abdominal pad, and wrap with kerlix twice a day, started on 10/15/25.Resident C's clinical record and TAR indicate the treatment was not completed on 10/16/25 and 10/18/25 from 6:00 P.M. through 6:00 A.M. due to the resident sleeping, 10/21/25 from 6:00 P.M. through 6:00 A.M. due to the resident's condition, and 10/21/25 due to the resident was unavailable.During an interview on 11/13/25 at 11:28 A.M., Certified Nurse Aide (CNA) 3 indicated Resident C was not a resident who needed to be turned and repositioned every 2 hours. At that time, CNA 3 verified on the CNA assignment form that Resident C was not listed as a resident who needed to be turned and repositioned every 2 hours.During an interview on 11/13/25 at 1:25 P.M., the DON indicated Resident C was supposed to be turned and repositioned every 2 hours. The treatments should have been completed as ordered, and the MAR and TAR should not have been left blank. She further indicated that if Resident C was asleep, staff should have attempted to wake the resident.On 11/13/25 at 1:19 P.M., the Assistant Administrator indicated the facility did not have a policy related to following Physician's Orders, but it would be their policy to follow orders.This citation was related to intake 2657654.3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure residents dependent on staff for ADLs (activities of daily living) were showered for 7 of 8 residents reviewed for ADL care. (Resident B, Resident C, Resident D, Resident E, Resident F, Resident H, and Resident J)Findings include: 1. On 9/3/25 at 8:53 A.M., Resident E indicated that she didn't always get showers twice a week. She indicated that sometimes she would go two to three weeks without a shower, and if she refused a shower, staff did not allow her to have it at a different time. On 9/3/25 at 1:17 P.M., Resident E's clinical record was reviewed. Diagnoses included, but were not limited to, rheumatoid arthritis and major depressive disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 7/29/25, indicated Resident E was cognitively intact, required partial to moderate assistance of staff (staff does less than half of the effort) for bathing, and did not reject care during the look-back period. A care plan conference was completed on 7/29/25 with the resident in attendance. Care plans were reviewed and updated. A current ADL care plan, dated 1/12/23, included the intervention Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. A Preferences for Customary Routine and Activities note, dated 7/24/25, indicated the resident preferred to be bathed more than twice per week in the morning and preferred showers. A current shower schedule indicated Resident E received showers on Tuesdays and Fridays during the day shift. The Point of Care (POC) (a charting system for Certified Nurse Aides) Task Response for Showering and shower sheets were reviewed. Resident E did not receive showers or a complete bed bath on the following days in August 2025: 8/8/25 8/12/25 8/22/25 2. On 9/2/25 at 12:11 P.M., Resident D's hair appeared unbrushed and greasy. On 9/4/25 at 8:54 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 7/1/25, indicated Resident D had severe cognitive impairment, required substantial to maximal assistance of staff (staff does more than half of the effort) for bathing, and had no rejection of care during the look-back period. A care plan conference was completed on 7/1/25 with the resident in attendance. Care plans were reviewed and updated. A current self-care deficit care plan, dated 3/14/14, included an intervention to Provide shower two times per week, partial bath in between. A Preferences for Customary Routine and Activities note, dated 7/1/25, indicated the resident preferred showers. A current shower schedule indicated Resident D received showers on Wednesdays and Saturdays during the day shift. The Point of Care (POC) (a charting system for Certified Nurse Aides) Task Response for Showering and shower sheets were reviewed. Resident D did not receive showers or a complete bed bath on the following days in August 2025: 8/27/25 8/30/25 3. On 9/2/25 at 2:51 P.M., Resident J indicated that she hadn't had a shower in a week. She indicated that sometimes staff wanted to give her a shower after 10:00 P.M., and she preferred her showers earlier so she didn't have to get out of bed. She indicated on those nights, staff told her that they had other things to do before they showered her. On 9/5/25 at 9:55 A.M., Resident J's clinical record was reviewed. Diagnoses included, but were not limited to, major depressive disorder and generalized anxiety disorder. The most current admission Minimum Data Set (MDS) Assessment, dated 6/26/25, indicated Resident J was cognitively intact, required partial to moderate assistance of staff (staff does less than half of the effort) for bathing, and did not reject care during the look back period. A care plan conference was completed on 6/24/25. Care plans were reviewed and updated. A current ADL care plan, dated 6/23/25, included an intervention to Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. A Preferences for Customary Routine and Activities note, dated 6/26/25, indicated the resident preferred to be bathed more than twice per week in the morning and preferred showers. A current shower schedule indicated Resident J received showers on Tuesdays and Fridays during the day shift. The Point of Care (POC) (a charting system for Certified Nurse Aides) Task Response for Showering and shower sheets were reviewed. Resident J did not receive showers or a complete bed bath on the following days in August 2025: 8/5/25 8/8/25 8/12/25 8/15/25 8/22/25 8/29/25 4. On 9/2/25 at 12:20 P.M., Resident C's hair appeared unbrushed and oily. On 9/4/25 at 9:25 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease. The most current admission Minimum Data Set (MDS) Assessment, dated 6/21/25, indicated Resident C had severe cognitive impairment, required partial to moderate assistance of staff (staff does less than half of the effort) for bathing, and had no rejection of care during the look back period. A care plan conference was completed on 8/26/25 with a family member in attendance. Care plans were reviewed and updated. A current ADL care plan, dated 6/16/25, included an intervention to Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. A Preferences for Customary Routine and Activities note, dated 9/3/25, indicated the resident preferred showers. A current shower schedule indicated Resident C received showers on Wednesdays and Saturdays during the day shift. The Point of Care (POC) (a charting system for Certified Nurse Aides) Task Response for Showering and shower sheets were reviewed. Resident C did not receive showers or a complete bed bath on the following days in August 2025: 8/2/25 8/6/25 8/9/25 8/27/25 8/30/25 5. On 9/2/25 at 12:16 P.M., Resident H was observed screaming in the middle of the dining room that she had not had a shower for 2 weeks and wanted one at that time. Resident H was also observed with greasy hair. On 9/4/25 at 10:48 A.M., Resident H's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and diabetes mellitus. The Current Quarterly MDS dated [DATE] indicated the resident was cognitively intact and needed supervision with hygiene, dressing, transferring, and mobility. A care plan conference was conducted on 5/20/25, and the care plan was reviewed and updated. A current ADL care plan dated 5/20/25 included an intervention, assist with bathing as needed per resident preference. Offer showers two times per week, a partial bath in between. A current Shower Sheet indicated the resident received showers on Tuesday and Thursday during the day shift. Shower sheets indicated Resident H did not receive showers on the following dates: 8/14, 8/18, 8/25. The Point of Care Task indicated the resident did not receive a shower or partial bath on 08/22/2025. 6. On 9/3/25 at 12:31 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 8/15/25, indicated Resident B was maximal assist (staff do more than half of the work) for bathing. A current shower schedule indicated Resident B received showers on Monday and Thursday during the day shift. The Point of Care Task Response for Showering and shower sheets were reviewed. Resident B did not receive or refuse showers or a complete bed bath on the following scheduled days in August 2025: 8/4/25 8/7/25 8/14/25 8/28/25 7. On 9/4/25 at 12:02 P.M., Resident F's clinical record was reviewed. Resident F's diagnoses included, but were not limited to, quadriplegia. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 8/6/25, indicated Resident F was dependent on staff (staff do all of the work) for bathing. The current care plan included, but was not limited to: Resident requires assistance with ADLs (activities of daily living); Assist with bathing as needed per resident preference. Offer full bed bath two times per week, partial bath in between. Start date: 9/23/24 A current shower schedule indicated Resident F received showers on Tuesday and Friday during the evening shift. The Point of Care Task Response for Showering and shower sheets were reviewed. Resident F did not receive or refuse showers or a complete bed bath on the following scheduled days in August 2025: 8/1/25 8/5/25 8/12/25 8/22/25 On 9/4/25 at 9:36 A.M., the Director of Nursing (DON) indicated that shower sheets were a part of the clinical record. Staff were supposed to transfer all information on the shower sheets over to the POC Response, but sometimes they forgot. On 9/4/25 at 2:42 P.M., the Assistant Director of Nursing (ADON) indicated that residents got at least two showers per week or more if that was what they preferred. If a resident refused a shower, staff should reattempt or offer to give the shower on a day and time that the resident preferred. On 9/8/25 at 11:00 A.M., the Administrator provided a current undated Resident Rights policy that indicated You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose. This citation is connected to Intake 2592689. 3.1-38(a)(2)(A)3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident's comprehensive care plan interventions were implemented for 1 of 1 residents reviewed for falls. Resident G was not observed to have Dycem in use in the wheelchair.(Resident G) Findings include: On 9/3/25 at 10:30 A.M., Resident G was observed lying in bed with the wheelchair (W/C) next to the bed. There was no Dycem (non-slip device) observed in the w/c. On 9/4/25 at 3:42 P.M., Resident G was observed lying in bed with W/C next to the bed. There was no Dycem observed in the W/C. On 9/3/25 at 1:11 P.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of the upper lobe, right bronchus, secondary malignant neoplasm of the liver, and chronic obstructive pulmonary disease (COPD). The most Current admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident G was cognitively intact. Resident G is dependent on toileting and dressing and needs partial assistance of 1 for hygiene. Current physician orders included but were not limited to Dycem to W/C every shift, dated 8/29/25. The current fall care plan was reviewed on 8/28/25. Interventions included were not limited to Dycem to W/C and W/C at bedside. During an interview on 9/4/25 at 3:42 P.M., Resident G indicated that the Dycem was supposed to be in the W/C but has not been there for a while. During an interview on 9/5/25 at 9:30 A.M., Licensed Practical Nurse (LPN) 4 indicated the resident is care planned for a Dycem pad. She indicated that for this resident, there should be one on top and one on the bottom. She did not know why it was not in the wheelchair. On 9/8/25 at 11:00 A.M., the Administrator provided a current policy IDT Comprehensive Care Plan Policy revised 8/23. The policy indicated .the care plan must include . specific interventions based on the resident's needs and preferences to promote the resident's highest level of functioning . Physician orders are considered part of the comprehensive care plan . 3.1-35(a)

Based on record review and interview, the facility failed to ensure a Resident's medication side effects were addressed after a medication change for 1 of 1 residents reviewed for mood and behaviors. (Resident F) Finding includes: On 9/4/25 at 12:02 P.M., Resident F's clinical record was reviewed. Resident F's diagnoses included, but were not limited to, quadriplegia. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 8/6/25, indicated Resident F was dependent on staff (staff do all of the work) for bathing and toileting. Current physician orders included, but were not limited to: Citalopram (antidepressant medication) tablet, take 10 milligrams (mg) at bedtime; Start date: 8/20/25 Discontinued physician orders included, but were not limited to: Citalopram tablet, take 20 milligrams (mg) at bedtime; Started on 3/21/25 and discontinued on 8/20/25 Anti-Anxiety Medication Use - Observe the resident closely for significant side effects. Special Instructions: Document observed side effects in progress notes and notify MD, as needed. Start date 1/21/25 Anti-Depressant Medication Use - Observe the resident closely for significant side effects. Special Instructions: Document observed side effects in progress notes and notify MD, as needed. Start date: 1/21/25 The current care plan included, but was not limited to: Resident is at risk for signs and symptoms of depression; Start date 09/25/2024 The resident is at risk for signs and symptoms of anxiety. Psych services as appropriate; Start date 9/30/24 A nursing progress note, recorded as a late entry on 8/22/25 at 12:04 A.M., indicated Resident F was tearful that shift. An Interdisciplinary team note, dated 8/22/25 at 9:47 A.M. and 12:17 P.M., indicated acknowledgement of Resident F's increased side effects of tearfulness following the medication reduction. A nursing progress note, dated 8/28/25 at 09:00 P.M., indicated Resident F was tearful that shift; multiple staff members witnessed the resident crying. A nursing progress note, dated 8/29/25 at 11:55 P.M., indicated Resident F was tearful and emotional that shift. The resident's family reported that the resident has been more tearful and angry this past week. A nursing progress note, dated 8/30/25 at 6:46 P.M., indicated Resident F was tearful again at this time. A nursing progress note, dated 9/1/25 at 3:09 A.M., indicated Resident F was tearful off and on that shift. A nursing progress note, dated 9/1/25 at 6:00 P.M., indicated that the family reported that the resident had been tearful many times that day. A nursing progress note, dated 9/3/25 at 12:37 A.M., indicated Resident F was tearful at the beginning of the shift. Staff reported that the resident had been more tearful over the last week and a half. Notification to the psychiatric nurse practitioner, or follow-up from the nurse practitioner, for experiencing side effects post medication reduction was not documented from 8/20/25 through 9/3/25. During an interview on 9/4/25 at 2:38 P.M., the Assistant Director of Nursing indicated if a resident has side effects following a medication reduction, it would be addressed immediately, the psychiatric nurse practitioner visits the building twice a week, and that staff were aware of Resident F's increased tearfulness follow the medication reduction but had not notified the psychiatric nurse practitioner to evaluate the resident yet. On 9/8/25 at 11:16 A.M., the Administrator provided a policy titled Psychotropic Management, revised 7/25, that indicated It is the policy to ensure a resident's psychotropic medication regimen helps promote the resident's highest practicable mental, physical, and psychosocial well being For all psychotropic medication order changes, the resident will be observed for 72 hours for any changes in symptoms or adverse effects.3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary environment during 2 of 2 days of the survey. Resident room halls had a build up of dust/dirt on 2 of 3 units observed, linen closets were not clean, 2 of 2 shower rooms were unclean or not maintained, urinals were not stored properly in a shared restroom, and urine odors were present throughout the survey. (First floor unit, Second floor unit, Hall 1100, 1200, 1400, 1500, 2100, 2200, 2400, 2500, room [ROOM NUMBER], 1208, 12010, room [ROOM NUMBER], 2100 Shower room, 2500 shower room, Resident D) Findings include: 1. A review of a facility concern/grievance form, dated 11/4/24, indicated a resident in room [ROOM NUMBER] had a concern, [Third] time no housekeeping on weekends . Hall [1200] was skipped this first week of [November] . A facility concern/grievance form, dated 12/25/24, indicated a resident in room [ROOM NUMBER] had a concern, .housekeepers don't do a good job in my room or my bathroom . 2. On 2/12/25 at 1:45 P.M., the 1200 Hall was observed to have a build up of dust and dirt along the bottom of the cove base, around the base of room doors and fire doors, throughout the hall. On 2/13/25 at 9:15 A.M., the 1200 Hall was observed to have a build up of dust and dirt along the bottom of the cove base, around the base of room doors and fire doors, throughout the hall. On 2/13/25 at 9:20 A.M , the 1400 Hall was observed to have a build up of dust and dirt along the bottom of the cove base, around the base of room doors and fire doors, throughout the hall. On 2/13/25 at 9:25 A.M., the 1500 Hall was observed to have a build up of dust and dirt along the bottom of the cove base, around the base of room doors and fire doors, throughout the hall. On 2/13/25 at 9:30 A.M., the 2400 Hall was observed to have a build up of dust and dirt along the bottom of the cove base, around the base of room doors and fire doors, throughout the hall. On 2/13/25 at 9:55 A.M., the fire doors leading the second floor dining room was observed to have dust and dirt build up along the base of the door frame. 3. During an interview and observation on 12/13/25 at 11:55 A.M., Housekeeper 4 indicated all floors in the facility, including restroom, resident rooms, room halls, and dining rooms were swept and mopped daily. Housekeeper 4 unlocked and opened a clean linen closet door on the 1100 hall. The linen closet floor had a build up of dust and dirt. A safety razor was observed on the linen closet floor. Housekeeper 4 removed the safety razor and indicated that linen closets were cleaned monthly. 4. During an interview and observation on 2/12/25 at 1:50 P.M., Resident D indicated she shared a restroom with a female resident in the room next to hers. Resident D indicated two urinals were being stored in their bathroom. At 1:55 P.M., two uncovered urinals were observed on the bathroom floor near the base of the commode. On 2/13/25 at 9:20 A.M., two urinals were observed on Resident D's shared bathroom floor near the base of the commode, uncovered. rooms [ROOM NUMBERS] shared a bathroom. During an interview on 2/13/24 at 12:00 P.M., CNA 9 indicated resident urinals should be stored covered and should not be stored on a bathroom floor. 5. On 12/13/25 at 1:45 P.M. the 2500 hall shower room was observed. The second stall from the shower room door had a black and brown discoloration to the shower floor tile grout along base of the shower walls and in the shower corners. A tile was cracked at the base of a shower wall, a build up of dust and dirt was observed in the back corner of the shower room along with debris and a build-up of dust behind the shower room commode. On 12/13/25 at 1:55 P.M., the 2100 hall shower room was observed. A tiled, walk-in shower furthest from the shower room door had a window with window blinds obstructing the outside view. Two window blind pull/draw strings were broken and hanging down the tile wall onto the shower floor. A tile along the window seal was cracked. 6. On 2/13/25 at 9:15 A.M., a strong urine odor was present on the 1100. The odor was present throughout the hall. On 2/13/25 at 10:00 A.M., a strong urine odor was present on the 1100. The odor was present throughout the hall. 6. On 2/12/25 at 4:15 A.M. upon entry to the facility, a strong urine odor was present on the first and second floors of the facility. On 2/13/25 at 8:15 A.M., the facility was observed to have a urine odor in the lobby by the front entrance, and on the first floor unit. 7. On 2/12/25 at 4:45 A.M., the 2200 Hall was observed to have a build up of dust and dirt along the bottom of the cove base, around the base of room doors and fire doors, throughout the hall. On 2/13/25 at 9:30 A.M., the 2100 Hall was observed to have a build up of dust and dirt along the bottom of the cove base, around the base of room doors and fire doors, throughout the hall. A chair used to weigh residents was observed to have debris built up around the base of the chair. On 2/13/25 at 9:35 A.M., a clean linen closet on the 2500 Hall was observed to have debris built up on the floor, trash, and gloves laying on the floor. A strong urine smell was observed throughout the hall. On 2/13/25 at 9:45 A.M., a clean linen closet on the 2100 Hall was observed to have trash on the floor, dust and dirt built up. On 2/13/25 at 2:40 P.M., the Facility Administrator supplied a facility policy, titled, Housekeeping, Laundry and Floor Care Policies, Procedures and Guidelines dated 12/2021. The policy included a daily cleaning procedure that indicated, .7. Sweep flooring to include under beds, corners, edging and under chairs/equipment . 8. Mop flooring to include under beds, corners, edging and under chairs/equipment . A cleaning guideline included, Daily extra duties for resident rooms and all common areas: .Tuesday: Wipe down walls where apparent dirt, food debris, etc. is apparent, clean lower doors . Thursday: Wipe down cove base, edging and corners where accessible . 3.1-19(f) 3.1-19(f)(5) 3.1-19(g)

