Every finding on record at Countryside Manor Health & Living Community

Based on interview and record review, the facility failed to ensure a resident's wounds were assessed weekly to ensure monitoring of healing or worsening for 1 of 3 residents reviewed for wounds. (Resident D) Findings include:Resident D's clinical record was reviewed on 8/12/26 at 12:34 p.m. Diagnoses included Parkinson's disease, dementia, abnormal weight loss, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic systolic (congestive) heart failure, and pressure ulcer of right heel.Current orders included the following:All wounds except surgical sites: Cleanse wounds with saline or distilled water, surrounding tissue with soap and water. Apply skin protectant to periwounds (area surrounding wounds) for protection. Apply moisturizing lotion to surrounding tissue. Apply Idodosorb (antimicrobial wound cleansing gel) and alginate (highly absorbent dressing) to the wound bed and in between toes. Cover with abdominal dressings (thick, highly absorbent dressing), bulky soft roll, and rolled gauze. Secure with tape and stretch netting. Locations: left top foot, right third toe, right second toe, left heel, right lateral ankle, right heel, and distal right top foot once a day on Tuesdays. All wounds except surgical sites: Cleanse wounds with saline or distilled water, surrounding tissue with soap and water. Apply skin prep to periwounds for protection. Apply moisturizing lotion to surrounding tissue. Apply Idodosorb and alginate to the wound bed and in between toes. Cover with abdominal dressings (thick, highly absorbent dressing), bulky soft roll, and rolled gauze. Secure with tape and stretch netting. Locations: left top foot, right third toe, right second toe, left heel, right lateral ankle, right heel, and distal right top foot as needed. A quarterly Minimum Data Set (MDS) assessment, dated 7/21/26, indicated the resident was moderately cognitively impaired. He required partial to moderate staff assistance with rolling in bed and was dependent on staff for bathing, toileting hygiene, moving from sitting to lying, moving from lying to sitting, and transfers. He was always incontinent of bowel. He was at risk for and had multiple pressure injuries. A current care plan for pressure injuries, revised 4/17/26, indicated the resident was at risk for further skin breakdown related to diabetes mellitus, cerebral vascular accident, pain, weakness, and incontinence. Interventions included the following: elevate heels as resident will allow (initiated 2/20/25) and weekly skin assessment (initiated 2/20/25). A current care plan for pressure injuries, revised 8/12/26, indicated the resident had a stage II pressure injury (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the right heel, history of vascular ulcers, and history of incision. Interventions included the following: Notify physician if area worsens, increases in pain or shows signs or symptoms of infection (initiated 2/13/25) and Resident is followed by the wound center - will update measurements with wound center visits (initiated 8/12/26). The care plan was last reviewed/revised on 8/12/26. Wound center measurements and assessments for the resident's wounds on 7/8/26 were as follows: Arterial ulcer (skin wound caused by a lack of blood flow) to the right distal footWound Length (cm) - 4 cmWound Width (cm) - 16 cmWound Depth (cm) - 0.1 cmExposure - Subcutaneous fat layer exposedDrainage Amount - Small Arterial ulcer to the left distal footWound Length (cm) - 4 cmWound Width (cm) - 9 cmWound Depth (cm) - 0.1 cmExposure - Subcutaneous fat layer exposedDrainage Amount - Small Wound center measurements and assessments for the resident's wounds on 7/29/26 were as follows: Arterial ulcer (skin wound caused by a lack of blood flow) to the right distal footWound Length (cm) - 3.7 cmWound Width (cm) - 6.3 cmWound Depth (cm) - 0.1 cmExposure - Subcutaneous fat layer exposedDrainage Amount - Small Arterial ulcer to the left distal footWound Length (cm) - 1.3 cmWound Width (cm) - 2 cmWound Depth (cm) - 0.2 cmExposure - Subcutaneous fat layer exposedDrainage Amount - Moderate The clinical record lacked assessment of the wounds between the wound clinic visit on 7/8/26 and the wound clinic visit on 7/29/26. The clinical record lacked assessment of the wounds after the wound clinic visit on 7/29/26 through 8/12/26. During an interview, on 8/12/26 at 3:51 p.m., LPN 5/Unit Manager indicated the wound team followed the residents' wounds every Thursday. Resident D's treatments were completed weekly by the nurse on duty between wound center visits. The resident had been going to the wound center weekly, but lately it had been every two to three weeks. During an interview, on 8/13/26 at 11:45 a.m., the DON indicated Resident D's wounds were not measured by the facility due to possible discrepancies since he went to the wound clinic where the measurements were obtained. When the nurses changed the residents' dressings, they assessed the residents' wounds. The facility nurses generally charted by exception, so unless the wounds had worsened or looked infected, they would not have documented the wounds' characteristics. During an interview, on 8/13/26 at 11:53 a.m., LPN 3 indicated the wound team followed resident wounds in the facility. The DON measured wounds weekly unless the resident went to the wound center, then the wound team entered those measurements in the resident's clinical record. During an interview, on 8/13/26 