Based on interview and record review, the facility failed to ensure documentation was complete and accurate for 4 of 8 resident records reviewed. Insulin administration and nebulizer treatments were not marked as complete on the Medication Administration Record. (Resident C, Resident O, Resident M, Resident U) Findings include: 1. On 12/30/24 at 10:32 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 12/6/24, indicated Resident C had moderate cognitive impairment, required substantial to maximal assistance from staff (staff did more than half) for bathing, and received insulin seven out of seven days during the lookback period. A current risk for hyperglycemia care plan, initiated 5/19/22 and last revised on 12/10/24, included an intervention to give medications as ordered. Physician orders included, but were not limited to: Fiasp FlexTouch U-100 Insulin (insulin aspart) (a short-acting insulin) - 100 unit/mL (units per milliliter) - Administer subcutaneously per sliding scale: If Blood Sugar is less than 60, call Medical Doctor (MD). If Blood Sugar is 0 to 199, give 0 Units. If Blood Sugar is 200 to 249, give 2 Units. If Blood Sugar is 250 to 299, give 3 Units. If Blood Sugar is 300 to 349, give 4 Units. If Blood Sugar is 350 to 399, give 5 Units. If Blood Sugar is 400 to 499, give 6 Units. If Blood Sugar is greater than 500, call MD, dated 11/19/24. insulin glargine solution (a long-acting insulin) 100 unit/mL - Administer 10 units subcutaneously twice a day, dated 11/29/24 with a stop date of 12/23/24. The December 2024 Medication Administration Record (MAR) lacked documentation to indicate Resident C received the 11:00 P.M. dose of insulin aspart on 12/8/24 and 12/10/24 and the 8:00 P.M. dose of insulin glargine on 12/16/24. On 12/31/24 at 9:38 A.M., the Director of Nursing (DON) indicated that she was unsure if Resident C got their insulin as ordered on 12/8/24, 12/10/24, and 12/16/24 since it was not documented as given. 48057 2. On 12/30/24 at 11:24 A.M., Resident U's clinical record was reviewed. Diagnoses included, but were not limited to, type 2 diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 10/16/24, indicated Resident U was cognitively intact, required partial assistance from staff for transfers, and received insulin seven of seven days during the lookback period. Current physician orders included, but were not limited to: Basaglar KwikPen (a hypoglycemic injection); Amount to administer: 60 units subcutaneous, Give half dose of insulin if blood sugar is below 120, at bedtime every day. Start date 10/18/24. The electronic medication administration record (eMAR) lacked documentation for the following: 12/16/24 8:00 P.M. blood sugar results 12/16/24 8:00 P.M. Basaglar insulin administration 3. On 12/30/24 at 12:20 P.M., Resident M's clinical record was reviewed. Diagnoses included, but were not limited to, type 2 diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/29/24, indicated Resident M's cognition was too low to be assessed, resident was substantial assistance (staff did more than half of the work) for toileting, bathing, and transfers, and received insulin seven of seven days during the lookback period. Current physician orders included, but were not limited to: insulin lispro pen; Amount to Administer: 9 units subcutaneous, three times a day, Start date 7/15/24. insulin lispro pen; Amount to Administer: If Blood Sugar is less than 60, call MD. If Blood Sugar is 0 to 149, give 0 Units. If Blood Sugar is 150 to 169, give 1 Units. If Blood Sugar is 170 to 189, give 2 Units. If Blood Sugar is 190 to 209, give 3 Units. If Blood Sugar is 210 to 229, give 4 Units. If Blood Sugar is 230 to 249, give 6 Units. If Blood Sugar is 250 to 269, give 8 Units. If Blood Sugar is 270 to 299, give 10 Units. If Blood Sugar is greater than 299, give 12 Units. If Blood Sugar is greater than 300, call MD. Subcutaneous three times a day, Start date 12/4/24. The electronic medication administration record (eMAR) lacked documentation for the following: 12/28/24 12:00 P.M. insulin lispro 9 units administration 12/28/24 12:00 P.M. blood sugar results 12/28/24 12:00 P.M. insulin lispro sliding scale administration 12/29/24 12:00 P.M. insulin lispro 9 units administration 12/29/24 12:00 P.M. blood sugar results 12/29/24 12:00 P.M. insulin lispro sliding scale administration 4. On 12/30/24 at 2:10 P.M., Resident O's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/20/24, indicated Resident M's cognition was too low to be assessed, resident was dependent assistance (staff did all the work) for toileting, bathing, and mobility, and received oxygen therapy. Current physician orders included, but were not limited to: ipratropium bromide solution 0.02% inhalation (bronchodilator nebulizer medication) four times a day, Start date 11/25/24 Observe pulse, respirations and breath sounds before each nebulizer treatment, Start date 10/31/24 Observe pulse, respirations and breath sounds after each nebulizer treatment, Start date 10/31/24 The electronic medication administration record (eMAR) lacked documentation for the following: 12/1/24 8:00 A.M. ipratrompium bromide administration 12/1/24 8:00 A.M. pre and post nebulizer assessment including pulse, respiration, and breath sounds 12/2/24 8:00 A.M. ipratrompium bromide administration 12/2/24 8:00 A.M. pre and post nebulizer assessment including pulse, respiration, and breath sounds 12/3/24 8:00 A.M. ipratrompium bromide administration 12/3/24 8:00 A.M. pre and post nebulizer assessment including pulse, respiration, and breath sounds 12/6/24 12:00 P.M. ipratrompium bromide administration 12/23/24 8:00 A.M. ipratrompium bromide administration 12/23/24 8:00 A.M. pre and post nebulizer assessment including pulse, respiration, and breath sounds 12/25/24 4:00 P.M. ipratrompium bromide administration 12/25/24 4:00 P.M. pre and post nebulizer assessment including pulse, respiration, and breath sounds On 12/30/24 at 3:09 P.M., the Administrator indicated the facility did not have a nebulizer treatment documentation policy, and indicated all nurses had a nebulizer treatment skills check off during orientation. At that time, she provided a document titled Nebulizer Treatment that indicated 6. Perform pre-assessment including pulse, respiration, and breath sounds . 11. Stay with resident during entire procedure . 13. During procedure perform assessment including pulse, respiration, and breath sounds . 16. Perform post-assessment including pulse, respiration, and breath sounds . 19. Document pertinent information on medication administration record (MAR) and nebulizer treatment flow sheet. During an anonymous interview, it was indicated that the facility was often not fully staffed during the evening shift making it difficult to complete all tasks. They indicated documentation was a task that was left unfinished. On 12/31/24 at 9:53 A.M., the DON provided a current Medication Administration policy, revised 7/2023, that indicated Mediation administration will be recorded on the MAR/EMAR or TAR (Treatment Administration Record) after given. This citation relates to complaint IN00449174. 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to follow the nebulizer policy for 1 of 1 resident reviewed for hospital discharge. (Resident D) The resident was not assessed prior to the nebulizer treatment, facility staff did not stay at bedside during the nebulizer treatment; Resident D was later found by a staff member with no respirations or pulse. Finding includes: On [DATE] at 10:54 A.M., Resident D's clinical record was reviewed. Resident D was admitted on [DATE]. A Minimum Data Set (MDS) Assessment had not been completed. Current physician orders included, but were not limited to: Continuous oxygen at 2 liters per nasal cannula, Start date [DATE] Albuterol sulfate solution (bronchodilator medication) for nebulization; 0.63 mg (milligrams) /3 mL (milliliters) inhalation every 4 Hours, Start date [DATE] Observe pulse, respirations and breath sounds before each nebulizer treatment, four times a day, Start date [DATE] Observe pulse, respirations and breath sounds after each nebulizer treatment, four times a day, Start date [DATE] Code status full code, Start date [DATE] A nursing progress note, dated [DATE] at 10:25 A.M., indicated a Qualified Medication Aide (QMA) yelled for help when Resident D was found not breathing and without a pulse during a breathing treatment. Cardiopulmonary resuscitation (CPR) was started and emergency medical technicians (EMT's) were notified. Resident D was transported to the hospital. The electronic medication administration record (eMAR) on [DATE] lacked documentation for the following: 10:00 A.M. albuterol nebulizer treatment Pulse, respirations, breath sounds, oxygen saturation before nebulizer treatment administration An SBAR physician communication event, dated [DATE] at 10:52 A.M., indicated Resident D was not using oxygen. During an interview on [DATE] at 8:31 A.M., Registered Nurse (RN) 5 indicated that on [DATE] Resident D started a breathing treatment and did not look well. RN 5 left the room while the breathing treatment was running to call the nurse practitioner. RN 5 indicated a QMA yelled for assistance when Resident D was found unresponsive. The Director of Nursing (DON) initiated CPR. During an interview on [DATE] at 9:39 A.M., the DON indicated assessments should be completed and charted by a nurse before, during, and after each breathing treatment, and indicated RN 5 was the only nurse scheduled to cover the nursing duties on all five halls of the first floor from 6:00 A.M. to 2:00 P.M. on [DATE]. On [DATE] at 3:09 P.M., the Administrator indicated the facility did not have a nebulizer treatment policy and indicated all nurses had a nebulizer treatment skills check off during orientation. At that time, she provided a document titled Nebulizer Treatment that indicated 6. Perform pre-assessment including pulse, respiration, and breath sounds . 11. Stay with resident during entire procedure . 13. During procedure perform assessment including pulse, respiration, and breath sounds . 16. Perform post-assessment including pulse, respiration, and breath sounds. 19 . Document pertinent information on medication administration record (MAR) and nebulizer treatment flow sheet. This citation relates to complaint IN00449174. 3XXX,d+[DATE](a)(6)

Based on interview and record review, the facility failed to ensure effective services to treat elevated blood glucose levels were provided in accordance with the physician and Nurse Practitioner (NP) orders for 1 of 2 residents reviewed for insulin administration. (Resident 59) This deficient practice resulted in the resident requiring emergent transport to an acute care hospital intensive care unit for the treatment of diabetic ketoacidosis (DKA) (a life-threatening complication of diabetes that occurs when the body doesn't have enough insulin to use blood sugar for energy.) Finding includes: On 10/29/24 at 12:59 P.M., Resident 59's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most recent comprehensive Significant Change Minimum Data Set (MDS) Assessment, dated 3/21/24, indicated Resident 59 was not assessed for cognitive impairment because the resident was rarely or never understood and the resident received insulin 6 days during the 7-day lookback period. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/29/24, indicated Resident 59 was not assessed for cognitive impairment because the resident was rarely or never understood and the resident received insulin 7 days during the 7-day lookback period. A risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus care plan, dated 4/7/20 and reviewed 9/25/24, included an intervention to document abnormal findings and notify the physician. The July 2024 Physician's order recapitulation included, but was not limited to, orders for staff to administer 20 units of insulin glargine (a long-acting insulin) once daily at bedtime, measure the resident's blood glucose once daily, and notify the physician if Accu-check result is below 60 milligram per deciliter (mg/dL) or greater than 400 mg/dL. A vital sign report, dated 7/2/24 at 10:14 A.M., indicated Resident 59's blood glucose level was 490 mg/dL. The July 2024 Medication Administration Record (MAR) indicated the physician was notified of the elevated blood glucose level on 7/2/24. The Progress notes, medication administration notes, and event forms, dated 7/2/24, lacked documentation to determine the physician responded to or the facility staff made attempts to follow-up with the physician to address the elevated blood glucose level. The progress notes, assessments, monitoring/evaluation tools, physician orders, and medication administration notes lacked documentation to indicate a physician response was received or the facility staff followed up with the physician between 7/2/24 at 10:14 P.M. and 7/6/24 at 1:55 P.M. A vital sign report, dated 7/6/24 at 10:06 A.M., indicated the blood glucometer read HI (blood glucose level greater than 600 mg/dL). The July 2024 MAR indicated the physician was not notified of Resident 59's elevated blood glucose level on 7/6/24. The progress notes, assessments, monitoring/evaluation tools, physician orders, and medication administration notes lacked documentation to indicate the physician was contacted between 7/6/24 at 10:06 A.M. and 7/6/24 at 1:55 P.M. A Physician Communication note, dated 7/6/24 at 1:55 P.M., indicated the physician was notified the resident was not acting like herself. The resident did not want to eat, refused to drink her fluids, was not walking according to her baseline, and was urinating a large amount. The note indicated the resident had an increased heart rate of 119 beats per minute (bpm) and respirations of 24 respirations per minute (rpm). A Physician/NP order, dated, 7/6/24 at 2:09 P.M., indicated orders were received for staff to immediately (STAT) obtain blood draws for a complete blood count (CBC) (a laboratory test to measure the number and type of cells in blood and a comprehensive metabolic panel (CMP) (a laboratory test that measures 14 substances in your blood to provide information about your metabolism and chemical balance). A Nursing progress note, dated 7/6/24 at 11:01 P.M., indicated the lab called the facility at 6:00 P.M. to report Resident 59 had a critical blood glucose level of 526 mg/dL. The NP was texted and called by Licensed Practical Nurse (LPN) 6 about critical lab value. A response was not received. A message screenshot, dated 7/6/24 at 6:50 P.M., indicated staff texted the critical blood glucose level to the NP and requested orders, but did not receive a response. A laboratory report, dated 7/6/24 at 4:53 P.M., indicated Resident 59 had a blood glucose level of 526 mg/dL. An untimed handwritten note on the report, signed by the Director of Nursing (DON) indicated the NP was notified on 7/7/24. The report did not include sufficient documentation to determine the facility notified the physician or the NP, between 7/6/24 at 4:54 P.M. and 7/7/24 at 8:53 A.M., of the elevated blood glucose level. A Nursing progress note, dated 7/7/24 at 8:54 A.M., indicated the nurse attempted to contact the NP again for the critical blood glucose level. The July 2024 Physician's recapitulation dated 7/7/24 at 9:39 A.M., indicated the following order was received: Humalog (insulin lispro) KwikPen - insulin lispro (a short-acting insulin) - Give per Sliding Scale subcutaneous, three times a day, If Blood Sugar is less than 60 mg/dL, call physician. If Blood Sugar is 0 to 199, give 0 Units. If Blood Sugar is 200 to 249, give 1 Units. If Blood Sugar is 250 to 299, give 2 Units. If Blood Sugar is 300 to 349, give 3 Units. If Blood Sugar is 350 to 399, give 4 Units. If Blood Sugar is 400 to 499, give 5 Units. If Blood Sugar is greater than 500, call physician. A vital sign report, dated 7/7/24 at 12:24 P.M., indicated Resident 59's blood glucose level was 548 mg/dL. The July 2024 Medication Administration Record (MAR) indicated no insulin lispro was administered to Resident 59, on 07/07/24, to treat the blood glucose level of 548 mg/dL. A vital sign report, dated 7/7/24 at 4:25 P.M., indicated Resident 59's blood glucose level was 582 mg/dL. The progress notes, medication administration notes, monitoring/evaluation tools, and physician orders, dated 7/7/24, did not include documentation to indicate the physician was notified of the elevated blood glucose levels or new orders were received to treat the blood glucose levels of 548 mg/dL or 582 mg/dL. The July 2024 MAR indicated Resident 59's 8:00 A.M. dose of insulin lispro on 7/8/24 was given by Registered Nurse (RN) 15, but did not indicate the blood glucose was measured prior to administration, how much insulin was given, or the body site where the insulin was given. Progress notes and the vital sign report, dated between 7/7/24 at 4:25 P.M. and 7/8/24 at 11:25 A.M., lacked documentation to indicate a blood glucose level was obtained. A nursing progress note, dated 7/9/24 at 9:04 A.M., indicated Resident 59 became unresponsive during a meal, staff performed a sternal rub, and a blood glucose check was conducted. The Accu-check measured the blood glucose as, HI, the heart rate was 123 bpm the respirations were 22 rpm, and the resident was panting. The progress note indicated the resident had no recent fluid intake. The note indicated the NP was notified and orders were received to send the resident to the emergency room (ER) for evaluation and treatment. A hospital admission assessment, dated 7/9/2024 at 9:54 A.M., identified the resident had a urinary tract infection (UTI). The assessment included, but was not limited to, the following laboratory results: The blood glucose measured 742 mg/dL with a reference range of 70 - 99 mg/dL. The white blood cell count measured 21.2 thousands per microliter (THOUS/uL) with a reference range of 4.0 - 10.3 THOUS/uL. The urinalysis measured positive for greater than 1000 mg/dL glucose with a reference range of negative. The assessment indicated Resident 59 was admitted to the Intensive Care Unit (ICU) for treatment of diabetic ketoacidosis (DKA). Hospital discharge papers, dated 7/15/24 at 10:14 A.M., indicated Resident 59 was discharged back to the facility after being admitted to the hospital for acute metabolic encephalopathy (ME) (a condition that occurs when the body lacks oxygen, glucose, or vitamins), DKA, and UTI. During an interview with the DON on 10/30/24 at 11:59 A.M., she indicated all notifications to the physician was documented as a progress note. During an interview with the Director of Nursing (DON) on 10/30/24 at 1:44 P.M., she indicated the nurse called the NP for the blood sugars over 500 mg/dL on 7/7/24. The NP said to give five units over the maximum units on the sliding scale. The documentation system would not let her input that she gave 10 units, so she put she gave zero units. She did not document the notification to the NP, the new order, or the insulin administration amount in a progress note or as a medication administration note, but she should have. At that time, the DON was unable to provide documentation to indicate the nurse gave 10 units of insulin. During an interview with the DON on 10/30/24 at 1:59 P.M., she indicated Licensed Practical Nurse (LPN) 6 did not remember if she gave the 8 A.M. dose of insulin lispro or not. The DON was unsure what Resident 59's blood glucose was at 8:00 A.M. on 7/8/24 at 8:00 A.M., or how many units of insulin lispro were given if any. During an interview, on 11/1/24 at 8:15 A.M., the Administrator indicated text messages were not part of the clinical record. During an interview with the Administrator on 11/1/24 at 8:51 A.M., she indicated staff texted the NP and didn't need to document all communication in the progress notes. During an interview with the Nurse Practitioner (NP) on 11/1/24 at 9:00 A.M., the NP indicated staff texted her and if there was no response after 15 to 30 minutes, they would call her. If she still didn't respond, they were to call the on-call physician. She did not have a record of being contacted on 7/2/24 in relation to Resident 59's elevated blood glucose level. She indicated she would have advised staff to recheck the blood sugar in an hour and call back if it was still high. The NP indicated she was unable to find a recheck of blood glucose levels for Resident 59 on 7/2/24. The NP indicated the sliding scale insulin order was for one week on a trial basis and then the resident would be re-evaluated. At that time, the NP was unable to provide documentation that the insulin order was on a trial basis and when the resident was to be re-evaluated. The NP indicated she did not have documentation of being contacted on 7/7/24 in relation to Resident 59's elevated blood glucose level. She indicated she would have ordered four units of insulin above the highest number on the sliding scale to be given, making the total insulin nine units for that administration time. She indicated four units of insulin above the highest number on the sliding scale for a blood glucose level over 400 mg/dL should have been a standing order from that point on. The NP indicated that she was not contacted by a nurse on 7/8/24 about Resident 59's blood glucose level, insulin, or a missed dose. The NP was unsure what Resident 59's blood glucose was at 8:00 A.M. on 7/8/24 or how many units of insulin lispro were given. On 11/1/24 at 11:33 A.M., the Administrator provided a current Blood Glucose Monitoring policy, dated 2/2015, that indicated, .The physician will be notified when the resident's blood glucose is outside the physician stated parameters or if the resident is experiencing signs or symptoms of high or low blood sugars . On 11/1/24 at 2:06 P.M., the Administrator provided a current Resident Change of Condition policy, dated 12/2017, that indicated, .It is the policy of this Community that changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention occurs . All nursing actions, physician contacts, and resident assessment information will be documented in the Progress Notes . Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation . If unable to contact attending physician timely, the resident will be transferred for emergency services . Documentation will include time and family/physician response . On 11/1/24 at 2:06 P.M., the Administrator provided a current General Dose Preparation and Medication Administration policy, dated 4/30/24, that indicated .Document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site) on appropriate forms . On 11/1/24 at 2:06 P.M., the Administrator provided a current Authorization and Communication of Orders policy, dated 6/1/24, that indicated .Facility should ensure that the authorized person receiving a verbal order immediately records it in the resident's chart or electronic order system, including the date and time of the order, the name of physician/prescriber, the signature of the person recording the order and other information as permitted by and in accordance with applicable law . The article, About Diabetic Ketoacidosis, dated 5/15/24, was retrieved on 11/5/24 from the Center for Disease Control and Prevention (CDC) website at https://www.cdc.gov/diabetes/about/diabetic-ketoacidosis.html#:~:text=also%20develop%20DKA.-,DKA%20develops%20when%20your%20body%20doesn't%20have%20enough%20insulin,dangerous%20levels%20in%20your%20body. The guidance included: .DKA is a serious complication of diabetes that can be life-threatening. DKA is most common among people with type 1 diabetes. People with type 2 diabetes can also develop DKA. DKA develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body . The article, Metabolic Encephalopathy, dated 7/10/24, was retrieved on 11/5/24 from the Cleveland Clinic website at https://my.clevelandclinic.org/health/diseases/metabolic-encephalopathy. The guidance included: .Metabolic encephalopathy is a brain dysfunction caused by an underlying condition. Many possible conditions can cause metabolic encephalopathy, but these mainly target your metabolism. Your metabolism is the chemical process that converts the things you eat and drink into energy. Brain dysfunction can affect your mood, thinking and memory or cause a loss of consciousness (coma). All metabolic encephalopathies require medical attention. If left untreated, they can be life-threatening or cause permanent brain damage . 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure medications were properly dated, labeled, and not expired in 5 of 5 medication carts and 2 of 2 treatment carts. (1500 Hall Medication Cart, 1400 Hall Medication Cart, Memory Care Medication Cart, ,d+[DATE] Hall Medication Cart, 2500 Hall Medication Cart, First Floor Treatment Cart, Second Floor Treatment Cart) Findings include: 1. On [DATE] at 8:45 A.M., 1500 Hall Medication Cart was observed to with the following: RN (Registered Nurse) 12 indicated each resident had their own glucometer (Instrument to measure blood sugars) and insulin is kept in the pouches. [Resident Name]106's insulin pouch had the following: 1 vial of opened Humulin R (Regular) insulin with no open date 2 Glargine Insulin Pen with no label [Resident Name] insulin pouch had the following: Glargine Insulin pen with no open date 1 bottle of Nasal Saline for [Resident Name] expired ,d+[DATE] 1 bottle of Liquid Protein no label During an interview on [DATE] at 8:45 A.M., RN 12 indicated medication bottles should have an open date and label. There should not be anything expired in the carts. 2. On [DATE] at 9:02 A.M., the 1400 Hall Medication cart was observed with the following: 1 bottle of Sterile Water with an expiration of [DATE] 3. On [DATE] at 9:08 A.M., the Treatment Cart for the First Floor was observed to have: 1 opened bottle of Betadine (Antiseptic Cleaner) labeled with [Resident Name] in black Sharpee without and open date. During an interview on [DATE] at 9:10 A.M., RN 12 indicated when a resident is discharged the medication will be returned or destroyed. 4. On [DATE] at 9:20 A.M., the Medication Cart for the Memory Care Unit was observed with the following: In the top drawer of the medication cart: 1 silver colored necklace 1 silver colored ring 1 silver colored with blue stones watch 1 unopened 0.1 mg (Milligrams) Clonidine pill package 1 Bottle of MiraLAX (laxative) with no label During an interview on [DATE] at 9:25 A.M., RN 16 indicated there should not be any jewelry in the medication drawer and it should be labeled 5. On [DATE] at 9:30 A.M., the ,d+[DATE] Hall Medication Cart was observed with the following: 1 small white oblong pill 1 opened bottle of Nitroglycerin (Antianginal) for [Resident name] with no date 6. On [DATE] at 9:49 A.M., the 2500 Medication Cart was observed with the following: ,d+[DATE] small round orange pill 1 small round white pill # 49 3 opened bottles of MiraLAX with no open date 7. On [DATE] at 10:15 A.M., the Second Floor Treatment Cart was observed with the following: 1 bottle of Nystatin Powder for [Resident Name] no open date 1 bottle of antifungal cream no label or date open 1 bottle of Ketoconazole shampoo that expired in ,d+[DATE] 3 tubes of open hydrophile for [Resident Name] no open date 9 bottles of Ketoconazole shampoo with [Resident's Names] that were not dated when opened 1 opened container of Bag Balm (ointment) that had no label or open date There was a sticky white substance on a drawer of the treatment cart During an interview on [DATE] at 10:20 A.M., LPN (Licensed Practical Nurse) 13 indicated the Bag Balm should be labeled and dated. LPN 13 also indicated that she would date any tubes that were opened. During an interview on [DATE] at 12:29 P.M., the DON (Director of Nursing) indicated antifungals were stock medications until they were opened at which time they would be assigned to a resident and require a label. 8. On [DATE] at 10:27 A.M., the 2200 Hall Medication Cart was observed with the following: 2 opened bottles of MiraLAX for [Resident Named] no open date 9. On [DATE] at 10:40 A.M., the Medication Refrigerator in the Medication Storage room was observed with the following: 1 container of Mary's Magic cream for [Resident Name] with no open date. On [DATE] at 12:59 P.M., the Administrator provided a current policy Storage and Expiration Dating of Medications and Biologicals revised on [DATE]. The policy indicated .facility should ensure that medications and biologicals that: have an expired dated on the label and have been retained longer than the recommended manufacturer or supplier guidelines until destroyed .Once any medication or biological is opened .facility staff should record the date opened on the primary container 3XXX,d+[DATE](j) 3XXX,d+[DATE](o)

Based on interview and record review, the facility failed to ensure a resident did not develop an avoidable pressure ulcer by monitoring skin for 1 of 3 residents reviewed for facility acquired pressure ulcers. (Resident 89) Finding includes: During an interview on 10/24/24 at 2:22 P.M., Resident 89 indicated she had pressure injuries on her right leg from her knee immobilizer not being monitored. On 10/28/24 at 2:40 P.M., Resident 89's clinical record was reviewed. Diagnoses included, but were not limited to congestive heart failure and diabetes mellitus. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 8/7/24, indicated resident 89 was cognitively intact, was fully dependent on staff for transfers, required substantial assistance from staff (staff do more than half the work) for toileting and bathing, and did not have any unhealed pressure ulcers. Current physician orders included, but were not limited to: Right calf: cleanse wound with wound cleanser, pat dry; wound to be packed by wound NP (nurse practitioner) with skin sub, cover with silicone dressing, then steri-strips, then cover with a dry dressing. Change 1x weekly by Wound NP. Outer dressing to be changed PRN if soiled/dislodged. Once a day on Wednesday, Start date 10/2/24. Current care plans included, but were not limited to: Impaired mobility related to: right nondisplaced fracture medial tibial plateau; Assess and document skin condition weekly and as needed. Date initiated 6/12/24. The care plan did not specify to remove the immobilizer and check skin under the immobilizer. A nursing progress note, dated 6/12/24 at 10:14 P.M. indicated Resident 89 returned from a hospital stay, from 6/8/24 through 6/12/24 due to fall with fracture in facility that occurred on 6/8/24, with a knee immobilizer to the right leg. A nursing progress note, dated 7/23/24 at 2:33 P.M., indicated Resident 89 had returned from an orthopedic appointment with orders to discontinue the knee immobilizer on Resident 89's right leg. An IDT (interdisciplinary team) note, dated 7/26/24 at 9:48 A.M., indicated Resident 89's right lateral calf noted to have two unstageable pressure wounds related to the knee immobilizer. A skin and wound note, dated 7/31/24 at 6:45 P.M., indicated Resident was assessed by the wound NP due to a deep tissue injury to the right posterior leg caused by right leg brace, measured at 4.8 centimeters (cm) by 1.3 cm by 0.1 cm. The clinical record, including assessments, observations, events, progress notes, and documents, lacked skin assessments completed during the following weeks while Resident 89 had a right knee immobilizer in place: 6/12/24-6/18/24 6/20/24-7/2/24 7/4/24-7/23/24 During an interview on 11/1/24 at 2:09 P.M., the Director of Nursing indicated there were not skin assessments completed during the missing weeks in June and July. On 11/1/24 at 11:36 A.M., the Administrator provided a policy titled Skin Management Program, revised 5/22, that indicated the purpose of the policy was To promote the prevention of pressure/ulcers/injury development. Avoidable pressure ulcer/injury: means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to manufacture and professional standard for 1 of 5 residents observed during medication pass. (Resident 89) Two medication errors were observed during 26 opportunities for error in medication administration. This resulted in a 7.69% error rate. (Resident 89) Findings include: During a medication administration on 10/25/24 at 7:55 A.M., LPN (Licensed Practical Nurse) 13 prepared Glargine Insulin 30 Units SQ (Subcutaneous) bid (two times a day) and Lispro 10 units SQ tid (three times a day) and did not prime the two insulin injection pens with two units prior to administering. On 10/25/24 at 1:45 P.M., Resident 89's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus and Systemic Lupus erythematosus. Physician orders included, but were not limited to, Insulin Glargine-insulin pen; 100 unit/mL (Milliliters) (3 mL); amt (amount): 30 units; subcutaneous. Special Instructions: Give half dose of insulin if BS (Blood Sugar) < (Less Than)120, Twice A Day, 8:00 A.M. and 8:00 P.M, dated 10/24/24. Lispro Insulin pen; 100 unit/mL; amt: 10 units; subcutaneous. Special Instructions: Do not administer if BS is below 100. Give Three Times A Day, 8:00 A.M., 12:00 P.M., and 5:00 P.M. dated 9/10/24. During an interview on 10/25/24 at 8:00 A.M., LPN 13 indicated she was unaware of priming the insulin prior to administering. On 10/25/24 at 12:59 P.M., the Administrator provided a current, non-dated Patient Information Insert for Humalog Kwik Pen. The insert indicated .turn the knob to 2 units .priming ensures the Pen is ready and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin . 3.1-48(c)(1)

Based on interview and record review, the facility failed to ensure documentation was complete and accurate for 1 of 2 residents reviewed for insulin use. (Resident 59) Finding includes: On 10/29/24 at 12:59 P.M., Resident 59's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/29/24, indicated Resident 59 was not assessed for cognitive impairment because the resident was rarely or never understood and the resident received insulin 7 days during the 7-day lookback period. The July 2024 Physician's recapitulation orders dated 7/7/24 at 9:39 A.M., indicated the following order was received: Humalog (insulin lispro) KwikPen - insulin lispro (a short-acting insulin) - Give per Sliding Scale subcutaneous, three times a day, If Blood Sugar is less than 60 mg/dL, call physician. If Blood Sugar is 0 to 199, give 0 Units. If Blood Sugar is 200 to 249, give 1 Units. If Blood Sugar is 250 to 299, give 2 Units. If Blood Sugar is 300 to 349, give 3 Units. If Blood Sugar is 350 to 399, give 4 Units. If Blood Sugar is 400 to 499, give 5 Units. If Blood Sugar is greater than 500, call physician. A risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus care plan, dated 4/7/20 and reviewed 9/25/24, included an intervention to document abnormal findings and notify the physician. A vital sign report, dated 7/2/24 at 10:14 A.M., indicated Resident 59's blood glucose level was 490 mg/dL. The July 2024 Medication Administration Record (MAR) indicated the physician was notified of the elevated blood glucose level on 7/2/24. The Progress notes, medication administration notes, and event forms, dated 7/2/24, lacked documentation to determine the physician responded to or the facility staff made attempts to follow-up with the physician to address the elevated blood glucose level. A Physician/NP order, dated, 7/6/24 at 2:09 P.M., indicated orders were received for staff to immediately (STAT) obtain blood draws for a complete blood count (CBC) (a laboratory test to measure the number and type of cells in blood and a comprehensive metabolic panel (CMP) (a laboratory test that measures 14 substances in your blood to provide information about your metabolism and chemical balance). A Nursing progress note, dated 7/6/24 at 11:01 P.M., indicated the lab called the facility at 6:00 P.M. to report Resident 59 had a critical blood glucose level of 526 mg/dL. The NP was texted and called by Licensed Practical Nurse (LPN) 6 about critical lab value. A response was not received. A message screenshot, dated 7/6/24 at 6:50 P.M., indicated staff texted the critical blood glucose level to the NP and requested orders, but did not receive a response. A vital sign report, dated 7/7/24 at 12:24 P.M., indicated Resident 59's blood glucose level was 548 mg/dL. The July 2024 Medication Administration Record (MAR) indicated no insulin lispro was administered to Resident 59, on 07/07/24, to treat the blood glucose level of 548 mg/dL. A vital sign report, dated 7/7/24 at 4:25 P.M., indicated Resident 59's blood glucose level was 582 mg/dL. The July 2024 Medication Administration Record (MAR) indicated no insulin lispro was administered to Resident 59, on 07/07/24, to treat the blood glucose level of 582 mg/dL. The July 2024 MAR indicated Resident 59's 8:00 A.M. dose of insulin lispro on 7/8/24 was given by Registered Nurse (RN) 15, but did not indicate the blood glucose was measured prior to administration, how much insulin was given, or the body site where the insulin was given. During an interview with the Director of Nursing (DON) on 10/30/24 at 1:44 P.M., she indicated the nurse called the NP for the blood sugars over 500 mg/dL on 7/7/24. The NP said to give five units over the maximum units on the sliding scale. The documentation system would not let her input that she gave 10 units, so she put she gave zero units. She did not document the notification to the NP, the new order, or the insulin administration amount in a progress note or as a medication administration note, but she should have. At that time, the DON was unable to provide documentation to indicate the nurse gave 10 units of insulin. During an interview with the DON on 10/30/24 at 1:59 P.M., she indicated Licensed Practical Nurse (LPN) 6 did not remember if she gave the 8 A.M. dose of insulin lispro on 7/8/24 or not. The DON was unsure what Resident 59's blood glucose was at 8:00 A.M. on 7/8/24 at 8:00 A.M., or how many units of insulin lispro were given if any. During an interview, on 11/1/24 at 8:15 A.M., the Administrator indicated text messages were not part of the clinical record. During an interview with the Administrator on 11/1/24 at 8:51 A.M., she indicated staff texted the NP and didn't need to document all communication in the progress notes. During an interview with the Nurse Practitioner (NP) on 11/1/24 at 9:00 A.M., the NP indicated that she did not have a record of being contacted on 7/2/24 in relation to Resident 59's elevated blood glucose level. She indicated she would have advised staff to recheck the blood sugar in an hour and call back if it was still high. The NP indicated she was unable to find a recheck of blood glucose levels for Resident 59 on 7/2/24. The NP indicated the sliding scale insulin order was for one week on a trial basis and then the resident would be re-evaluated. At that time, the NP was unable to provide documentation that the insulin order was on a trial basis and when the resident was to be re-evaluated. The NP indicated she was not contacted by a nurse on 7/8/24 about Resident 59's blood glucose level, insulin, or a missed dose. The NP was unsure what Resident 59's blood glucose was at 8:00 A.M. on 7/8/24 or how many units of insulin lispro were given. On 11/1/24 at 2:06 P.M., the Administrator provided a current General Dose Preparation and Medication Administration policy, dated 4/30/24, that indicated Document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site) on appropriate forms. On 11/1/24 at 2:06 P.M., the Administrator provided a current Authorization and Communication of Orders policy, dated 6/1/24, that indicated Facility should ensure that the authorized person receiving a verbal order immediately records it in the resident's chart or electronic order system, including the date and time of the order, the name of physician/prescriber, the signature of the person recording the order and other information as permitted by and in accordance with applicable law. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation and interview, the facility failed to ensure infection control practices were in place for 2 of 2 residents during incontinence care and 1 of 1 resident during wound care. Staff failed to sanitize hands and change gloves between soiled to clean tasks, as well as failed to use enhanced barrier precautions during wound care. (Resident 64, Resident 85, and Resident 86) Findings included: 1. On 10/24/24 at 10:43 A.M., CNA (Certified Nurses Aide) 3 went into Resident 64's room. CNA 3 donned gloves, checked the resident's brief to see if they were incontinent, started to act upon changing the soiled brief but then indicated they would go get another staff member to assist. CNA 3 touched the resident's remote to their bed, and bedside table with soiled gloves before removing them then did not sanitize or wash hands. On 10/29/24, at 11:44 A.M., Resident 64's clinical record was reviewed. The Annual MDS (Minimum Data Set) Assessment on 8/5/24 indicated the resident was not cognitively intact, required substantial or maximum assistance with toileting and personal hygiene, was always incontinent of bowel and bladder, and had a diagnosis that included but was not limited to dementia. 2. On 10/25/24 at 10:58 A.M. Resident 85 indicated that they got frequent urinary tract infections because staff did not clean her properly. The clinical record was reviewed on 10/28/24 at 2:49 P.M. A Quarterly MDS (Minimum Data Set) Assessment, dated 9/24/24, indicated the resident was cognitively intact, used a wheel chair, required substantial to maximum assistance with bathing and personal hygiene, was incontinent of bowel and bladder, had a primary diagnosis of COPD (chronic obstructive pulmonary disease), had a urinary tract infection within the last 30 days, had an intravenous catheter, had been on intravenous medications, required isolation precautions, and was on antibiotics. On 10/31/24, at 9:22 A.M., while peri care and linen change was performed for Resident 85 CNA (Certified Nurses Aide) 7 stopped QMA (Qualified Medication Aide) 5 to remind them to change their gloves before proceeding after the resident's soiled incontinence brief was removed and skin was cleansed. QMA 5 took off soiled gloves and put on clean gloves, did not wash or sanitize hands. CNA 7 did not change their gloves, wash or sanitize hands, after removing soiled bed pan from underneath the resident before continuing with care, including assisting the resident with washing their face. 48147 3. On 10/29/24 at 10:15 A.M., Resident 86's clinical record was reviewed. Diagnoses included, but were not limited to, stage 4 pressure ulcer of sacral region. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 10/11/24, indicated Resident 86 had no cognitive impairment, required substantial to maximal assistance of staff (staff does more than half) for all Activities of Daily Living (ADLs), and had one stage 4 pressure ulcer on admission to the facility. The most current wound assessment, dated 10/23/24, indicated Resident 86 had a pressure ulcer on the sacrum that measured 8.8 centimeters (cm) in length, 8 cm in width, and 1.3 cm in depth. Care plans included, but were not limited to: Resident is at risk of transferring or becoming colonized with an MDRO (multi-drug resistant organism) and requires enhanced barrier precautions due to an indwelling medical device and a chronic wound that requires a dressing, dated 9/16/24. Interventions included, but were not limited to, enhanced barrier precautions and wear gown and gloves prior to high contact resident care activities. The clinical record lacked physician orders for EBP. On 10/30/24 at 9:40 A.M., Licensed Practical Nurse (LPN) 4 was observed performing wound care for Resident 86. LPN 4 was not wearing a gown while performing the wound care. A sign indicating Resident 86 was on Enhanced Barrier Precautions (EBP) was observed hanging on the wall by the gloves in the room. On 10/31/24 at 10:44 A.M., the Infection Preventionist (IP) indicated that residents with wounds automatically got placed on EBP. Staff should wear gown and gloves while performing any major care for the resident on EBP. On 10/31/24 at 10:56 A.M., the Administrator provided a current undated Enhanced Barrier Precautions policy that indicated Enhanced Barrier Precautions expands the use of PPE (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated, it refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Enhanced barrier precautions are used for: Resident(s) with chronic wounds and/or indwelling medical devices, regardless of their MDRO status . 3.1-18(b)(2) 3.1-18(l)

Based on interview, observation, and record review, the facility failed to administer non-pharmalogical or pharmalogical interventions for pain prior to performing wound care for 1 of 2 residents observed for wound care. (Resident 104) Finding includes: On 10/29/24 at 9:46 A.M., Resident 104's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of lymph nodes of head, face, and neck and squamous cell carcinoma of skin of scalp and neck. A Significant Change MDS (Minimum Data Set) Assessment, dated 9/3/24, indicated Resident 104 was cognitively intact, was completely dependent on staff for transfers required substantial assistance from staff (staff does more than half the work) for toileting and bathing, received as needed pain medication in the last five days and had not received non-medication intervention for pain in the past five days. Current physician orders included, but were not limited to: hydrocodone-acetaminophen schedule II tablet 5-325 mg; oral every four hours as needed, start date 9/10/24. Betadine (povidone-iodine) solution; 10%; 1 application; topical. Special Instructions: Betadine wash to left heel once a day, start date 8/28/24. Care plans included, but were not limited to: Resident is at risk for pain. Offer non pharmacological interventions such as quiet environment, rest, shower, back rub, reposition. Administer medications as ordered. Start date 8/5/24. During an observation on 10/30/24 at 10:56 A.M., RN 12 entered Resident 104's room and told Resident 102 she was going to start the wound treatment on his foot. Resident 104 requested pain medication before RN 12 started the wound treatment. RN 12 started to perform wound care and Resident 102 began grimacing and stating he was in pain and would like pain medication before wound care. RN 12 yelled into the hall for another nurse; RN 10 entered Resident 104's room and RN 12 handed RN 10 the medication cart keys and asked her to get a narcotic pain medication for Resident 102. RN 12 continued cleaning Resident 102's wound and painted the left heel with Betadine. Resident 104 continued to grimace and request pain medication. RN 10 returned to Resident 104's room and handed RN 12 a medication cup. RN 12 spoon the medication and applesauce slurry into Resident 104's mouth. RN 12 did not offer to reposition Resident 104 or to postpone the wound treatment. During an interview on 11/1/24 at 1:42 P.M., Resident 104 indicated he does not receive routine pain medications and that staff never give the pain medication time to take effect before beginning wound treatments. On 11/1/24 at 11:36 A.M., the Administrator provided a policy titled Pain Management, revised 7/24, that indicated It is the policy to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management. A plan of care will be written with the initiation of pain medication and individualization to the resident and alternative pain relief techniques. 3.1-37(a)

Based on record review and interview the facility failed to ensure a resident had a care plan implemented related to frequent urinary tract infections (UTI) with multidrug resistant organisms for 1 of 1 residents reviewed for UTI. (Resident 85) Finding includes: On 10/25/24 at 10:58 A.M. Resident 85 indicated that they got frequent urinary tract infections because staff did not clean her properly. The clinical record was reviewed on 10/28/24 at 2:49 P.M. Resident 85 had diagnoses that included but was not limited to urinary tract infection. A Quarterly MDS (Minimum Data Set) Assessment, dated 9/24/24, indicated the resident was cognitively intact, used a wheel chair, required substantial to maximum assistance with bathing and personal hygiene, was incontinent of bowel and bladder, had a primary diagnosis of COPD (chronic obstructive pulmonary disease), had a urinary tract infection within the last 30 days, had an intravenous catheter, had been on intravenous medications, required isolation precautions, and was on antibiotics. Current physician orders included but was not limited to: Urine is colonized with ESBL (Extended-spectrum beta-lactamase, causes problems in efficacy of antibiotics making infection resistant to treatment) dated, 9/6/22. On 11/1/24 at 9:45 A.M., the DON (Director of Nursing) indicated that she would have expected Resident 85 to have an ongoing careplan related to recurrent urinary tract infections and colonization of ESBL in the resident's urine. A policy provided by the Administrator on 11/1/24, at 11:33 A.M., titled IDT Comprehensive Care Plan Policy, indicated it is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on the Resident Assessment Instrument process. The care plan must include measurable goals and resident specific interventions based on the resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being. 3.1-35(a) 3.1-35(b)(1)