at 12:09 p.m., RN 4 indicated the wound team performed the wound assessments and recorded them in the residents' clinical records. She was uncertain how often the wound team completed the wound assessments, but the wound team was responsible for following the wounds once they were notified. During an interview, on 8/13/26 at 3:14 p.m., the DON indicated she did not have additional assessments of Resident D's wounds. The assessments and the measurements were updated when Resident D returned with paperwork from the wound center. Sometimes, if the paperwork was not provided from the wound center, the facility called the wound center to ensure the facility received the updated assessments and measurements. If the resident did not receive the wound center services weekly, then dressing changes would be completed as ordered and changes in the wound characteristics would be documented. A current facility policy, dated 2/1/19, titled Wound Management Policy, was provided by the DON on 8/13/26 at 2:34 p.m., and indicated the following: .The Wound Team meets each week, preferably the same day and time to benefit the resident(s) assessed. Each wound will be observed by the wound team to provide oversight of the care plan interventions and ensure that each resident's condition is accurately assessed in a timely manner.The interdisciplinary team (IDT) will document the wound assessment weekly in the medical record. During an interview at the time the policy was provided, the DON indicated if the wound was managed by the wound clinic, then this did not apply to those wounds as the wound clinic provided the wound management for those wounds.A facility policy for when a resident used the wound center services was not provided during the survey. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a) This Federal tag related to Intake 3120801.

Based on record review and interview, the facility failed to provide assessments of a resident's pressure injuries weekly to monitor for healing or worsening for 1 of 3 residents reviewed for pressure injuries. (Resident D) Finding includes:Resident D's clinical record was reviewed on 8/12/26 at 12:34 p.m. Diagnoses included Parkinson's disease, dementia, abnormal weight loss, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic systolic (congestive) heart failure, and pressure ulcer of right heel.Current orders included the following:All wounds except surgical sites: Cleanse wounds with saline or distilled water, surrounding tissue with soap and water. Apply skin protectant to periwounds (area surrounding wounds) for protection. Apply moisturizing lotion to surrounding tissue. Apply Idodosorb (antimicrobial wound cleansing gel) and alginate (highly absorbent dressing) to the wound bed and in between toes. Cover with abdominal dressings (thick, highly absorbent dressing), bulky soft roll, and rolled gauze. Secure with tape and stretch netting. Locations: left top foot, right third toe, right second toe, left heel, right lateral ankle, right heel, and distal right top foot once a day on Tuesdays. All wounds except surgical sites: Cleanse wounds with saline or distilled water, surrounding tissue with soap and water. Apply skin prep to periwounds for protection. Apply moisturizing lotion to surrounding tissue. Apply Idodosorb and alginate to the wound bed and in between toes. Cover with abdominal dressings (thick, highly absorbent dressing), bulky soft roll, and rolled gauze. Secure with tape and stretch netting. Locations: left top foot, right third toe, right second toe, left heel, right lateral ankle, right heel, and distal right top foot as needed. A quarterly Minimum Data Set (MDS) assessment, dated 7/21/26, indicated the resident was moderately cognitively impaired. He required partial to moderate staff assistance with rolling in bed and was dependent on staff for bathing, toileting hygiene, moving from sitting to lying, moving from lying to sitting, and transfers. He was always incontinent of bowel. He was at risk for and had multiple pressure injuries. A current care plan for pressure injuries, revised 4/17/26, indicated the resident was at risk for further skin breakdown related to diabetes mellitus, cerebral vascular accident, pain, weakness, and incontinence. Interventions included the following: elevate heels as resident will allow (initiated 2/20/25) and weekly skin assessment (initiated 2/20/25). A current care plan for pressure injuries, revised 8/12/26, indicated the resident had a stage II pressure injury (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the right heel, history of vascular ulcers, and history of incision. Interventions included the following: Notify physician if area worsens, increases in pain or shows signs or symptoms of infection (initiated 2/13/25) and Resident is followed by the wound center - will update measurements with wound center visits (initiated 8/12/26). The care plan was last reviewed/revised on 8/12/26. Wound center measurements and assessments for the resident's wounds on 7/8/26 were as follows: Pressure injury to the right posterior heelPressure Injury Stage - Stage 3 (full thickness skin loss where fat tissue is visible)Wound Length (cm) - 3 cmWound Width (cm) - 3 cmWound Depth (cm) - 0.2 cmExposure - Subcutaneous fat layer exposedDrainage Amount - Moderate Pressure injury to the right lateral malleolus (ankle on the outer side)Pressure Injury Stage - Unstageable (full-thickness skin and tissue loss where the extent of damage is obscured by dead