Based on interview and record review, the facility failed to notify the physician of blood glucose levels outside of parameters for 1 of 2 residents reviewed for insulin administration. (Resident 59) Finding includes: On 10/29/24 at 12:59 P.M., Resident 59's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/29/24, indicated Resident 59 was not assessed for cognitive impairment because the resident was rarely or never understood and the resident received insulin 7 days during the 7-day lookback period. Physician orders included, but were not limited to: Accu-check (a blood glucose monitoring system) once a day - Notify physician if Accu-check is below 60 milligram per deciliter (mg/dL) or greater than 400 mg/dL, dated 4/22/20 A risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus care plan, dated 4/7/20 and reviewed 9/25/24, included an intervention to document abnormal findings and notify the physician. A vital sign report, dated 7/6/24 at 10:06 A.M., indicated the blood glucometer read HI (blood glucose level greater than 600 mg/dL). The July 2024 MAR indicated the physician was not notified of Resident 59's elevated blood glucose level on 7/6/24. A Nursing progress note, dated 7/6/24 at 11:01 P.M., indicated the lab called the facility at 6:00 P.M. to report Resident 59 had a critical blood glucose level of 526 mg/dL. The NP was texted and called by Licensed Practical Nurse (LPN) 6 about critical lab value. A response was not received. The clinical record lacked documentation of follow up with the physician about Resident 59's critical blood glucose level between 7/6/24 at 11:01 P.M. and 7/7/24 at 8:54 A.M. A Nursing progress note, dated 7/7/24 at 8:54 A.M., indicated the nurse attempted to contact the NP again for the critical blood glucose level. During an interview with the Nurse Practitioner (NP) on 11/1/24 at 9:00 A.M., the NP indicated staff texted her and if there was no response after 15 to 30 minutes, they would call her. If she still didn't respond, they were to call the on-call physician. On 11/1/24 at 11:33 A.M., the Administrator provided a current Blood Glucose Monitoring policy, dated 2/2015, that indicated The physician will be notified when the resident's blood glucose is outside the physician stated parameters or if the resident is experiencing signs or symptoms of high or low blood sugars. On 11/1/24 at 2:06 P.M., the Administrator provided a current Resident Change of Condition policy, dated 12/17, that indicated It is the policy of this Community that changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention occurs . All nursing actions, physician contacts, and resident assessment information will be documented in the Progress Notes . Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation . If unable to contact attending physician timely, the resident will be transferred for emergency services . Documentation will include time and family/physician response. 3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure a the facility implemented the resident's discharge process for 1 of 3 residents reviewed for transfer/discharge rights. A resident who lacked the ability to care for herself discharged home from the facility prior to the arrangement of a home health service and without documentation being completed according to the facility's discharge policy. (Resident B) Finding includes: During record review on 5/8/24 at 11:00 A.M., Resident B's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety, chronic pain, history of falls, weakness, and unsteadiness on feet. Resident B's hospital notes from a hospital admission on 3/22/24, prior to admitting to the facility on [DATE], included, but was not limited to the following physician note; .I have a great deal of concern with the overall safety and stability of this patient, both socially and mentally. As her own outpatient PCP (Primary Care Physician) team is unwilling to admit her, she was verbally abusive to hospital staff, she is questionably being neglected by her home care team, I really question her ability to maintain appropriate outpatient resources and follow up. She is extremely high-risk for multiple readmissions, decompensation, complications and death. I have made a case management referral at this time, I fully encourage and recommend an in-depth Adult Protective Services [APS] investigation into this patient's well-being . Resident B's care plan included but was not limited to; Resident requires assistance with ADLs (Activities of Daily Living) including bed mobility, transfers, eating, and toileting, started 4/12/24. Resident is at risk for falls, started 4/12/24. Resident B's progress notes included the following: A Nurse's Note dated, 4/14/24 at 7:30 A.M., Resident has been yelling out since arrival of nurse. Resident attempting to scoot self out of chair. Nurse explained to resident that she can't get up out of the chair on her own, and that it took a minimum of three staff members to transfer the resident. A Social Service Note dated, 4/14/24 at 2:55 P.M., Resident wanting to go home but SS 4 (Social Service) had explained to her that she needs to see the doctor in the morning. A Social Service Note dated, 4/15/24 at 11:00 A.M., Social Service sent referral to hospice company for resident upon discharge home per resident request. Awaiting response. A Nurse's Note dated, 4/15/24 at 1:52 P.M., Orders to discharge patient home on hospice with hospice company and husband. Resident being sent home with medications and belongings. Resident is going home via car. Resident is not showing any signs or symptoms of distress and is aware of the plans to discharge home with hospice. A Social Service Note dated, 4/15/24 at 2:27 P.M., Social Service informed resident is wishing to discharge from facility today, order for discharge obtained. Social Service reached out to hospice company requesting status on resident referral. Representative stated she would have hospice staff contact Social Service back with status and confirmation of acceptance from hospice company before proceeding with discharge. Resident B's physician order's included, but was not limited to, may discharge home with hospice services, dated 4/15/24. An invalidated Discharge Summary for Resident B, dated 4/15/24, was completed and lacked a signature from Resident B or a resident representative. The discharge summary was invalidated on 5/3/24. During an interview on 5/8/24 at 12:45 P.M., SS 4 indicated that when a resident is discharged from the facility, a discharge summary is completed and signed by the resident or resident representative. Once the resident signs the discharge summary, a discharge packet that includes discharge orders and a discharge plan is given to the resident. SS 4 indicated that a discharge summary was completed for Resident B and that the facility was waiting on Resident B to sign. SS 4 was unsure if Resident B ever signed the discharge summary before discharging from the facility. Resident B was discharged from the facility with an order for hospice services to evaluate her. The hospice company met Resident B at her home after the discharge from the facility and did not accept Resident B. The original hospice company then referred Resident B to another hospice company and SS 4 indicated being unsure if she was accepted by the second hospice company. SS 4 indicated that Resident B was unable to care for herself and that typically the facility would assure a resident had been accepted to a home healthcare provider before being discharged . During an interview on 5/9/24 at 9:05 A.M., the Administrator indicated that Resident B was supposed to be evaluated by the hospice company on 4/16/24 and had an order to discharge home with hospice. Resident B refused to wait to be evaluated and left the facility with her husband on 4/15/24. Resident B had been at the facility for four days, she was alert and oriented and had a referral for hospice care at home. The facility had not received any information regarding APS involvement with Resident B and the facility did not contact APS regarding Resident B's return home with her husband. During an interview on 5/9/24 at at 11:10 A.M., SS 4 indicated that Resident B was alert and oriented and had chosen to leave the facility without a transition of care being completed. SS 4 indicated when a resident wishes to leave the facility AMA (Against Medical Advice), staff should provide education and document that the education was provided to the resident. If a resident did leave the facility AMA, social service staff or nursing staff should complete an AMA observation to be included in the resident's record. Resident B's record lacked information regarding the exact time or date the resident left the facility and lacked documentation that education was given about leaving the facility AMA. No AMA observation was completed in Resident B's record. On 5/9/24 at 9:30 A.M., the Administrator supplied a facility policy titled, Discharge Against Medical Advice, dated 10/2022. The policy included, .If a resident has decision making capacity (as determined by the resident's physician) and or their legal representative wishes the resident to leave the facility prior to his or her planned discharge and despite facility efforts to explain the risks of leaving, the discharge would be considered leaving against medical advice (AMA). Documentation in the medical record should indicate the facility staff attempted to provide other options to the resident and informed the resident of potential risks of leaving AMA. Residents will never be pressured, intimidated, or coerced into leaving AMA. Procedure: .4. Facility staff will document in the medical record the options offered, risks explained, and information given to the resident/representative. Documentation will be completed on the Discharge Against Medical Advice observation in [the resident's electronic record] . 6. The Discharge Against Medical Advice observation and accompanying information should be reviewed with the resident/representative. If the resident/representative refuse the review, that must be noted on the observation . 7. Notify outside agencies (Adult Protective Services, etc.) if there is concern for the resident's safety and well-being . This citation relates to Complaint IN00432722. 3.1-12(a)(3)

Based on interview and record review, the facility failed to ensure dignity for 3 of 3 residents reviewed for quality of care and treatment. Residents were not assisted with care in a timely manner, not treated with respect and dignity. (Resident B, Resident C, Resident D) Findings includes: 1. On 3/25/24 at 9:24 a.m., Resident B indicated they have turned on their call light and waited two hours for care, staff come in and turned off the call light and leave without providing care. On 3/25/24 at 10:23 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unsteadiness on feet, muscle weakness (generalized). An admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was intact, toileting extensive assist x 1. Care plans were reviewed and included but were not limited to: Problem start date: 1/25/24: Resident requires assistance with toileting due to: dx of hemiplegia affecting right side, COPD, . 2. On 3/25/24 at 9:46 a.m., a Concern/Grievance form was reviewed and included, but was not limited to: Resident name: Resident D Date of Concern: 12/18/23 Time of Concern: 8:30 p.m. Nature of Concern: She left a complaint on the receptionist phone that she want too file grievance on all the staff on 2nd Floor. She had been waiting for over 2 hrs to be changed. They came in & promise they would but did not Department Head review and action taken: Resident stated [name] came in several times between 6p-10pm and would speak to her turn the light off and leave < changing her. Written warning given Date 12/19/23 Comments : Let resident know about the written warning and she will let me know if any concerns in future On 3/25/24 at 11:06 a.m., Resident D's clinical record was reviewed. Diagnoses included but were not limited to, hemiplegia and hemiparesis following other cerebrovasular disease affecting left non-dominant side, contracture, left elbow, contracture. left wrist, contracture left hand, muscle weakness (generalized). A Quarterly MDS (Minimum Data Set) assessment, dated 3/1/24, indicated Resident D's cognition was intact, toileting substantial/maximal. Care plans were reviewed and included but were not limited to: Problem start date: 1/8/19 Resident needs assist with toileting d/t decreased mobility, hx CVA w/residual left sided hemiplegia, incontinence. Approach start date 1/8/19: assist with incontinent care as needed Approach start date 1/8/19: check approximately every 2 hours for incontinence On 3/26/24 at 10:00 a.m., Resident D indicated staff do not always answer her call light, she had an incident where a staff came in and did not change her, she had been told before that she was the worst patient on the floor because she had her call light on, she is talked down to. 3. On 3/25/24 at 10:02 a.m. a Concern/Grievance form were reviewed and included but were not limited to: Resident Name : Resident C Date of Concern: 2/5/24 Time of Concern: 11:15 a.m. Nature of Concern: Late meds, couldn't get Aides to Refresh water, Requested Ice pack that never came, was told he couldn't have a 3rd pillow, couldn't get urinal emptied, too long of a wait for assistance to bathroom, Trouble getting assistance to go to Restroom (transfer) Department Head review and action taken: left blank Comments: Med delivery verified on time. Discussed with resident & staff to ensure timely call lights being answered. Resident Name: Resident C Date of Concern: 2/26/24 Time of Concern: 2/26/24 Nature of Concern: Resident states it took 1 hr to get Ice pack, Resident states it took about 2 hours to get breakfast tray on 2-26-24. Resident complained about Aides Not Answering call light & Empty urinal. Department Head review and action taken: Staff education completed, will continue to monitor call light wait time. Comments: States wait time improved on some days, I will continue to monitor and he will reach out to me for concerns On 3/25/24 at 1:11 p.m., Resident C's clinical record was reviewed. Diagnoses included but were not limited to, unspecified combined systolic (congestive) and diastolic (congestive) heart failure, chronic obstructive pulmonary disease, spinal stenosis. An Admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident C's cognition was intact, toileting hygiene/admission performance partial/moderate. The resident was in the hospital during the survey. Care Plans were reviewed and included but were not limited to: Problem start date: 1/31/24- Resident requires assistance with ADLs including bed mobility, transfers, eating, and toileting related to: weakness, decreased mobility, incontinence, unsteady gait HX of falls, fall risk, COPD . An anonymous interview indicated a nurse had called them and other residents druggies when passing their pain medication to them . On 3/25/24 at 10:45 a.m., LPN 1 indicated any staff member can answer a call light, if they can not provide resident care they should go to the appropriate staff, nurse, CNA, etc. to let them know the resident's needs. On 3/26/24 at 12:22 p.m., the Administrator indicated anytime a complaint about a call light is received, it should be put on a grievance form, an email is sent to her when an initial call light goes off, a secondary email will be sent if it is not answered in a set amount of time, the emails tend to be kept about a month. On 3/26/24 at 12:16 p.m., the current policy on resident rights was provided with a revision date of 1/06. The policy included, but was not limited to: .All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well being, and proper delivery of care . This citation relates to Complaint IN00429431. 3.1-3(a) 3.1-3(n)(4)

Based on observation, interview, and record review, the facility failed to ensure a resident did not experience abuse by taunting, laughing at them, spinning them in the wheelchair, rough treatment by pushing down on the head, arms, and shoulders, sitting them down roughly by grabbing the back of the pants, and pulling the neck of the back of the shirt over the wheelchair handle, resulting in an increase in agitation, which resulted in hospitalization . This also placed the resident at risk of serious harm from choking or strangulation. (Resident B) The Immediate Jeopardy began on 4/27/19 when CNA 1 and CNA 3 were observed on video to be spinning the resident's wheelchair around, and laughing at him, causing an increase in the resident's agitation. The Administrator was notified of the Immediate Jeopardy on 5/8/19 at 3:15 P.M. The Immediate Jeopardy was removed, and the deficient practice corrected on 5/3/19, prior to the start of the survey and therefore Past Noncompliance. Findings include: The clinical record of Resident B was reviewed on 5/3/19 at 1:30 P.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 2/6/19, indicated Resident B had a severe cognitive impairment, and required extensive assistance of two or more staff for transfer. Resident B did not ambulate, and required total dependence of 1 staff for locomotion off the unit. Nurses Notes included the following notations: No documentation was found on 4/27/19. 4/28/19 at 2:22 P.M.: This resident was up in w/c (wheelchair) and had noted to have previously been sitting in hall quietly and sitting still. Staff member then noted this resident to smack another resident on the leg .Confused to place and time. Unable to explain to staff why this occurred. Resident placed on one on one observation 4/28/19 at 8:21 P.M.: Resident tried to hit the same resident again. Combative et (and) hitting, kicking, biting and spitting on staff at this time during 1:1 (one on one). (LPN 1) placed a call to (Nurse Practitioner) to see if we can send the resident to the ER for evaluation. Resident can't be redirected at this time. 4/28/19 at 9:00 P.M.: (Name of ambulance company) here to transport the resident to (name of hospital) ER for evaluation at this time. A hospital note, dated 4/28/19 at 10:10 P.M., indicated, Pt (patient) arrives to ER .for c/o (complaints of) 'aggressive behavior' from biting staff and is combative. Pt currently not aggressive for staff but is attempting to climb out of bed A Physician's ER note, dated 4/28/19 at 10:59 P.M., indicated: Patient evaluated shortly after arrival. Here for aggressive behavior fighting with staff and patients at the nursing home where (the patient) lives .was biting at the staff and was punching had (sic) staff and other patients there from what was told . appears to be calm and controlled at this point On 5/8/19 at 10:15 A.M., the Director of Nursing (DON) was interviewed. She indicated that on Monday 4/29/19 at approximately 12:00 P.M., Resident C motioned to her. She indicated Resident C informed her, If you want to know what caused (Resident B's) behaviors, you should look at the cameras for Saturday night. She indicated she asked the resident what had happened, but he just told her to look at the cameras for the 1100/1200 hall at approximately 5:00 P.M. The DON indicated she informed the Administrator, and they both reviewed the video from that time. The DON indicated the video appeared to show staff dancing around the resident. The DON indicated CNA 1 and CNA 3 were suspended at that time, as well as QMA 1. The DON indicated when the Administrator went to inform Resident C that an investigation was started, Resident C told the Administrator to check the video footage for the front lobby for Sunday. The DON indicated when that video was reviewed, CNA 1 and CNA 2 were observed taunting and laughing at the resident. She indicated they were observed to lunge at the resident, and would pull the resident backwards by the pants. She indicated CNA 2 was also observed restraining the resident, by placing the back of the resident's shirt on a wheelchair handle, so he could not stand up. She indicated both CNA 1 and CNA 2 were terminated. On 5/8/19 at 11:30 A.M., Resident C was interviewed. Resident C indicated the staff had been taunting Resident B, causing the resident to become agitated. Resident C indicated CNA 3 was overheard telling Resident B, You can't get me on Saturday 4/27/19. Resident C indicated, (CNA 1) was the main one. She worked Saturday and Sunday. Resident C indicated CNA 1 grabbed the shirt and was rough. (Resident B) was trying to get away. (Resident B) just wanted to walk. Resident C indicated he observed staff teasing the resident on Saturday at the end of his hall, and then observed CNA 1 and CNA 2 taunting and laughing at the resident on Sunday 4/28/19 in the front lobby. Resident C indicated CNA 1 got (Resident B) going on Saturday, and then when the resident saw her on Sunday, the resident became agitated. Resident C indicated he didn't tell anyone what he saw until Monday 4/29/19, and then he told the Director of Nursing to check the cameras. On 5/8/19 at 12:00 P.M., with the Administrator present, video footage was reviewed. No audio was available. A video, dated 4/27/19 beginning at 5:21 P.M., indicated CNA 1 and CNA 3 danced around Resident B. At one point, CNA 1 spun the resident in the wheelchair. The resident was striking out with their arms, as the CNA 3 was making faces at the resident. QMA 1 was observed standing at the medication cart, in direct proximity of the staff and resident. Additional video footage, dated 4/28/19 from 7:29 P.M. through 8:37 P.M., was reviewed. CNA 1 was observed bringing Resident B to the front lobby. CNA 1 was observed making faces at the resident, lunged at, and laughed at the resident. CNA 1 was observed to grab the resident's pants to sit the resident down, and pushed on the head and shoulders. CNA 1 pointed her finger at Resident B, and grabbed the hands and arms roughly. The body language and expressions on the resident's face, indicated the resident became increasingly agitated. CNA 2 was observed to laugh at the resident, and eventually took the back of the neck portion of Resident B's shirt, and placed it over the back wheelchair arm. Resident B was observed to pull at the neckline of the shirt, and tried to unhook the back of the shirt. CNA 4 was observed on 2 different occasions to enter the lobby, and laughed with the other staff members. The Administrator indicated at that time CNA 1, CNA 2, CNA 3, CNA 4, and QMA 1 had all been terminated. On 5/8/19 at 10:40 A.M., the Administrator provided the current facility policy, Abuse Prohibition, Reporting and Investigation, revised (MONTH) (YEAR). The policy included: .Abuse - Willful infliction of injury .intimidation, or punishment with resulting physical harm, pain, or mental anguish .Abuse includes verbal, sexual, physical, and mental .Physical Abuse .Examples may include but not be limited to .pulling, twisting .and use of improper restraints .Mental Abuse- Verbal or nonverbal infliction of anguish, pain, or distress that results in psychological or emotional suffering .Examples of meant abuse include but not limited to: Harassing a resident. Mocking, insulting, ridiculing. Yelling or hovering over a resident, with the intent to intimidate .Abuse includes: Staff to resident abuse of any type The Past Noncompliance Immediate Jeopardy began on 4/27/19. The Immediate Jeopardy was removed and the deficient practice corrected on 5/3/19 after the facility implemented systemic plan that included the following: completed staff education/inservices on abuse training, interviewed alert residents, performed skin assessments on residents, and terminated CNA 1 and CNA 2. This Federal tag relates to Complaint IN 036. 3.1-27(a)(1) 3.1-27(b)

Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers on a dependent resident with a history of pressure ulcers, resulting in discovering an unstageable pressure ulcer with slough present and deep tissue pressure ulcers on the left heel, and a pressure ulcer on the right heel, for 1 of 3 residents reviewed for impaired skin integrity. (Resident D) Findings include: The clinical record of Resident D was reviewed on 4/22/19 at 4:05 P.M. [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment, dated 1/21/19, indicated Resident D required extensive assistance of two+ staff for bed mobility and transfer. The resident was at risk for developing pressure ulcers, and had 1 Stage 2 pressure ulcer. Resident Progress Notes included the following notations: 2/25/19 at 10:40 A.M.: Resident c/o (complains of) a sore spot on R (right) heel. There is a tiny scab there .Made a skin event and put in NP (nurse practitioner) book. 3/5/19 at 5:14 P.M. Thin, brown dry scab to right inner heel . Area measures 0.4 x 0.4 cm (centimeters). Area non tender to touch. Diagnois (sic) and contributing factors related to wound development: Frequently refuses to get OOB (out of bed), Contractures of multiple muscles, [MEDICAL CONDITION] (paralysis on one side) with [MEDICAL CONDITION] (weakness on one side) affecting left side, Dementia .totally dependent on ADLs (activities of daily living) .Current treatment: Skin prep bilateral heels BID (twice daily) x 10 days. Monitor for s/s (signs/symptoms) infection and update MD Further documentation regarding this area on the right inner heel was not found in the clinical record. Progress Notes continued: 4/17/19 at 10:33 A.M.: Resident has an open unstageable wound to left heel, and an unblanchable red/brown area on each heel .(Name of physician) has been called and orders have been put in A New Skin Event, dated 4/17/19, included: Date Wound/Area originally noted, 04/17/2019. Wound/Area present on admission: No. Site/Location of Wound/Area: left heel. Wound/Area measurements (as length x width x depth) in cm: 1.8 x 1.5 x 0.2 .Open area, Wound/area color, yellow slough .scant serous (watery) drainage .list the preventive measures that have been put in place: remove foot board from his bed, encourage resident to elevate bilateral feet as he tolerates A New Skin Event, dated 4/17/19, included: Date Wound/Area originally noted, 04/17/2019. Wound/Area present on admission: No. Site/Location of Wound/Area: non blanchable brown/purple area to left heel. Wound/Area measurements (as length x width x depth) in cm: 0.8 x 0.3 .Wound/area color, brown/purple .list the preventive measures that have been put in place: remove foot board from his bed, encourage resident to elevate bilateral feet as he tolerates A New Skin Event, dated 4/17/19, included: Date Wound/Area originally noted, 04/17/2019. Wound/Area present on admission: No. Site/Location of Wound/Area: brown/purple non blanchable area to right heel. Wound/Area measurements (as length x width x depth) in cm: 1.2 x 1.0 x 0.1 . Wound/area color, brown/purple .list the preventive measures that have been put in place: remove foot board from his bed, encourage resident to elevate bilateral feet as he tolerates A Physical Therapy (PT) Plan of Care, dated 4/18/19, included: Patient was referred for skilled PT services for wounds on bi (bilateral, or both) heels .Patient is total assist for transfers and bed mobility .Therapy is necessary for increasing wound healing for left heel wound .Patient has a left heel wound .requires therapy intervention An Initial Wound Review, dated 4/19/19, included: Describe new wounds: unstageable to left heel. DTI to left heel, Stage 2 right heel .Resident is at risk for skin breakdown .List new interventions in place now: Multivitamin with minerals, Remove foot board from bed, Prostat 30 cc .Current treatment order: Cleanse wound to left heel and apply santyl and [MEDICATION NAME] (dressing) BID (twice daily), cleanse wound to right heel and apply purachol and [MEDICATION NAME] daily. Skin prep both heels q (every) shift .IDT (interdisciplinary team) Notes: Noted resident obtained pressure wounds to bilateral feet with heels up device in place. IDT removed the foot board .denies any pain with assessment A Resident Care Plan, initially dated 8/31/12 and updated for a goal of 5/3/19, indicated, Potential for skin breakdown related to: Limited mobility, chairfast, hx (history) of skin breakdown, incontinence, and potential for friction/shearing. The Approaches included: 1/24/19 Heel float device in bed. Low air loss mattress in place on bed. Turn and reposition approximately every 2 hours and prn (as needed). A Resident Care Plan, dated 4/17/19, indicated, Resident has impaired skin integrity: wounds to left and right heels. Resident is at risk for skin breakdown r/t [MEDICAL CONDITION] .dementia, chronic pain, contractures .weakness, limited mobility, chairfast, hx (history) of skin breakdown . The Approaches indicated, 4/19/19 heel up device when in bed. 4/19/19 Remove foot board from bed. On 4/23/19 at 10:05 A.M., a wound assessment was requested. The Assistant Director of Nursing (ADON), Medical Records Staff 1, and the Corporate Float Director of Nursing (DON) were present. The resident had an open pressure ulcer on his left heel. The wound bed was mainly yellow. There was slight surrounding redness around the wound. On the inner left heel, a closed, flat, dark blood-blister type area was observed. The right heel was observed to have an open pressure ulcer. The wound bed was mainly yellow with no surrounding redness. The resident indicated his feet hurt. The Float DON indicated the areas were found the previous week. The Float DON indicated she would need to reclassify the wound on the right heel, as there was now yellow slough present. The Float DON indicated the wounds were found when she was closing previous skin events that had been opened by the previous wound care nurse. On 4/23/19 at 12:30 P.M., the Corporate Nurse provided the resident's most recent wound information, dated 4/23/19. The Wound Management documentation included: Wound Type: Pressure Ulcer, Wound Location: Left heel, Length 2 (cm) Width 1.6 (cm), Can depth be measured? No .Stage: Unstageable - Slough (yellowish dead tissue) and/or Eschar (black/brown dead tissue) Tissue Type: Necrotic Tissue, Percent of wound covered by slough tissue: 100 .Wound healing status: Declining .states routine pain medication sufficient at this time Wound Type: Pressure Ulcer, Wound Location:Left heel, left foot near heel. Length 0.8 (cm) Width 0.3 (cm), Can depth be measured? No .Stage: Unstageable - Deep Tissue, Tissue Type: Closed/Resurfaced Wound Type: Pressure Ulcer, Wound Location: Right heel, Length 1.4 (cm) Width 1.5 (cm), Can depth be measured? No .Stage: Unstageable - Slough and/or Eschar. Tissue Type: Necrotic Tissue, Percent of wound covered by eschar tissue: 75 .Wound healing status: Declining On 4/23/19 at 2:05 P.M., the corporate nurse provided the current facility policy, Skin Management Program, initially dated 3/10 and reviewed 4/18. The policy included: It is the policy of (name of corporation) to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable .Avoidable Pressure Ulcer/Injury: means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: .define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; and/or revise the interventions as appropriate .Pressure Injury: is localized damage to the skin and underlying soft tissue usually over a bony prominence .The injury can present as an intact skin or an open ulcer and may be painful. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear .Stage 2: Pressure Injury: Partial-thickness skin loss with exposed dermis (skin layer) .The wound bed is viable, pink or red, moist .These injuries commonly result from .shear in the heel .Stage 3: Pressure Injury: Full-thickness skin loss .in which adipose (fat) is visible in the ulcer .Slough and/or eschar may be visible .If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury .Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration intact or non-intact skin .The injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to obtain physician orders [REDACTED]. (Residents B and C) Findings include: 1. The clinical record of Resident B was reviewed on 6/13/18 at 1:35 P.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An additional physician's orders [REDACTED].Keep dry at all times .Indication: Permacath placement. A Care Plan, initially dated 1/6/16 and reviewed 5/8/18, indicated: Problem: Resident is receiving [MEDICAL TREATMENT] and is at risk for complications such as fluid imbalance, bleeding or infection. Access Site: Right Femoral Port. The Approaches included: Monitor bruit/thrill Q (every) shift. Assess [MEDICAL TREATMENT] every shift for excessive bleeding, drainage, swelling, redness, warmth. Document findings, report abnormal's to MD and [MEDICAL TREATMENT]. Resident Progress Notes included the following notations: 6/1/18 at 2:45 P.M.: Received call from (name of hospital) where resident was sent for [MEDICAL TREATMENT] cath (catheter) replacement from the [MEDICAL TREATMENT] center. Resident will be at the hospital until procedure is complete. 6/1/18 at 5:47 P.M.: Received call from (name of hospital) .he will be receiving [MEDICAL TREATMENT] from them this evening 6/1/18 at 9:56 P.M.: (Name) called to give report stated res. (resident) was still having [MEDICAL TREATMENT] using a new port without difficulty. Port was placed in R (right) groin where it was before .Staff went to (hospital) to bring res. back at this time. Documentation of the appearance of the new catheter site, or of a dressing, was not found. A Weekly Summary, dated 6/2/18 at 3:07 P.M., indicated, Physical assessment Bilateral lungs clear but diminished .Changes in condition since last summary: scattered abrasions to BLE (bilateral lower extremities) .Services provided to resident: [MEDICAL TREATMENT] Documentation of the new catheter inserted on 6/1/18, or an assessment of the dressing or site, was not found. The next Resident Progress Note, dated 6/3/18 at 2:26 A.M., indicated, Resident appears to be lethargic but responsive to verbal et (and) physical stimuli but is non verbal at this time. Resident skin warm to touch et face/head diaphoretic. V/S (vital signs) assessed .When name called or spoken too (sic), resident opens his eyes et will look at writer but remains nonverbal .O2 (oxygen) applied @ 2LPNC (2 liters per nasal cannula) as a nursing measure to get sats > 90% .Resident does not appear to be experiencing any pain or discomfort but will continue to monitor condition. A Progress Note, dated 6/3/18 at 2:36 A.M., indicated, Resident appears to be resting well with no visible signs of any distress noted. SPO2 (oxygen saturation) is at 97% on O2 @ 2LPNC with HOB (head of bed) elevated. When name called, resident opened eyes et looked at this writer but would not answer any questions or respond verbally at all. Will continue to monitor condition. A Progress Note, dated 6/3/18 at 8:05 A.M., indicated, Resident out to (name) ER via (name) ambulance service A transfer sheet, dated 6/3/18 at 8:40 A.M., indicated, Description: To (name of hospital) ER for an evaluation due to status change .Devices/special treatments: None . Documentation of the new [MEDICAL TREATMENT] catheter insertion was not found on the transfer sheet. An ambulance service note, dated 6/3/18, indicated, At pt (patient) side 7:41 A.M .Physical Findings: Right Femur/Thigh, [MEDICAL TREATMENT] shunt in R (right) groin w (with) odor and [MEDICAL CONDITION] (swelling) noted at insertion site .Primary impression:[MEDICAL CONDITION]. The note indicated they arrived at the hospital at 8:04 A.M. A hospital ER note, dated 6/3/18 at 8:12 A.M., indicated, .had a new [MEDICAL TREATMENT] cath placed in (right) groin Friday night (and) then was dialyzed. Saturday pt developed a fever and by Saturday evening patient 'not on his 'A' game.' Pt was found to have an altered status last night and was placed on oxygen. Pt cont to have an AMS (altered mental status) today . Catheter site right groin is bloody et (and) purulent drainage noted. A hospital ER note, dated 6/3/18 at 8:25 A.M., indicated, .wound in the right groin that appears purulent, bloody, and has an odor. Tegarderm is over the site, however is peeling off and has dried blood under it. There are 2x2's (dressings) that were placed over the site that appear to have pus and stool in them. The catheter was stitched in place, however there is a pencil eraser sized area that is open and the catheter, which is in the groin, can be seen through the skin A hospital ER note, dated 6/3/18 at 9:01 A.M., indicated, Pt arrived to this ED (emergency department) from (name of facility) with right femoral cath. Dressing was found to have large amount of stool and purulent drainage and site appears to have dehisced (opened). Cath is intact but it is visible while in groin. Soiled dressing removed, both sutures intact at groin site. Area was cleansed An ER history and physical, dated 6/3/18 at 9:31 A.M., indicated, .presents from the nursing home because of fever and altered mental status. This apparently began last night. Patient is a [MEDICAL TREATMENT] patient. He just had a new PermaCath placed in the right femoral site on (MONTH) 1st. He was last dialyzed on (MONTH) 1st. Apparently according to the facility the patient developed a fever and altered mental status last night. Apparently he is usually alert and oriented . Patient arrived febrile and apparently septic .T 104.4 .Cath had been cleaned up but nurses state cath was grossly purulent and soiled with feces .Final impression: fever,[MEDICAL CONDITION] Progress Notes included: 6/3/18 at 10:50 A.M.: Recorded as late entry from 6/2/18 1530 (3:30 P.M.). Note from 6/2 not saved by writer. Resident has been in bed this shift. Bites only for breakfast and no nutritional intake for lunch. Sips and small drinks only. Resident has been very tired today. Resident has been alert and talking to staff but then will go back to sleep. Resident vitals obtained except BP (blood pressure) was unobtainable due to failed visual sites all other vitals were within normal limits and resident was afebrile. Newly placed catheter remains in place. No redness warmth or swelling noted to area outside of dressing which remains intact. Documentation of the results of the vital signs obtained was not found in the clinical record. Progress Notes included: 6/3/18 at 11:18 A.M. (amended): Resident noted to be lethargic, diaphoretic, and shaking. Skin warm to touch. T (temperature) 98.1. Will open his eyes when spoken to, but closes them right away .[MEDICATION NAME] intact over [MEDICAL TREATMENT] cath. insertion site right groin. Exposed [MEDICAL TREATMENT] cath. is wrapped and covered with gauze. New order received to send to (name of hospital) ER for an evaluation. On 6/13/18 at 5:20 P.M., LPN 1 was interviewed. LPN 1 indicated she had sent Resident B to the hospital on [DATE]. She indicated, I know he was clean when we sent him. She indicated the resident's dressing was intact when she sent him. LPN 1 indicated she could not remember if there was any order for a dressing change. She indicated the Assistant Director of Nursing (ADON) had questioned her after the resident was at the ER, if she had looked at the dressing and if the resident was clean. She added that was why she amended her charting. On 6/14/18 at 11:20 A.M., during an interview with the Director of Nursing (DON) and the Administrator, the DON indicated she was on vacation during this incident. The Administrator indicated she had spoken to the Chief Nurse at the hospital, after one of the hospital nurses had called screaming at our nurse. The DON and the Administrator indicated the hospital should have sent paperwork with the resident when he returned with the new catheter. 2. The clinical record of Resident C was reviewed on 6/13/18 at 6:15 P.M. [DIAGNOSES REDACTED]. A Care Plan, dated 5/29/18, indicated, Problem: Resident is receiving [MEDICAL TREATMENT] and is at risk for complications such as fluid imbalance, bleeding or infection. LUE (left upper arm) [MEDICAL TREATMENT] port. The Approaches included: Assess [MEDICAL TREATMENT] LUE every shift for excessive bleeding, drainage, swelling, redness, warth (sic), bruit/thrill (the vibration/sound of blood going through the site). Physician orders, initially dated 5/21/18 and on the (MONTH) (YEAR) orders, indicated, Access Site: L (left) arm, Monitor for s/sx (signs/symptoms) of infection, Check dressing site every shift and Check for Bruit and Thrill every shift. The resident was transferred to the hospital on [DATE] and returned to the facility on [DATE]. A Readmission form, dated 6/12/18 at 1:24 P.M., indicated, .Vascular Access Devices, [MEDICAL TREATMENT] fistula . A Nursing 72 hour readmission form, dated 6/12/18 at 9:50 P.M., indicated, Mental status, Lethargic .Vascular Access Devices, None of the above ([MEDICAL TREATMENT] fistula unmarked) The clinical record of Resident D was reviewed again on 6/14/18 at 8:45 A.M. A Treatment Administration Record (TAR), dated (MONTH) (YEAR), indicated the resident's access site on his left arm had not been checked since his return on 6/11/18. The Bruit and Thrill had not been checked since 6/11/18. On 6/14/18 at 9:45 A.M., Resident C was observed sitting in his room. He lifted up his left shirt sleeve, and revealed his fistula site in his left upper arm. On 6/14/18 at 11:20 A.M., during an interview with the Director of Nurses, she indicated she would expect her staff to assess a resident's fistula site every shift. She indicated they were in the process of going over the resident's readmission at that time. On 6/14/18 at 1:50 P.M., the DON provided the current facility policy, [MEDICAL TREATMENT] Care, revised 11/2017. The policy included: .The facility will assure that each resident receives care and services for the provision of [MEDICAL TREATMENT] .consistent with professional standards of practice including: Ongoing assessment of the resident's condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments .Ongoing communication and collaboration with the [MEDICAL TREATMENT] facility regarding [MEDICAL TREATMENT] care and services .Access sites are clean, dry, and dressing is changed with clean technique .All specific resident care areas will be addressed on the plan of care .The physician will be notified of any unusual findings and/or change in condition based upon the assessments This Federal tag relates to Complaint IN 842. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a Foley catheter was medically necessary for 1 of 1 residents reviewed for Foley catheter use, resulting in a multi-drug resistant infection. (Resident #B) Findings include: On 10/4/16 at 3:53 a.m., Resident #B was observed lying in bed. A Foley catheter bag was observed to be hanging from the bed. On 10/5/16 at 9:29 a.m., Resident #B's clinical record was reviewed. Resident #B's [DIAGNOSES REDACTED]. The most recent signed physicians recapitulation orders, signed 8/30/16, included, but were not limited to: Foley catheter due to unstageable wound to coccyx, initiated on 2/27/16. The Progress Notes included, but were not limited to: 2/1/16 at 9:30 a.m., Resident returned from hospital on [DATE] Resident continues to receive wound treatment for [REDACTED]. 6/23/16 at 2:15 p.m., IDT (Interdisciplinary Team) evaluated residents wound to coccyx. On today's date this wound appears as healed with no redness, no drainage, no odor and slight indention with scarring noted. 6/24/16 at 10:25 a.m., Foley catheter draining dark yellow urine 6/26/16 at 1:02 p.m., Foley catheter draining dark yellow urine without any noted sediment 6/28/16 at 5:50 a.m., Foley catheter patent and draining yellow urine 8/9/16 at 8:12 a.m., Orders received and noted for treatment to open area on coccyx . 8/9/16 at 1:29 p.m., Resident with blood tinged urine and scant amount of sediment in catheter tubing 8/12/16 at 12:33 p.m., Received report from (Name of Lab) of resident with positive ESBL (Extended Spectrum Beta-Lactamase) in urine. 8/22/16 at 1:36 p.m., Resident is followed by NAR (Nutritionally at Risk) per pressure wound policy related to state II pressure wound to coccyx. A Urinalysis, dated 10/3/16, indicated Resident #B had ESBL in the urine. A Significant Change MDS (Minimum Data Set) Assessment, dated 8/20/16, indicated Resident #B had a Stage 2 pressure area. The MDS further indicated Resident #B had a Foley catheter. The Care Plans included, but were not limited to: Resident requires an indwelling urinary catheter related to impaired skin integrity, initiated on 2/27/15 On 10/5/16 at 3:44 p.m., the DON was queried regarding the [DIAGNOSES REDACTED]. On 10/6/16 at 8:38 a.m., the DON (Director of Nursing) indicated Resident #B had a Foley catheter related to a Stage 2 pressure injury to the coccyx. The DON further indicated the Foley catheter had been removed on the previous day (10/5/16). On 10/7/16 at 12:40 p.m., the Nurse Consultant provided the Bladder Program policy, dated 11/2014. The policy included, but was not limited to: Residents who have an indwelling urinary catheter will be assessed upon admission or when a new order for indwelling urinary catheter is received and during care plan review. 3.1-41(a)(1)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for 2 of 3 residents reviewed for falls. Fall interventions were not in place, resulting in a skull fracture and subarachnoid hemorrhage. (Resident #E), and failed to determine a root cause analysis for the cause of falls, (Resident #C). And ensure equipment was securely in place for 2 of 6 units observed. (Units 1200,1300) Findings include: 1. On 10/5/16 at 3:04 p.m., Resident #E was observed sleeping in bed. No non-skid strips were observed in front of Resident E's toilet. On 10/5/16 at 2:39 p.m., Resident #E's clinical record was reviewed. An Event Report, dated 9/28/16, indicated Resident #E had an unwitnessed fall. The Event Report indicated Resident #E was walking into the bathroom and was found lying on the bathroom floor. The Event Report indicated Resident #E's head as bleeding. The Event Report indicated Resident E was sent to the emergency room . A Progress Note, dated 9/28/16 at 10:51 a.m., included, but was not limited to: Resident lying on the floor in the bathroom after hearing a large commotion. Assessed resident and found that she was unresponsive with an open injury to the cranium A Discharge Summary note dated 9/26/16 from the (Name of Hospital), included, but was not limited to: Identified basilar skull fracture and small subarachnoid hemmorhage Had blood drainage from ear .admitted to neuro step down unit for serial neurological exams . The Care Plans included, but were not limited to: Fall risk related to ., initiated on 3/16/13. The interventions included, but were not limited to: non-skid strips in front of toilet, initiated on 6/12/15. On 10/5/16 at 3:24 p.m., the DON and Administrator were quiered regarding the missing non-skid strips in Resident #E's bathroom. The Administrator and DON indicated they would investigate why the non-skid strips were no longer in the bathroom and if they had been present at the time of Resident #E's fall. On 10/5/16 at 3:37 p.m., the Administrator indicated she was unable to determine if the non-skid strips were in place at the time of Resident #E's fall. The Administrator further indicated the floor could have been stripped and waxed. On 10/5/16 at 3:52 p.m., the Housekeeping Supervisor indicated the bathroom for Resident #E's room was stripped on 8/24/16. On 10/7/16 at 12:40 p.m., the Nurse Consultant provided the Fall Management Program policy, revised 7/2016. The policy included, but was not limited to: A care plan will be developed at time of admission with specific care plan interventions to address each resident's fall risk factors 2. During an interview on 10/3/16 at 4:06 p.m., the ADNS (Assistant Director of Nursing Services) indicated Resident #C had experienced four unwitnessed falls in September 2016. All four of the falls resulted in minor injuries. The record was reviewed on 10/5/16 at 2 p.m. The Admission, Minimum Data Set assessment, dated 6/25/16, indicated he had fallen one time since admission to the facility. The resident had good cognition, and required the extensive assistance of two staff for bed mobility, transfers and toilet use. The resident required limited assistance of one for ambulation in the room, did not ambulate in the corridor and was independent in self-propelling a wheelchair in the corridor. The plan of care, dated, 6/20/16, indicated the interventions for the resident's risk for falls included: to educate the resident to call for assistance, provide a visual reminder to lock the wheelchair brakes, added 7/27/16: provide the visual cue to the bathroom call light, added 8/8/16: educate the resident to call for assistance with transfers and visual reminder to lock wheelchair brakes, and added 9/29/26: Resident to have posterior tilt wheelchair with anti-rollbacks. Review of the progress notes indicated the resident fell on [DATE] in the dining room, on 7/5/16 was found on the floor in his room, on 7/22/16 fell out of his bed, on 7/27/16 fell in the bathroom, on 8/5/16 at the side of the bed, on 8/22/16 in his room, on 9/9/16 went outside with a visitor and fell out of wheelchair, on 9/15/16 found lying on floor beside bed, on 9/20/16 found on the bathroom floor, and on 9/22/16 found on the floor of the bathroom. The root cause analysis of the September 2016 falls were provided on 10/6/16 at 3:10 p.m. For the 9/9/16 fall, no interventions were put into place regarding the resident falling from his wheelchair while outside. The intervention listed was: resident taken inside of facility to treat and measure wounds to (R) (right) knee. The root cause analysis for the 9/15/16 fall resulted in the facility removing the resident's wheelchair from his room every time the resident was in bed. There was no indication the facility had completed a root cause analysis including whether the resident had tried to call for help, or when the resident was last toileted. The root cause analysis of the 9/20/16 fall indicated he was found in the bathroom on the floor. There was no indication there was a thorough review of the bathroom to determine the cause of the resident's fall. The root cause analysis for the 9/22/16 fall in the bathroom resulted in the intervention, resident assisted to the commode and brought to the nurses station for neurochecks and observation. There was no review of the location of the fall for possible problems. During the observation of the resident's bathroom on 10/4/16 at 8:33 a.m. and again on 10/7/16 at 10:20 a.m., with LPN #1, the grab bars on either side of the toilet were loose and wiggled from side to side and could come up off the floor when moved from the front to back. The LPN stated she would prepare a work order to fix the grab bars. 3. Observation of the bathroom for room 1208 on 10/4/16 at 9:29 a.m., indicated the the grab bars around the toilet were loose and wobbly. On 10/7/16 at 12: p.m. during the environment tour the grab bars around the toilet were observed to be loose. 4. Observation of the bathroom for room 1310 on 10/4/16 at 9:25 a.m., indicated the grab bars around the toilet were loose on both sides. On 10/7/16 at 12:25 p.m. during the environment tour the grab bars around the toilet were observed to be loose. 5. Observation of the bathroom for room 1311 on 10/4/16 at 9:15 am., indicated the toilet grab bars were loose. On 10/7/16 at 12:12 p.m. during the environment tour the grab bars around the toilet were loose. On 10/7/16 at 1:09 p.m. interview with the Housekeeping Supervisor and Maintenance #1 indicated all times needed to be repaired. This Federal tag relates to Complaint IN 869. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to identify non-compliance for ensuring interventions were in place and root cause analysis had been determined for fall, pharmacy reviews were being completed timely, and a system to in place to follow infection control issue through the quality assurance protocol. (Resident E, Resident C, Resident #178) Findings include: Interview with the administrator on 10/7/16 at 2:19 p.m., indicated the facility had a Quality Assurance Committee that meet every month and it included, but was not limited to, Administrator, Medical Director, DON, ADON, (MDS Minimum Data Set) Coordinator, CEO, Housekeeping Manager, Dietician, Dietary manager, Maintenance, Human Resource Manager and Activities. The Administrator indicated how the committee had worked in the past on an environmental issue. She further indicated they had worked on infection control general practice. She indicated the Corporate office will provide a top monthly for them to work on and then they add what else in needed in their facility. She indicated there was no plan for specific infection control, falls or pharmacy review plans in place. 1. On 10/5/16 at 3:04 p.m., Resident #E was observed sleeping in bed. No non-skid strips were observed in front of Resident E's toilet. On 10/5/16 at 2:39 p.m., Resident #E's clinical record was reviewed. An Event Report, dated 9/28/16, indicated Resident E had an unwitnessed fall. The Event Report indicated Resident E was walking into the bathroom and was found lying on the bathroom floor. The Event Report indicated Resident E's head as bleeding. The Event Report indicated Resident E was sent to the emergency room . A Progress Note, dated 9/28/16 at 10:51 a.m., included, but was not limited to: Resident lying on the floor in the bathroom after hearing a large commotion. Assessed resident and found that she was unresponsive with an open injury to the cranium A Discharge Summary note from the (Name of Hospital), included, but was not limited to: Identified basilar skull fracture and small subarachnoid hemmorhage Had blood drainage from ear .admitted to neuro step down unite for serial neurological exams . The Care Plans included, but were not limited to: Fall risk related to ., initiated on 3/16/13. The interventions included, but were not limited to: non-skid strips in front of toilet, imitated on 6/12/15. On 10/5/16 at 3:24 p.m., the DON and Administrator were quiered regarding the missing non-skid strips in Resident E's bathroom. The Administrator and DON indicated they would investigate why the non-skid strips were no longer in the bathroom and if they had been present at the time of Resident #E's fall. On 10/5/16 at 3:37 p.m., the Administrator indicated she was unable to determine if the non-skid strips were in place at the time of Resident #E's fall. The Administrator further indicated the floor could have been stripped and waxed. 2. During an interview on 10/3/16 at 4:06 p.m., the ADNS (Assistant Director of Nursing Services) indicated Resident #C had experienced four unwitnessed falls in September 2016. All four of the falls resulted in minor injuries. The record was reviewed on 10/5/16 at 2 p.m. The Admission, Minimum Data Set assessment, dated 6/25/16, indicated he had fallen one time since admission to the facility. The resident had good cognition, and required the extensive assistance of two staff for bed mobility, transfers and toilet use. The resident required limited assistance of one for ambulation in the room, did not ambulate in the corridor and was independent in self-propelling a wheelchair in the corridor. The plan of care, dated, 6/20/16, indicated the interventions for the resident's risk for falls included: to educate the resident to call for assistance, provide a visual reminder to lock the wheelchair brakes, added 7/27/16: provide the visual cue to the bathroom call light, added 8/8/16: educate the resident to call for assistance with transfers and visual reminder to lock wheelchair brakes, and added 9/29/26: Resident to have posterior tilt wheelchair with anti-rollbacks. Review of the progress notes indicated the resident fell on [DATE] in the dining room, on 7/5/16 was found on the floor in his room, on 7/22/16 fell out of his bed, on 7/27/16 fell in the bathroom, on 8/5/16 at the side of the bed, on 8/22/16 in his room, on 9/9/16 went outside with a visitor and fell out of wheelchair, on 9/15/16 found lying on floor beside bed, on 9/20/16 found on the bathroom floor, and on 9/22/16 found on the floor of the bathroom. The root cause analysis of the September 2016 falls were provided on 10/6/16 at 3:10 p.m. For the 9/9/16 fall, no interventions were put into place regarding the resident falling from his wheelchair while outside. The intervention listed was: resident taken inside of facility to treat and measure wounds to (R) (right) knee. The root cause analysis for the 9/15/16 fall resulted in the facility removing the resident's wheelchair from his room every time the resident was in bed. There was no indication the facility had completed a root cause analysis including whether the resident had tried to call for help, or when the resident was last toileted. The root cause analysis of the 9/20/16 fall indicated he was found in the bathroom on the floor. There was no indication there was a thorough review of the bathroom to determine the cause of the resident's fall. The root cause analysis for the 9/22/16 fall in the bathroom resulted in the intervention, resident assisted to the commode and brought to the nurses station for neurochecks and observation. There was no review of the location of the fall for possible problems. During the observation of the resident's bathroom on 10/4/16 at 8:33 a.m. and again on 10/7/16 at 10:20 a.m., with LPN #1, the grab bars on either side of the toilet were loose and wiggled from side to side and could come up off the floor when moved from the front to back. The LPN stated she would prepare a work order to fix the grab bars. Observation of the glucometer testing of Resident #C on 10/5/16 at 11:55 a.m., indicated QMA #1 donned gloves, performed a finger stick and went to the medication cart to clean the glucometer. She indicated the wipes used for disinfection required the product to remain wet on the glucometer for three minutes. While the bleach wipe was used, there was no clock or timer in the area, but the QMA stated, I need a timer. The glucometer remained wet from 11:59:32 a.m. to 12:01:06 p.m. (2:28 minutes) Review of the manufacturer's instructions for the Micro-Kill Bleach germicidal bleach wipe indicated: Remove the pre-saturated towelette and wipe the desired surface to be disinfected. Three minute contact time is required to kill all the bacteria [MEDICAL CONDITION] on the label except a 1 minute contact time is required to kill [MEDICAL CONDITION][MEDICATION NAME] and [MEDICATION NAME] mentagrophytes and a 3 minute contact time is required to kill [MEDICAL CONDITION] spores. Interview with RN #1 on 10/6/16 at 11:45 a.m., indicated she had already completed all her glucometer checks on her halls. She indicated she used alcohol between all the residents. She indicated she was to use alcohol and had nothing else on the cart to use. There were no bleach wipes on the medication cart. The facility policy was provided on 10/6/16 at 12:27 p.m. and indicated a single-use germicidal wipe was to be used. The entire surface of the blood glucose meter was to wiped for minutes. During an interview with Resident #C on 10/3/16 at 4 p.m., the resident constantly rubbed his lips. His lips were dry. During observation on 10/6/16 at 11:49 a.m., the resident sat at the dining room table and continually rubbed his lips. During an interview with Resident #C on 10/3/16 at 4:00 p.m., the resident constantly rubbed his lips. His lips were dry. During observation on 10/6/16 at 11:49 a.m., the resident sat at the dining room table and continually rubbed his lips. Review of the clinical record for Resident #C on 10/05/2016 at 2:26 p.m. The physician progress notes [REDACTED].*****d off They will not let me use a mug. I threw a temper tantrum yesterday. A guy in the room down from him hoards sugar and his food in night stand. It bothers everybody. I can deal (with) him. He is in wheelchair - rubbing lower lip constantly. I get real nervous and agitated (SIC) because of the above need [MEDICATION NAME] added. A nurses progress note, dated 8/27/16, indicated, res (resident) yelled at other res, no physical contact, (resident's name) removed from DR (dining room). res has flat affect, does not start conversations, but will answer slowly like he plans out what he is going to say, lying in bed eyes open, rubs bottom lip almost constant while awake, appears angry much of time. (sic) No other maladaptive behaviors were noted in the progress notes. Review of the psychologist review, dated 9/7/16, indicated the resident complained of difficulty coping with headache. [MEDICATION NAME] was added on 8/27/16 by the primary physician for behaviors. Interview with the Social Service Director (SSD) on 10/06/16 at 8:19 a.m., indicated there were no other interventions attempted prior to starting the second antipsychotic drug. There was no indication the resident's constant rubbing of his lip had been reviewed for possible abnormal movement from the antipsychotic drugs. She provided the most recent Abnormal Involuntary Movement Scale (AIMS), dated 9/7/16, which indicated the resident had no abnormal body movements. There was no indication the resident's four falls in September had been considered a result of the addition of the second antipsychotic drug. The pharmacy consultant reviews were requested and the SSD indicated there had been no pharmacy review since July. Interview with the Director of Nursing Services (DNS), on 10/6/16 at 2:28 p.m. indicated they did not have a consultant pharmacist to call upon. The first visit planned for the new pharmacy would be on 10/22/16. 3. Record review on 10/05/16 at 10:28 a.m., indicated Resident #178 was admitted to the facility in May 2016 with a [MEDICAL CONDITION]. The resident was in contact isolation for [MEDICAL CONDITION]. Observation on 10/5/16 at 1:58 p.m. a visitor went into the resident's room. She did not stop at the door to put Personal Protective Equipment (PPE) on, or see the nurse before entering. She was observed standing at the bedside talking with the resident and then sitting in the lift chair at the bedside used for the resident. The CNA was asked if she knew who the visitor was entering the room and she did not. The CNA entered the room and upon exiting was asked if the visitor was asked to don PPE and she indicated, no. Interview with Housekeeper #1 on 10/5/16 at 1:55 p.m., indicated she cleaned the isolation room for Resident #178. She indicated she would don PPE and go into the room and clean. When asked if she used anything special to clean with, she indicated she did not, but they tell her if she needs to use bleach for[DIAGNOSES REDACTED], but nothing special was used for this room. Trach care was observed on 10/6/16 at 9:52 a.m. with LPN #1 providing cleansing and suctioning of the [MEDICAL CONDITION], changing the inner cannula and applying a dressing to the tracheal area. Before tracheal care, LPN #1 entered the room without gloves and touched the resident's bed and bed control. washed his hands, then reached into the pocket on the outside of his right pant's leg to obtain scissors. He placed them on the over the bed table where he had also placed the dressings and sterile suction equipment. He used the scissors to cut a gauze packets to be used on the [MEDICAL CONDITION]. LPN #1 had difficulty donning the sterile gloves because the size was too small for his hands. He tore, put his hand through, and went through three pair before getting a glove on without tearing. He indicated the facility did not have sterile gloves the appropriate size for him. He donned a sterile glove on his right hand and immediately contaminated the right glove with his bare left hand. As soon as he donned both sterile gloves, he touched the front of his gown and turned on the suction machine with his gloved hands. Review of the Cleaning, Changing Inner Cannula & Change [MEDICAL CONDITION] Ties Policy, provided at 12:40 p.m. on 10/7/16, indicated .Put on sterile gloves and prepare field. Empty contents onto drape. Your dominant had will remain 'clean' throughout the procedure. LPN #1 used the same gloves throughout the procedure. Following the procedure, he removed his gloves, took a pen out his scrub pocket from under his gown, and dated the equipment. He touched the bed controls and television remote with his bare hands. Following the procedure, the LPN went to the Soiled Utility Room where there was no functioning paper towel dispenser. The front of the automatic dispenser was broken off. There were two rolls of paper towel on top of the automatic dispenser, but there was no way to obtain the paper towel without making the roll wet. Interview with LPN #1 following the procedure, he acknowledged he knew had touched his gown with his sterile gloves as soon as he did it. He indicated he had used his scissors and pen from his pockets. Observation of the room set up outside Resident #178's room door indicated there were no gloves to wear to enter the room. LPN #1 indicated we could enter the room and use the gloves on the wall. The gloves had no tightness at the wrist so would not protect the person who donned the gloves at the wrist as they did not fit tightly around the gown at the wrist. Observation of CNA #1 on 10/6/16 at 2 p.m. indicated she worked the 2 - 10 p.m. shift. She had not found any gloves on the isolation cart so had gone into the room next door. The gloves did not have any tightness at the wrist so could not provide a tight fit over the gown wrist. 3.1-52(a)(20

Based on interview and record review, the facility failed to discover a resident's impaired skin integrity until the toes were black and draining; failed to document the resident's skin condition timely; failed to notify the physician when the resident had a significant change in the wound status; and failed to correctly protect the resident's foot wounds, resulting in maggot infestation of the wound and hospitalization for 1 of 3 residents reviewed with impaired skin integrity, in a sample of 21. (Resident K) Findings include: The closed clinical record of Resident K was reviewed on 4/27/16 at 10:50 A.M. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 3/18/16, indicated the resident scored a 13 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for bed mobility and transfer, and was totally dependent on one staff for bathing. The resident had no pressure, arterial, or venous ulcers. The resident had no infections of the foot or [MEDICAL CONDITION]. A Shower Report, dated 4/6/16, indicated the resident had no skin problems. A Registered Dietician note, dated 4/6/16 at 3:59 P.M., indicated, .continues to receive tx (treatment) to diabetic ulcers on R (right) foot and toes A Weekly Summary, dated 4/6/16 at 3:39 A.M., indicated, Indicate any areas of skin integrity alteration the resident currently has .Open areas -weeping to right leg . A Progress Note, dated 4/7/16 at 9:52 P.M., indicated, (Name of physician) faxed to repot (sic) resident rt. (right) foot swollen drainage noted between toes, 2, 3, 4, et (and) 5th top of toes black in color warn (sic) to touch, yellow drainage note (sic) resident encourage (sic) to keep feet elevated. V/S (vital signs) stable. A Non-Pressure Wound Skin Evaluation Report, dated 4/8/16 at 5:57 A.M., indicated, New area .Full Thickness Wound, Site right foot four toes and surrounding tissue Describe measurements undefined .Describe wound color 50% dark red/50% black, Describe wound drainage moderate serous, Describe wound odor none .Cleanse with NS (normal saline), place gauze between all toes, paint with [MEDICATION NAME], cover with gauze, pad heel and secure with Kerlix from toes to ankle, change daily and PRN (as needed). A Progress Note, dated 4/8/16 at 7:27 A.M., indicated: (Recorded as Late Entry on 04/20/2016 at 08:05 AM) Resident noted on this date 4/8/16, to have new wound to right lower extremity. Wound is noted to cover four toes and discoloration covering foot, toes are noted to be dark and appear to be necrotic with yellow in color fluid weeping from the leg and the foot. MD notified with new orders to start PO (by mouth) ATB (antibiotic) .culture Right toe for drainage, Arterial Doppler to right leg, treatment order .Resident is a [MEDICAL TREATMENT] patient and goes three times a week .Resident is alert and oriented with confusion at times, in one assist care, ADL's (activities of daily living), two for transfers A Weekly Update Skin Events form, indicated: Event Date: 04/13/2016, Date Recorded: 04/20/2016 08:11 AM, Diabetic Ulcers Right Foot/Toes Describe measurements, undefined, Describe tunneling, possible, Describe wound color, 50% dark black/50% red, Describe wound drainage, moderate amount of purulent (pus-like), Describe wound odor, Slight Progress Notes included the following notations: 4/15/16 at 8:14 A.M., indicated, (Recorded as Late Entry on 04/20/2016 08:40 AM) IDT (Interdisciplinary Team) evaluated resident's wound to right lower extremity. Site continue (sic) to remain the same at this time, toes are dark and top of foot is red with noted drainage from leg and foot, there is a slight odor present. Resident does show an increase in pain on assessment to this area ad there is nonverbal sign/symptoms. PRN pain medication is available as needed 4/19/16 at 8:50 A.M., indicated, (Recorded as Late Entry on 04/20/2016 09:05 AM) Resident assessed .Resident is noted to be more confused, not responding as normal for resident. This nurse sat down and fed resident and noted he has harder time eating the mechanical soft food .On starting treatment change this nurse noted excessive amount of drainage on bed and that a foul odor was present .On assessment noted that wound was worse and had noted increase drainage to back of leg with discoloration of toes and foot spreading .Pain was noted nonverbally .This nurse became concerned about resident's change in condition and notified unit manager and Social Services along with residents (sic) brother Documentation that the physician was notified of the resident's change in condition was not found in the progress notes. A Weekly Update Skin Events form, indicated, Event date: 04/19/2016, Date Recorded: 04/20/2016 08:47 AM, Description Diabetic Ulcers Right Foot/Toes .Describe measurements, undefined, Describe tunneling, possible, Describe wound color, 60% dark black/40% red, Describe wound drainage, moderate amount of purulent, Describe wound odor, Foul .Physician notified: Yes, Date/Time: 04/19/2016 Progress Notes continued: 4/20/16 at 3:40 A.M.: Resident was not responding to stimuli for CNA on duty. This nurse assessed resident and noted that he was very difficult to arouse and only opened his eyes 4/20/16 at 4:00 A.M.: Assessment complete. (Name of physician) called with full report and order received to send resident to (name of hospital) ER for eval (evaluation) and treat 4/20/16 at 4:10 A.M.: (Ambulance service) arrived and resident transferred onto stretcher A Emergency Resident Transfer form, dated 4/20/16 at 3:40 A.M., indicated, Reason for transfer, Difficult to arouse, and non verbal .Describe resident's skin condition at time of transfer, Multiple scabs and scratch marks on extremities A Hospital ER record, dated 4/20/16 at 5:03 A.M., indicated, This is a very ill gentleman on [MEDICAL TREATMENT] with severe [MEDICAL CONDITION] .Evidently for the last 24 hours has had decreasing level of consciousness. Responsive only to sternal rub. Entirely unclear to me why now 4:00 four a.m. (sic) they decided he needed to be seen. But rather than at the outset of altered mental status. In any event he arrives here by ambulance .Physical Exam: .Extremities - patient is noted to have a below-the-knee amputation on the left, right foot had a dressing in place. I took it down. I sounds (sic) black toes [DIAGNOSES REDACTED] (redness) to the for (sic) foot extending up the lateral lower leg with diffuse maggot infestation .Medical Decision Making: .necrotic right foot with maggots. Likely will need amputation. Likely infection A Hospital History and Physical, dated 4/20/16 at 5:08 A.M., indicated, .Extremities: .R LE (lower extremity) wrapped with bag in place, dorsal aspect of R foot [DIAGNOSES REDACTED]tous, 2-5th digits black, maggots present in between 4th and 5th digit A Facility Care Plan, dated 3/17/16 and updated 4/22/16, indicated, Resident is at risk for skin breakdown: hx (history) of impaired skin integrity, decreased mobility, DM (Diabetes Mellitus), [MEDICAL CONDITIONS] . The Approaches included: Assess and document skin condition weekly and as needed. Notify MD of abnormal findings .Preventative treatment as ordered A Facility Care Plan, dated 4/8/16 and updated 4/22/16, indicated, Resident has impaired skin integrity: Necrotic Diabetic Ulcers to Right Foot. Resident has a hx of impaired skin integrity . The Approaches included: Notify MD of worsening or no change in wound or for signs of infection. Observe for signs of infection: redness, pain, drainage, malodorous drainage On 4/27/16 at 1:40 P.M., during an interview with LPN # 2, she indicated she was the nurse who transferred Resident K to the hospital. She indicated the resident wasn't hardly responding at all. She indicated she thought the resident's right leg was wrapped with a dressing, as well as the left stump. LPN # 2 indicated she thought the resident's dressing was changed three times a week. She indicated, The wound care nurse takes care of wounds, so I didn't see it once it was discovered. On 4/27/16 at 2:50 P.M., during an interview with Resident K's physician's office nurse, she indicated she checked all of the communications on 4/19/16 from the facility, and there was no record of notification of a condition change regarding Resident K. On 4/27/16 at 3:00 P.M., during an interview with LPN # 1, she indicated she was the facility's wound care nurse. She indicated she discovered Resident K's wound on April 8. She indicated she looked at the resident's foot almost every day, but that her documentation is usually late. She indicated that she did change the resident's dressing on 4/19/16, gave the resident a bath, and didn't notice any maggots. LPN # 1 indicated she did not notify the physician on 4/19/16, because she was going to let social services take care of that. On 4/28/16 at 9:35 A.M., during an interview with the Director of Nursing (DON), she indicated LPN # 1 discovered the resident's wounds on 4/8/16. She indicated she didn't know why the resident's skin wounds were not found prior to becoming black and draining. The DON indicated she read the computerized hospital notes regarding Resident K on 4/20/16, and then asked LPN # 1 to document her wound notes. She indicated LPN # 1 frequently documents her wound notes late. She indicated she spoke to the nurse performing the treatment on 4/18/16, and he didn't see any bugs on the resident. The DON indicated that she did not know why the physician was not notified on 4/19/16. The DON indicated the Registered Dietician's note should not have been dated on 4/6/16, and she would have her correct that. The DON indicated she did do a skin sweep on residents following this incident, and she had staff update skin care plans. On 4/28/16 at 10:50 A.M., the Administrator provided the current facility policy on the Skin Management Program, dated 1/2016. The policy included: .Residents will have a skin assessment completed no less than weekly by the licensed nurse in an effort to assess overall skin condition, skin integrity, and skin impairment .Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness .The licensed nurse is responsible for assessing any and all skin alterations as reported .Wound rounds will be completed on a weekly basis to assess wounds .When a new alteration in skin integrity is identified .Skin event will be opened, Treatment order obtained as indicated This Federal tag relates to Complaint IN 086. 3.1-37(a)

Based on interview and record review, the facility failed to ensure the physician was notified of a resident's change in condition, for 1 of 3 residents reviewed for physician notification, in a sample of 22. This deficient practice resulted in the Resident K being admitted to the local hospital for treatment of [REDACTED]. (Resident K) Findings include: The closed clinical record of Resident K was reviewed on 4/27/16 at 10:50 A.M. [DIAGNOSES REDACTED]. A Progress Note, dated 4/8/16 at 7:27 A.M., indicated: (Recorded as Late Entry on 04/20/2016 at 08:05 AM) Resident noted on this date 4/8/16, to have new wound to right lower extremity. Wound is noted to cover four toes and discoloration covering foot, toes are noted to be dark and appear to be necrotic with yellow in color fluid weeping from the leg and the foot. MD notified with new orders to start PO (by mouth) ATB (antibiotic) .culture Right toe for drainage, Arterial Doppler to right leg, treatment order .Resident is a [MEDICAL TREATMENT] patient and goes three times a week .Resident is alert and oriented with confusion at times, in one assist care, ADL's (activities of daily living), two for transfers Progress Notes included the following notations: 4/19/16 at 8:50 A.M., indicated, (Recorded as Late Entry on 04/20/2016 09:05 AM) Resident assessed .Resident is noted to be more confused, not responding as normal for resident. This nurse sat down and fed resident and noted he has harder time eating the mechanical soft food .On starting treatment change this nurse noted excessive amount of drainage on bed and that a foul odor was present .On assessment noted that wound was worse and had noted increase drainage to back of leg with discoloration of toes and foot spreading .Pain was noted nonverbally .This nurse became concerned about resident's change in condition and notified unit manager and Social Services along with residents (sic) brother Documentation that the physician was notified of the resident's change in condition was not found in the progress notes. A Weekly Update Skin Events form, indicated, Event date: 04/19/2016, Date Recorded: 04/20/2016 08:47 AM, Description Diabetic Ulcers Right Foot/Toes .Describe measurements, undefined, Describe tunneling, possible, Describe wound color, 60% dark black/40% red, Describe wound drainage, moderate amount of purulent (pus-like), Describe wound odor, Foul .Physician notified: Yes, Date/Time: 04/19/2016 A Hospital ER record, dated 4/20/16 at 5:03 A.M., indicated, This is a very ill gentleman on [MEDICAL TREATMENT] with severe [MEDICAL CONDITION] .Evidently for the last 24 hours has had decreasing level of consciousness. Responsive only to sternal rub. Entirely unclear to me why now 4:00 four a.m. (sic) they decided he needed to be seen. But rather than at the outset of altered mental status. In any event he arrives here by ambulance On 4/27/16 at 2:50 P.M., during an interview with Resident K's physician's office nurse, she indicated she checked all of the communications on 4/19/16 from the facility, and there was no record of notification of a condition change regarding Resident K. On 4/27/16 at 3:00 P.M., during an interview with LPN # 1, she indicated she was the facility's wound care nurse. LPN # 1 indicated she did not notify the physician on 4/19/16, because she was going to let social services take care of that. On 4/28/16 at 9:35 A.M., during an interview with the Director of Nursing (DON), she indicated that she did not know why the physician was not notified on 4/19/16. She indicated the Skin Events form was not pre-filled out with documentation that the physician was notified, but that the documenting nurse would have to check Yes to indicate notification. On 4/28/16 at 10:50 A.M., the Administrator provided the current facility policy on Resident Change of Condition, dated 1/2015. The policy included: It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician .All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met .The nurse in charge is responsible for notification of physician .prior to end of assigned shift when a significant change in the resident's condition is noted This Federal tag relates to Complaint IN 086. 3.1-5(a)(2)

Based on interview and record review, the facility failed to ensure a newly admitted resident had the hospital transfer orders verified by the primary physician, for 1 of 3 residents reviewed for new admission physician orders, in a sample of 6. This resulted in the resident receiving a high dose of insulin causing an adverse medication reaction resulting in hospitalization . Resident E Findings include: The closed clinical record of Resident E was reviewed on 7/7/15 at 1:30 P.M. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Hospital transfer orders, dated 6/19/15, indicated, [MEDICATION NAME] (insulin).74 unit (insulin) Subcutaneous 3 times per day before meals; diabetes. Facility physician orders, dated 6/19/15, included: [MEDICATION NAME] 74 units inj (inject) SQ (subcutaneously) TID (three times daily) AC (before meals) DM (diabetes mellitus). The times listed for the insulin to be given were 7:30 A.M., 12:00 P.M., and 5:30 P.M. The physician order [REDACTED]. Initial (RN # 1). Progress Notes included the following notations: 6/19/15 at 9:07 P.M.: Alert resident transferred to facility per stretcher from other facility.denies pain or discomfort. 6/20/15 at 4:36 A.M.: Lying quietly in bed.Alert to person, confused to time. Has rested all night with no s/s (signs/symptoms) of distress. 6/20/15 at 2:09 P.M.: 1200 (12:00 P.M.) accu check 24 [MEDICATION NAME] (a medication to treat severe low blood sugar) given left deltoid, 1205 bs (blood sugar) 25 oral gel given 1/4 tube, 1210 bs 37 [MEDICATION NAME] given left deltoid, 1220 38 oral gel 1/4th tube oral gel (sic), 1245 bs 38 oral gel given 1/4 tube, 1300 (1:00 P.M.) 47 1/4th tube given, 1310 (1:10 P.M.) blood sugar 84, call placed to (name of physician) 1345 (1:45 P.M.) bs 55 call placed to (name of physician), 1400 (2:00 P.M.) bs 65, order written per family request to send to (name of hospital) ER for low blood sugar. According to the Accu Chek guidelines, Recommended blood sugar levels are: Before meal between 70 and 130.After meal less than 180. Progress Notes continued: 6/20/15 at 2:53 P.M.: Transferred care to (ambulance name) services to transport to (name of hospital) ER. 6/20/15 at 3:05 P.M.: (Recorded as Late Entry on 06/21/2015 10:10 A.M.). Skin warm dry pale, blowing resp. (respirations), decreased LOC (level of consciousness), unable to respond to verbal, and tactile stimuli. A hospital ER note, dated 6/20/15, indicated: Chief Complaint: Adverse medication reaction.Apparently she received 74 units of [MEDICATION NAME] as a scheduled order there.She normally receives 7 units 3 times a day as needed.The patient's initial glucose level when she arrived here was in the 45 (sic).Final Diagnosis: [REDACTED]. 2. Insulin overdose. A hospital history and physical, dated 6/21/15, indicated: Patient presents with [DIAGNOSES REDACTED] (low blood sugar).Impression: frail, debilitated [AGE] year-old female with history of diabetes with prolonged hypoglycemic reaction, [MEDICAL CONDITION] with exacerbation and impending [MEDICAL CONDITION] and [MEDICAL CONDITION] with uncertain disposition. Plan:.condition on admission guarded but stable. On 7/7/15 at 3:10 P.M., during an interview with LPN # 3, she indicated she was the nurse who gave Resident E the insulin on 6/20/15. She indicated she thought the dose was high, but that she knew (RN # 1) had verified the order. She indicated she administered the insulin after breakfast, at approximately 8:30-9:00 A.M. On 7/9/15 at 8:55 A.M., during an interview with RN # 1, she indicated she had received the transfer orders from the hospital for Resident E on 6/19/15. She indicated she had transcribed the orders to the facility physician orders, and kept double checking the orders, since they had come from a hospital out-of-state. She indicated she had not called the primary physician or any physician to verify the orders. On 7/8/15 at 10:45 A.M., the Director of Nursing provided the current facility policy on Nursing Admission/Return Admission Procedure, dated 2/2015. The policy included: .1. Upon admission, physician orders [REDACTED]. The admitting nurse must call the attending physician to verify all orders upon admission. This federal tag relates to Complaint IN 988. 3.1-30(a)

Based on interview and record review, the facility failed to ensure the correct insulin dosage was administered to a resident, resulting in a hospitalization for an insulin overdose, for 1 of 3 diabetic residents reviewed, in a sample of 6. Resident E Findings include: The closed clinical record of Resident E was reviewed on 7/7/15 at 1:30 P.M. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Hospital transfer orders, dated 6/19/15, indicated, [MEDICATION NAME] (insulin).74 unit (insulin) Subcutaneous 3 times per day before meals; diabetes. Facility physician orders, dated 6/19/15, included: [MEDICATION NAME] 74 units inj (inject) SQ (subcutaneously) TID (three times daily) AC (before meals) DM (diabetes mellitus. The times listed for the insulin to be given were 7:30 A.M., 12:00 P.M., and 5:30 P.M. The physician order [REDACTED]. Initial (RN # 1). The resident's weight was recorded as 128.2 pounds, or 58 kilograms (kg). Progress Notes included the following notations: 6/19/15 at 9:07 P.M.: Alert resident transferred to facility per stretcher from other facility.denies pain or discomfort. 6/20/15 at 4:36 A.M.: Lying quietly in bed.Alert to person, confused to time. Has rested all night with no s/s (signs/symptoms) of distress. 6/20/15 at 2:09 P.M.: 1200 (12:00 P.M.) accu check 24 [MEDICATION NAME] (a medication to treat severe low blood sugar) given left deltoid, 1205 bs (blood sugar) 25 oral gel given 1/4 tube, 1210 bs 37 [MEDICATION NAME] given left deltoid, 1220 38 oral gel 1/4th tube oral gel (sic), 1245 bs 38 oral gel given 1/4 tube, 1300 (1:00 P.M.) 47 1/4th tube given, 1310 (1:10 P.M.) blood sugar 84, call placed to (name of physician) 1345 (1:45 P.M.) bs 55 call placed to (name of physician), 1400 (2:00 P.M.) bs 65, order written per family request to send to (name of hospital) ER for low blood sugar. According to the Accu Chek guidelines, Recommended blood sugar levels are: Before meal between 70 and 130.After meal less than 180. Progress Notes continued: 6/20/15 at 2:53 P.M.: Transferred care to (ambulance name) services to transport to (name of hospital) ER. 6/20/15 at 3:05 P.M.: (Recorded as Late Entry on 06/21/2015 10:10 A.M.). Skin warm dry pale, blowing resp. (respirations), decreased LOC (level of consciousness), unable to respond to verbal, and tactile stimuli. A hospital ER note, dated 6/20/15, indicated: Chief Complaint: Adverse medication reaction.Apparently she received 74 units of [MEDICATION NAME] as a scheduled order there.She normally receives 7 units 3 times a day as needed.The patient's initial glucose level when she arrived here was in the 45 (sic).Final Diagnosis: [REDACTED]. 2. Insulin overdose. A hospital history and physical, dated 6/21/15, indicated: Patient presents with [DIAGNOSES REDACTED] (low blood sugar).Impression: frail, debilitated [AGE] year-old female with history of diabetes with prolonged hypoglycemic reaction, [MEDICAL CONDITION] with exacerbation and impending [MEDICAL CONDITION] and [MEDICAL CONDITION] with uncertain disposition. Plan:.condition on admission guarded but stable. According to the [MEDICATION NAME]prescribing information: Dosage: must be individualized.The total daily insulin requirement may vary and is usually between 0.5 to 1.0 units/kg/day. The residents's weight of 58 kg indicated a normal dose would have been approximately 29-58 units of insulin a day. On 7/7/15 at 3:10 P.M., during an interview with LPN # 3, she indicated she was the nurse who gave Resident E the insulin on 6/20/15. She indicated she thought the dose was high, but that she knew (RN # 1) had verified the order. She indicated she gave the resident her insulin after breakfast, at approximately 8:30-9:00 A.M. She indicated she was called to the resident's room before lunch, and found the resident trembling and semi-conscious. She indicated she gave the resident [MEDICATION NAME] and liquid gel glucose, but could not get the sugar to go higher. On 7/9/15 at 8:55 A.M., during an interview with RN # 1, she indicated she had received the transfer orders from the hospital for Resident E on 6/19/15. She indicated she had transcribed the orders to the facility physician orders, and kept double checking the orders, since they had come from a hospital out-of-state. She indicated she had not called the primary physician or any physician to verify the orders. RN # 1 indicated she did question the resident on 6/20/15 early in the morning about her high insulin dose, and the resident told her she did what the dr. told me to do. This federal tag relates to Complaint IN 988. 3.1-48(c)(2) This federal tag relates to Complaint IN 988.

Based on observation, interview, and record review, the facility failed to ensure a dependent resident was safely propelled in a wheelchair, ensuring proper positioning, resulting in falls with sutures and steri strips to the head, and failed to safely provide care to a resident by leaving her unattended on the bed, resulting in a fall, for 1 of 5 residents reviewed with falls, in a sample of 20. Resident E Findings include: The clinical record of Resident E was reviewed on 10/8/14 at 5:00 A.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 8/14/14, indicated Resident E was unable to complete a brief interview for mental status, had a short-term and long-term memory problem, and was severely impaired in cognitive skills for daily decision making. The resident required extensive assistance of two+ staff for bed mobility, transfer, and did not ambulate. The resident required total dependence of one staff for locomotion on and off of the unit ("how resident moves between locations in his/her room and adjacent corridor...If in wheelchair, self-sufficiency once in chair"). A test for balance during transitions and walking indicated the resident was "Not steady, only able to stabilize with staff assistance" during moving from seated to standing position and surface-to-surface transfer. A Nursing Weekly Summary, dated 9/1/14 at 10:07 P.M., indicated, "Alert et (and) responsive. Fed per staff...Needs anticipated (sic) per stff (sic). Popels (sic) self in w/c (wheelchair). Totalare (sic) with ADL's (activities of daily living)...." Nursing Progress Notes included the following notations: 9/2/14 at 12:00 P.M.: "Laceration to res's (resident's) head measures 5.5 cm x 1.7 cm x 0.5 cm...Top of left hand noted to have small bruise 2 cm x 1.5 cm...Transferred res to w/c (wheelchair) with assist of 3. Nurse stayed with res until arrival of EMS (emergency medical system) services...." 9/2/14 at 12:15 P.M.: "Res left with EMS services at this time for transport to (hospital) ER...." 9/2/14 at 8:16 P.M.: "Res returned at this time. Orders received to resume previous orders et (and) remove sutures 9/9/14...." 9/2/14 at 11:00 P.M.: "Res in bed the whole shift, no distress noted but had to change dressing on forehead which was soaking in blood d/t (due to) sutures. Vitals stable." 9/3/14 at 3:42 P.M.: "IDT (interdisciplinary team) Fall Review from 9/2/14 at 12:23 p.m. Resident had an (sic) witnessed fall on day shift. Resident was sitting up in w/c in activity area at time of fall. Resident was being propelled by activity staff via w/c. Residents (sic) foot got caught under other foot making her come forward in her chair and out of w/c on to floor...Resident was noted to have a laceration to forehead with moderate amount of bloody red drainage...Post Fall Intervention; Send resident to ER...and staff education on safely propelling resident while in a w/c...." 9/8/14 at 3:29 P.M.: "IDT Fall Review from 9/5/14 at 1. Resident was in room at time of fall getting peri care per nursing staff. Resident was sitting on side of bed with feet planted on the floor. Staff member turned away from resident to reach an item to provide daily care. Resident then slid fell forward down from bed to floor, staff being unable to prevent fall, bed was in low position...Resident was noted to have a laceration to right side of face near eye with moderate amount of bloody red drainage...Resident was assist x 2 staff members back into w/c...Post Fall Intervention; staff education on safely provide care (sic) and not leave resident unattended while in a bed...." 9/9/14 at 8:15 P.M.: "(Recorded as Late Entry on 9/10/2014 12:20 AM) Resident was propelling self down (number) hallway via w/c. Staff was walking behind resident noted resident lean forward in w/c and attempted to reach resident. Resident then fell to the floor face forward in front of w/c. Resident noted to had (sic) a skin tear to forehead related to red bloodily (sic) drainage...site was cleansed and steri strips applied to site...Resident was assist x 3 staff back into w/c and was taken to bed and laid down for evening...." A Resident Care Plan, initially dated 10/25/12 and updated with a goal target date of 12/28/14, indicated, "Problem, Fall risk related to: [DIAGNOSES REDACTED]." The Approaches included: "1/14/14 assist x 2 with transfers - may use Hoyer lift prn (as needed), 7/30/12 Dycem to w/c (wheelchair), 12/7/11 Keep resident eye glasses clean and make sure she has glasses on when out of bed, 6/13/11 Observe for fall risk contributors such as medications, hypotension, pain, unsteady gait, 9/2/14 staff education, 9/5/14 staff education, 9/5/14 prepare all things needed for care within reach before providing care, 9/9/14 Therapy to assess w/c...9/22/14 wheelchair with bilateral leg rest at all times." On 10/9/14 at 9:45 A.M., during interview with the Director of Nursing (DON), she provided a witness statement from Activity Assistant # 1 who was propelling Resident E on 9/2/14. The statement indicated, "I was helping push residents down to the dining room. I noticed (Resident E) was having difficulties moving towards the dining room. I told her I was going to assist her and began pushing. She appeared to be somewhat hunched over and was shuffling her feet as she normally does when someone pushes her. I think she lost balance and fell forward hitting the crown molding on the wall. After she had fallen I saw blood coming from her head...." The DON indicated it was her understanding that the resident "all of a sudden put down her feet." At that time, the DON and Assistant Director of Nursing (ADON) indicated on 9/5/14, the CNA providing care to the resident turned away from the resident to get a towel, leaving the resident sitting on the bed. The ADON indicated the staff member was not in arm's reach of the resident. The DON and ADON indicated the staff member was educated that she should have laid the resident down to provide care. No additional information was provided regarding the resident's fall on 9/9/14. On 10/9/14 at 11:45 A.M., Resident E was observed sitting in a wheelchair in the dining room. A healed pink scar was observed on the resident's upper forehead. The resident spoke with nonsensical speech, and was unable to reply to questions. On 10/9/14 at 1:15 P.M., the Administrator provided the current facility policy on the "Fall Management Program," dated 9/2013. The policy included: "It is the policy...to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls...." This Federal tag relates to Complaint IN 481. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident's medications were adequately monitored, in that a resident was on multiple medications which could effect lab values, and no lab was ordered. This contributed to the resident being admitted to the hospital with [REDACTED]. This affected 1 of 3 residents reviewed for medications, in a sample of 3. Resident A Findings include: The closed clinical record of Resident A was reviewed on 7/23/14 at 11:10 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission physician orders, dated May 2014, indicated there was no lab ordered. Physician orders, dated July 2014, included, but were not limited to, the following medications: [REDACTED] [MEDICATION NAME] 20 mg (milligram) once daily (for swelling), initial order 3/18/14 [MEDICATION NAME] 20-25 mg once daily for hypertension (for high blood pressure), initial order 3/18/14 K-Dur 20 mEq (milli equivalent) once daily for dietary supplement (replacement for potassium), initial order 3/18/14 [MEDICATION NAME] 500 mg once daily for chronic pain, initial order 4/15/14 Bactrim DS three times daily for wound infection, started on 6/22/14 for 10 days A consulting Pharmacist note, dated 4/15/14, recommended a decrease in the use of an anti-depressant. The consulting Pharmacist had no recommendations for the resident in May 2014. A consulting Pharmacist note, dated 6/11/14, indicated the resident was on duplicate "NSIADs," and recommended the discontinuation of prn (as needed) [MEDICATION NAME] (used for pain and/or anti [MEDICAL CONDITION]), which the physician agreed to on 6/16/14. Lab orders, including those which monitored the resident's potassium and kidney function, were not found in the clinical record. Documentation indicated the resident was transferred to the hospital emergency roiagnom on [DATE]. A hospital history and physical, dated 7/1/14, included: "Assessment, Acute [MEDICAL CONDITION]. Stop Bactrim. Hold ACE inhibitors and potassium...." A hospital consultation, dated 7/1/14, indicated, "Reason For Consultation: Acute [MEDICAL CONDITION] and [MEDICAL CONDITION] (high potassium)...workup revealed her potassium was 9 (normal value 3.5-5.0) and kidney function which previously had creatinine of 1.0 was now 8 or so (normal value .56-1.0). She was on Bactrim recently. Besides that, she has been on ACE inhibitor and nonsteroidal [MEDICATION NAME]/Recommendations:...All offending medications including ACE inhibitor, Bactrim and non-steroidal have already been discontinued...." A hospital discharge summary, dated 7/15/14, included: "Brief history and hospital course...Upon arrival to ED (emergency department) she was unresponsive, and hypotensive (low blood pressure), was [MEDICAL CONDITION]ly combo of Bactrim, ACE, [MEDICATION NAME], [MEDICAL CONDITION]. Was dialyzed and now improved...." On 7/24/14 at 10:50 A.M., during interview with the Unit Manager, she indicated when a resident was admitted to the facility, she always asked the physician what lab work he wanted to order. She indicated since this resident was admitted to the first floor, she did not know why there were no lab orders. On 7/24/14 at 11:30 A.M., during interview with the Unit Manager, she indicated she had spoken to the resident's physician, and he informed her that there had been a break in the continuity of care, and he had just taken the resident on in May 2014. The physician indicated to the Unit Manager that he had planned on ordering lab work. 2. According to the "Nursing 2014 Drug Handbook," the following was documented: [MEDICATION NAME] - Interactions: NSAIDs - May inhibit diuretic response. Use together cautiously...Effects on Lab Test Results - May increase cholesterol, glucose, BUN, creatinine, and urine acid levels...Nursing Considerations - Monitor fluid intake and output and electrolyte, BUN, and carbon [MEDICATION NAME] levels frequently. [MEDICATION NAME] - class ACE inhibitor, Potassium-sparing diuretics, potassium supplements: May increase risk of [MEDICAL CONDITION]. Avoid use together. Nursing Considerations, Monitor glucose, electrolyte, and lipid levels during therapy. [MEDICATION NAME] ([MEDICATION NAME]) - class Nonsteroidal anti-[MEDICAL CONDITION] drug (NSAID) - Use cautiously in patients with heart failure, hypertension...fluid retention, renal insufficency...." Bactrim - Effects on Lab Test Results - May increase...BUN and Creatinine levels...Monitor renal and liver function test results...." K-Dur (Potassium Chloride) - Interactions: ACE inhibitors: May cause [MEDICAL CONDITION]. Use together with extreme caution. Monitor potassium level. Nursing considerations, Monitor ECG and electrolyte levels during therapy. Monitor renal function...Many adverse reactions may reflect [MEDICAL CONDITION]. This Federal tag relates to Complaint IN 594. 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure the physician was notified of "STAT" multiple abnormal lab results timely, resulting in admission to the hospital with a [DIAGNOSES REDACTED]. Resident D Findings include: 1. The clinical record of Resident D was reviewed on 7/2/14 at 1:20 P.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Progress notes included the following notations: 6/21/14 at 7:30 A.M.: "Resident alert and with noted respiratory distress at this time. Resp (respirations) shallow and increased @ 26/min. SpO2 @ 86% with O2 [MEDICAL CONDITION] at 35%...MD notified to request STAT CXR (chest x-ray) and labwork. Orders received (sic) and noted, (X-ray and Lab services) notified of orders...Will continue to monitor closely." A physician's orders [REDACTED]. Obtain STAT CXR D/T (due to) (increased) SOB (shortness of breath), c/o (complaints of) dyspnea, (decreased) SpO2 et (and) (increased) RR (respiratory rate). 2. Obtain CBC CMP TSH level STAT D/T (increased) SOB, c/o dyspnea...." Progress notes continued: 6/21/14 at 2:14 P.M.: "In bed with HOB (head of bed) elevated...Bil (bilateral) lungs lightly congested with pursed lip respirations. Has c/o (complained of) difficulty breathing at times and has been extremely anxious. PRN (as needed) respiratory treatments given as ordered and this seems to help and is able to breath (sic( better...." 6/21/14 at 3:16 P.M.: "CXR results received (sic) and reported to MD. Impressions showing mild acute bilateral perihilar infiltrates are noted. Awaiting any new orders...Close monitoring continues...." 6/22/14 at 7:07 A.M.: "Noted STAT lab work received. Immediately paged MD to verbally report due to numerous abnormal values. Full H/P (history/physical) reported to MD along with resp status...Order received to send to (hospital) ER for evaluation...Resp status currently stable with rate of 22. SpO2 @ 94% [MEDICAL CONDITION] at 35%...." Lab reports, dated 6/21/14, indicated the blood was collected at 5:05 P.M. and faxed from the lab to the facility from 9:30 P.M.- 9:50 P.M. The results included the following: WBC 52.7 (normal 4.5-11.5), Sodium 132 (normal 136-144), Potassium 5.8 (normal 3.6-5.1), Chloride 93 (101-111), BUN 100 (8-20), Creatinine 5.4 (0.4-1.0), and Alkaline [MEDICATION NAME] 107 (32-91). A written notation indicated, "Faxed 6/21." A hospital ER record, dated 6/22/14 at 8:33 A.M., included: "...brought in by EMS to the Emergency Department for abnormal labs...The patient complains of shortness of breath..." Lab results, dated 6/22/14 at 9:15 A.M., included: "White Blood Count, 62.5, Critical result noted...Potassium 7.9, Critical result noted...Emergency Diagnosis: [REDACTED]. On 7/2/14 at 3:45 P.M., during an interview with LPN # 1, she indicated she was working on 6/21/14 and 6/22/14. She indicated she received the lab and CXR orders for Resident A. She indicated when she got to work on 6/22/14 at 7:00 A.M., and saw that the resident's lab work had not been addressed, she immediately notified the physician. She indicated she was not sure if the previous shift had faxed the lab results to the physician, or triage system. On 7/3/14 at 11:00 A.M., during an interview with the Administrator, she indicated the nursing staff should have called the physician with the lab results when they were received on 6/21/14. 2. On 7/3/14 at 11:30 A.M., the Medical Records manager provided the current facility policy on "Guidelines for Lab Tracking," undated. The policy included, "When lab result comes in - notify MD of results - note date/time/signature that lab was faxed to MD. NOTE: CRITITAL (sic) LABS SHOULD BE REPORTED BY TELEPHONE TO THE MD...." This Federal tag relates to Complaint IN 080. 3.1-49(f)(2)

Based on observation, interview, and record review, the facility failed to ensure a foley catheter drainage bag and tubing was kept off of the floor, resulting in the resident requiring antibiotics for a urinary tract infection, for 1 of 1 residents reviewed with foley catheters, in a sample of 5. Resident A Findings include: 1. On 1/22/13 at 12:20 P.M., Resident A was observed lying in a low bed, asleep. A foley catheter bag, in a blue protective cover, was observed lying on the floor. On 1/22/13 at 2:25 P.M., Resident A was observed sitting up in bed, eating. A foley catheter bag, outside of the blue cover, was observed lying on the floor. The side of the bag with the outlet valve was on the floor. The blue cover was hanging on the bed frame. On 1/23/13 at 8:30 A.M., Resident A was observed lying in a low bed, asleep. A foley catheter bag in a blue protective cover was hanging on the bed frame, lying on the floor. The clinical record of Resident A was reviewed on 1/23/13 at 8:45 A.M. [DIAGNOSES REDACTED]. Physician orders, initially dated 9/10/12 and on the January 2013 recertification orders, indicated, "Foley Catheter care every shift," and "16 Fr (French foley catheter) to BSD (bedside drainage) Dx (diagnosis) [MEDICAL CONDITION] Bladder." A Minimum Data Set (MDS) assessment, dated 12/9/12, indicated the resident scored a 4 out of 15 for cognitive status, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two + staff for bed mobility, transfer, and was totally dependent on two + staff for toilet use. A Care Plan, dated 9/20/12, indicated: "Problem, Resident requires an indwelling urinary catheter R/T (related to): [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder...Approach...Do not allow tubing or any part of the drainage system to touch the floor...Store collection bag inside a protective dignity pouch." On 1/23/13 at 1:20 P.M., during interview with the Administrator, she indicated the foley catheter bag should not be placed on the floor. On 1/24/13 at 10:55 A.M., during interview with the interim Director of Nursing, she indicated she had just received an order for [REDACTED]. The clinical record of Resident A was reviewed again on 1/24/13 at 2:30 P.M. A physician's orders [REDACTED].M., indicated, "Cipro (antibiotic)...for 10 days d/t (due to) cloudy, foul smelling urine (and) malaise." 2. On 1/24/13 at 2:20 P.M., the Administrator provided the current facility policy on "Indwelling Urinary Catheter," reviewed 12/2012. The policy included: "...Place drainage bag below level of bladder. Do not place bag on side rail or on bed...." The policy did not include specifically not placing the drainage bag on the floor. This federal tag relates to Complaint IN 655. 3.1-41(a)(1) 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure accurate weights were obtained and recorded, thereby failing to provided interventions to prevent weight loss, for 2 of 3 residents reviewed for weight loss, in a sample of 5. Resident A, Resident C Findings include: 1. On 1/22/13 at 9:50 A.M., during the initial tour, the interim Director of Nursing (DNS) and the 2nd floor Unit Manager indicated Resident A had experienced a weight loss in the previous 2 months. On 1/22/13 at 2:25 P.M., Resident A was observed sitting in bed in his room, eating a piece of pizza left from lunch. The clinical record of Resident A was reviewed on 1/23/13 at 8:45 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders, dated 9/9/12, indicated Resident A was on a CCHO (concentrated carbohydrate) diet. An admission Minimum Data (MDS) assessment, dated 9/16/12, indicated the resident scored a 3 out of 15 for cognitive status, with 15 indicating no memory impairment. The MDS assessment indicated the resident required limited assistance of one person for eating, and his weight was 165 lbs. A Care Plan, dated 9/17/12 and discontinued on 1/22/13, indicated: "Problem, Resident requires a therapeutic diet related to dx (diagnosis) of DM (diabetes mellitus). Goal, Resident will not display significant weight loss through next review. Approach, meal is consumed (sic), Provide diet per MD order, Review labs as available." Speech therapy treatment notes included the following notations: 11/5/12: "Pt (patient) reportedly eating sweets for nutrition all day and not consuming any dietary offerings. Unbalanced meals or refusal of balanced meals leads to poor health, overall body weakness, and unsafe/weakened swallow when appropriate appetite does improve...." 12/3/12: "Pt continues to eat a very poorly balance (sic) diet, at this point. Most meals aren ' t' even consumed. He tends to snack on candy and dessert off and on throughout the day when he is hungry rather than eat what is offered by dietary...SLP (speech language pathologist) approached the 1st shift nurse concerning an appetite enhancing drug. After discussion, therapist investigated possible wt. (weight) loss. According to the past 2 1/2 to 3 months of his residency in current nursing facility, he has gained 6 lbs not lost...." 12/4/12: "Continue to brain storm with 1st shift nurse concerning swallow, nutrition and motivation to improve his current appetite...It is difficult to treat his swallow when he barely eats his meals...Pt has not lost wt in past couple of months, so an appetite enhancing drug would not be appropriate...." A dietary progress note, dated 12/6/12 at 2:14 P.M., indicated, "...Resident on consistent carbohydrate diet per order. On average resident consumed 50% B (breakfast)/100%L (lunch)/100%D (dinner) of meals recorded in the consumption record over the last 7 days...Weight 162 lbs (11/12)...No new recommendations at this time." A Speech therapy note, dated 12/7/12, indicated: "...He admits he has a poor appetite for bldg (building) food and likes to eat snacks/candy instead. There have been days when he has been observed eating 60-75% of his meal in the past two weeks...." Nursing progress notes, dated 12/8/12 at 2:28 A.M., indicated, "...Alert and oriented with periods of confusion at times...Eats meals in his room per his request and feeds self...." Nursing progress notes, dated 12/17/12 at 10:04 P.M., indicated, "...Feeds self with tray set up...." Nursing progress notes, dated 1/1/13, indicated, "...Feeds self with set up eats in room per request...." A dietary progress note, dated 1/13/13, indicated, "January wt (weight) 132 # (lbs) - this is down 19% x 30 days. Meal intakes 0-50%. Spoke with nursing who reports rsd (resident) refusing to eat at times. Rsd typically consumes 51-100% of meals...Recommend change diet to regular, 7.5 mg [MEDICATION NAME] (appetite stimulant) daily. Will add to weekly wts." A Care Plan, dated 1/22/13, indicated, "Problem, Resident has experienced significant weight loss x 30 days. Goal, Resident will not experience further significant weight loss...." On 1/23/13 at 10:00 A.M., during interview with the Registered Dietician (RD), Administrator, and MDS Coordinator, the Administrator indicated they had identified a problem with the facility weights. The RD indicated she started at the facility on 12/17/12, and when the January weights were obtained, the RD notified the Administrator the facility appeared to have more residents with weight loss than they had ever had previously. The Administrator indicated the previous system for weights were for 1 restorative aide to obtain the monthly weights, and then would give them to the previous DON to be entered into the computer. The Administrator indicated she was unsure if the previous DON was entering the correct weights, in order to minimize weight loss. The Administrator indicated she did not think Resident A had lost 30 lbs in 1 month, but maybe had had a gradual weight loss. The RD indicated it was unclear if the resident had first been weighed with his prosthesis on, but that would have been only a 6 lb difference. The Administrator indicated a new system for recording and entering weights was now in place. 2. On 1/22/13 at 10:25 A.M., during interview with a family member of Resident C, she indicated she was very surprised to know that her mother had lost so much weight since last fall. She indicated she visited her mother approximately every 2 weeks, but that her mother was usually covered up, and she did not notice the weight loss. The closed clinical record of Resident C was reviewed on 1/24/13 at 2:00 P.M. [DIAGNOSES REDACTED]. Physician orders, initially dated 2/6/12 and on the January 2013 recertification orders, indicated, "Regular diet with thin liquids." An additional order, dated 12/6/12, indicated, "Double portein (sic) at breakfast." A MDS assessment, dated 9/25/12, indicated the resident was unable to complete a test for cognitive status, required extensive assistance of 1 staff for eating, and weighed 145 lbs. A MDS assessment, dated 12/5/12, indicated the resident was unable to complete a test for cognitive status, required extensive assist of 1 staff for eating, and weighed 140 lbs. A dietary note, dated 12/6/12 at 1:52 P.M., indicated, "...Resident is on a regular diet with thin liquids per order. On average resident consumed 75% B/ 63% L/ 50% D; weight 140 lbs (11/12)...Recent abnormal pertinent lab values as of 12/4...Recommend double protein at breakfast r/t (related to) low [MEDICATION NAME] level and best intake being at breakfast meal." A Care Plan regarding weight loss was not located in the clinical record. The resident was transferred to the hospital on [DATE] at 5:00 P.M. due to lethargy. On 1/23/13 at 2:30 P.M., the Administrator provided a weight report for Resident C, which indicated the resident's weight on 11/12/12 was 140 lbs, and on 12/11/12 was 142 lbs. The Administrator indicated there was no January weight, because the resident had been discharged on [DATE], and the weights weren't due to be completed until the 11th of the month. On 1/24/13 at 9:15 A.M., admission hospital records were reviewed. The resident's weight was documented as 120 lbs on 1/7/13 at 5:29 P.M. The resident had lost 22 lbs since 12/11/12. On 1/24/13 at 12:00 P.M., the Administrator provided a written weight record for January, undated. The Administrator indicated the record was from the restorative aide. The record indicated Resident C's weight was 136 lbs. The Administrator indicated she did not know the date of the weight, but that it was not recorded due to the resident being transferred to the hospital on [DATE]. The Administrator indicated she could not explain the 16 lb weight difference, but that perhaps the hospital utilized a different scale. The Administrator indicated the facility was using a different system now for recording the residents' weights. 3. On 1/23/12 at 1:20 P.M., the Administrator provided the current facility policy on "Resident Weights," dated 3/10. The policy included: "A monthly weight log is sent to the following individuals by the (blank) day of the month: Director of Nursing, Registered Dietician, Dietary Services Manager, MDS Coordinator...." This federal tag relates to Complaint IN 655. 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure medications were provided to residents in accordance with their physicians' orders, for 2 of 21 current sampled residents in the sample of 24 (Residents G, I), and 1 of 1 supplemental sample resident, in the supplemental sample of 20 (Resident Z), and failed to ensure qualified persons were administering medications, for 1 of 4 CNA/QMAs (Certified Nursing Assistants/Qualified Medication Aides) reviewed. (CNA/QMA #6) Two (2) of 6 nursing staff observed during or after medication passes failed to follow physicians' orders. (LPN #6, RN #5) This deficient practice resulted in one resident experiencing [MEDICAL CONDITION] and being transferred to the hospital. Findings include: 1. The clinical record for resident G was reviewed on 9/8/10 at 10:00 a.m. The record contained [DIAGNOSES REDACTED]. The record contained the following: A telephone order, dated 8/2/10 1300 (1:00 p.m.) for the facility to change the [MEDICATION NAME] order of 500 milligrams (mg) once a day at 0800 (8:00 a.m.) to HS (hours of sleep). A copy of the results of a [MEDICATION NAME] Level blood test, conducted on 8/3/10, with the results documented as 26.4 (normal range 10.0 -20.0). A faxed copy of the results that had been submitted to the physician. The faxed copy contained new orders to "Hold the [MEDICATION NAME], recheck [MEDICATION NAME] level 8/6/10." The orders signed by the physician were dated 8/4/10. A physician's telephone order dated 8/6/10 1500 (3:00 p.m.) to "Hold [MEDICATION NAME] 8/4, 8/5, recheck on 8/6." The [MEDICATION NAME] level was rechecked on 8/7/10. The results were recorded as 17.9 and were faxed to the physician on 8/7/10. The medication record, dated 8/1-31/10, reviewed at that time, contained documentation that the once a day bedtime dose of [MEDICATION NAME] 500 mg had been documented as "hold" on 8/4 and 8/5. The medication record contained no further documentation of the administration of [MEDICATION NAME] until 8/9/10. On that date, 8/9/10 at 1540 (3:40 p.m.), a new order was received to " D/C (discontinue) [MEDICATION NAME] 500 mg/20 ml (milliliters) 20 ml PO (by mouth) QD (once a day) and "Start [MEDICATION NAME] 100 mg 15 ml PO QD. Recheck [MEDICATION NAME] level in one week." On 8/16/10, the [MEDICATION NAME] Level report documented the results as 4.2 L (low) normal range 10.0-20.0. The report contained a signature by an LPN that the information had been faxed to the physician on that date (no time). The Nurses Notes were reviewed and contained the following entry, dated 9/5/10 at 1908 (7:08 p.m.): "called to room by CNA (certified nursing assistant) res (resident) was observed to be non-verbal, having involuntary jerking of entire body. Skin pink W (warm) D (dry) Resp (respirations) shallow non labored, no cyanosis (bluish coloration). Invol (involuntary) jerking of entire body lasted approx 40 seconds. [MEDICATION NAME] Ped 2.5 given rectal for [MEDICAL CONDITION] activity. Inc (incontinent) B & B (bowel and bladder). On 9/5/10 at 1925 (7:25 p.m.), new orders were received to send resident G to a local hospital for evaluation and treatment for [REDACTED]. The nurses notes, dated 9/6/10 at 0545 (5:45 a.m.), documented the return of resident G to the facility at that time. The nurses notes contained the following information: "...Notified of pts return from hospital. Discussed c (with) (physician's name) nurse [MEDICATION NAME] level of 2.7 @ (hospital name) and report from (hospital name) that pt was administered 1000 mg of [MEDICATION NAME] @ (hospital name) for [MEDICAL CONDITION] activity..." The record was reviewed with the Director of Nurses (DON), on 9/9/10 at 3:45 p.m., during the daily exit conference. The DON indicated the nurse who had signed the fax was no longer employed by the facility, and she would have to check with the physician. On 9/10/10 at 10:15 a.m., the DON indicated a call had been made to the physician's office and she was told they had no copy of the lab. According to the DON, the facility had a lab tracking policy, but they were not using it, and were going to be re-implementing it. 2. On 9/14/10 at 5:48 p.m., resident I was observed sitting in her room. On the overbed table beside the resident was a plastic medicine cup. The cup contained a light yellow substance mixed with white flecks, and a dark green round pill. Resident I, identified as alert and oriented by the facility on the resident roster, identified the mixture as applesauce with crushed [MEDICATION NAME] (medication to control stomach acid) and an Iron pill. The resident indicated the medication had been left by the nurse. LPN #6 was the nurse for that hall. At 5:55 p.m., LPN #6 was queried about the medication. He indicated he had put resident I's medication in the cup and identified the two medicines. He indicated he had given the medications at 4:30 p.m. He was unaware the resident had not taken them. LPN #6 indicated resident I was not able to self administer her medication. A review of the Medication Record was conducted at that time. LPN #6's initials were on the record for both medications and identified that the [MEDICATION NAME] had been ordered with meals, with the time given initialed in the 1600 (4:00 p.m.) block. The iron pill was identified as [MEDICATION NAME], to be given with meals, with the time given initialed on the Medication Record as 1630 (4:30 p.m.). LPN #6 was queried, about the time he had given the medications, at 5:55 p.m. LPN #6 indicated he had given them around 4:30 p.m. The resident did not have her meal tray at that time. According to the meal times provided by the facility's dietary department, on 9/7/10 at 11:00 a.m., they identified the meal times for the evening meal as 5:00 p.m. to 6:00 p.m. At 6:20 p.m., resident I was observed with her meal tray. The clinical record, reviewed at that time, contained the most recent physician's orders [REDACTED]. "[MEDICATION NAME] 325 mg 1 daily with meals 0730 (7:30 a.m.) 1130 (11:30 a.m.) 1630 (4:30 p.m.)." "[MEDICATION NAME] (generic for [MEDICATION NAME]) 1 gm (gram) with meals and HS 0800 (8:00 a.m.), 1130 (11:30 a.m.), 1600 (4:00 p.m.), 2100 (9:00 p.m.)." On 9/17/10 at 9:25 a.m., the Director of Nurses provided the current policy relating to Medication Administration. The policy lacked a date or time of its origination. The policy contained documentation of the "Purpose: to ensure that: The right resident gets the right medication, At the right time, and The right dose, and the right route." "The Procedure: Medication Pass:" included, but was not limited to, the following: "Administering medications too early or too late is considered a medication error and must be followed by an incident report." "Medications specifically order AC (before meals) or PC (after meals) must be administered as such or will be considered a medication error." 3. On 9/9/10 at 2:00 p.m., the personnel files were reviewed. CNA/QMA (Certified Nursing Assistant/Qualified Medication Aide) #6's file indicated she was originally hired 3/20/08 as a CNA/QMA. The file indicated her status as a Certified Nursing Assistant in a neighboring state had been checked, and her status as a Qualified Medication Aide in that state had been checked as well. All indications in the record were that the staff member worked as a Qualified Medication Aide. The records indicated the CNA/QMA was rehired on 1/19/10, after leaving employment 10/08, with her reason for leaving documented as "hours cut." There was no indication the staff member was ever registered as a CNA in Indiana, nor was there evidence the staff member qualified, in Indiana, to administer medications. There was no indication the nurse aide registry was re-checked upon rehire. The Weekday Staffing Grid for the month of July, 2010 was provided by the Director of Nurses, on 9/10/10 at 10:10 a.m. and reviewed at that time. CNA/QMA #6 worked on the following dates and times, as a QMA administering medications to residents: -7/19/10 night shift 1300 unit -7/20/10 night shift 2100 unit -7/21/10 night shift 2400 unit -7/24/10 night shift 1200 unit -7/25/10 night shift 1200 unit An Employee Data Sheet in the personnel file, dated 7/26/10, indicated the staff member's employment was terminated involuntarily, on 7/26/10, due to her not obtaining an Indiana CNA/QMA license. The Director of Nurses and Administrator were interviewed, on 9/9/10 at 2:45 p.m. They indicated they were "unsure how she got through." They indicated she had been asked for her CNA/QMA certification and could not produce them, so she was discharged from employment. 4. On 9/17/10 at 11:45 a.m., RN #5 was observed standing at the medication cart on the 2400 unit. A plastic medication cup was setting on the cart with one red egg shaped pill and one small white pill in the cup. The RN indicated she was giving a prn (as needed) medication to resident Z. She indicated the red pill was in the cup because she thought she might be able to administer all the resident's medications due at that time, along with the prn medication, but she hadn't yet checked the time to see if it was time for that pill to be given. RN #5 indicated Resident Z had requested [MEDICATION NAME] (for nausea) 25 milligrams (mg). The RN indicated she had been unable to find a 25 mg tablet of [MEDICATION NAME] in Resident Z's medications, but had found one in the room-mate's medications, so she had placed one of the room-mate's [MEDICATION NAME] 25 mg tablets in the cup. She indicated she was going to check with Resident Z to make sure that was what she wanted. At that time, she showed the only [MEDICATION NAME] tablets present and prescribed for Resident Z were 50 mg tablets. She then went to Resident Z's room and returned, indicating the resident had wanted 25 mg of [MEDICATION NAME] in a "shot." A review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The Unit Manager was summoned and informed RN #5 she could not give another resident's medications to this resident and must give the medications as ordered by the physician. The Assistant Director of Nurses then approached and ensured the resident got the medications as ordered. The Medication Administration Policy and Procedure was provided by facility office staff #1, on 9/17/10 at 9:25 a.m. The purpose of the policy was to ensure that the right resident got the right medication at the right time and the right route. The Procedure included, but was not limited to, the following: "-Medications can be administered within a two hour time frame (one hour before to one hour after the time prescribed by the physician)." "-Only a licensed nurse or a QMA (qualified medication aid) may dispense medications." "-Before giving a medications (sic) the nurse must follow the FIVE 'R's *THE RIGHT RESIDENT *THE RIGHT MEDICATIONS *THE RIGHT DOSE *THE RIGHT ROUTE *THE RIGHT TIME." This federal tag relates to complaint number IN 463 3.1-25(b) 3.1-25(b)(1) 3.1-35(g)(2)