tissue)Wound Length (cm) - 3 cmWound Width (cm) - 2 cmWound Depth (cm) - 0.2 cmExposure - Subcutaneous fat layer exposedDrainage Amount - Moderate Pressure injury to the left heelPressure Injury Stage - Stage 3Wound Length (cm) - 1 cmWound Width (cm) - 1 cmWound Depth (cm) - 0.1 cmExposure - Subcutaneous fat layer exposedDrainage Amount - Scant Pressure injury to the right lateral footPressure Injury Stage - UnstageableWound Length (cm) - 16 cmWound Width (cm) - 4 cmWound Depth (cm) - 0.2 cmExposure - Subcutaneous fat layer exposedDrainage Amount - Moderate Wound center measurements and assessments for the resident's wounds on 7/29/26 were as follows: Pressure injury to the right posterior heelPressure Injury Stage - Stage 4Wound Length (cm) - 3.6 cmWound Width (cm) - 2.5 cmWound Depth (cm) - 0.1 cmExposure - Tendon/Ligament exposedDrainage Amount - Moderate Pressure injury to the right lateral malleolus (ankle on the outer side)Pressure Injury Stage - Stage 4Wound Length (cm) - 2.2Wound Width (cm) - 3.2Wound Depth (cm) - 0.1 cmExposure - Tendon/Ligament exposedDrainage Amount - Moderate Pressure injury to the left heelPressure Injury Stage - Stage 3Wound Length (cm) - 0.1 cmWound Width (cm) - 0.1 cmWound Depth (cm) - 0.1 cmExposure - Subcutaneous fat layer exposedDrainage Amount - None Pressure injury to the right lateral footPressure Injury Stage - UnstageableWound Length (cm) - 16.5 cmWound Width (cm) - 5.4 cmWound Depth (cm) - 0.1 cmExposure - Subcutaneous fat layer exposedDrainage Amount - Moderate The clinical record lacked assessment of the wounds between the wound clinic visit on 7/8/26 and the wound clinic visit on 7/29/26. The clinical record lacked assessment of the wounds after the wound clinic visit on 7/29/26 through 8/12/26. During an interview, on 8/12/26 at 3:51 p.m., LPN 5/Unit Manager indicated the wound team followed the residents' wounds every Thursday. Resident D's treatments were completed weekly by the nurse on duty between wound center visits. The resident had been going to the wound center weekly, but lately it had been every two to three weeks. During an interview, on 8/13/26 at 11:45 a.m., the DON indicated Resident D's wounds were not measured by the facility due to possible discrepancies since he went to the wound clinic where the measurements were obtained. When the nurses changed the residents' dressings, they assessed the residents' wounds. The facility nurses generally charted by exception, so unless the wounds had worsened or looked infected, they would not have documented the wounds' characteristics. During an interview, on 8/13/26 at 11:53 a.m., LPN 3 indicated the wound team followed resident wounds in the facility. The DON measured wounds weekly unless the resident went to the wound center, then the wound team entered those measurements in the resident's clinical record. During an interview, on 8/13/26 at 12:09 p.m., RN 4 indicated the wound team performed the wound assessments and recorded them in the residents' clinical records. She was uncertain how often the wound team completed the wound assessments, but the wound team was responsible for following the wounds once they were notified. During an interview, on 8/13/26 at 3:14 p.m., the DON indicated she did not have additional assessments of Resident D's wounds. The assessments and the measurements were updated when Resident D returned with paperwork from the wound center. Sometimes, if the paperwork was not provided from the wound center, the facility called the wound center to ensure the facility received the updated assessments and measurements. If the resident did not receive the wound center services weekly, then dressing changes would be completed as ordered and changes in the wound characteristics would be documented. A current facility policy, dated 2/1/19, titled Wound Management Policy, was provided by the DON on 8/13/26 at 2:34 p.m. and indicated the following: .The Wound Team meets each week, preferably the same day and time to benefit the resident(s) assessed. Each wound will be observed by the wound team to provide oversight of the care plan interventions and ensure that each resident's condition is accurately assessed in a timely manner.The interdisciplinary team (IDT) will document the wound assessment weekly in the medical record.During an interview, at the time the policy was provided, the DON indicated if the wound was managed by the wound clinic, then this did not apply to those wounds as the wound clinic provided the wound management for those wounds.A facility policy for when a resident used the wound center services was not provided during the survey dates. 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2) This Federal tag relates to Intake 3120801.

Based on record review and interview, the facility failed to ensure Skilled Nursing Facility Advanced Beneficiary Notices (SFN ABN) were provided to residents and/or resident representatives at the end of Medicare A covered services and failed to ensure the forms were completed appropriately when provided to residents and/or resident representatives for 2 of 3 residents reviewed for Beneficiary Notice. (Residents 104 and 41) The deficient practice was corrected on 2/9/26, prior to the start of survey, and was therefore past noncompliance. Findings include: On 2/20/26 at 11:11 a.m., the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Forms were reviewed, and indicated the following:1.Resident 104 was admitted to Medicare Part A Skilled Services on 7/10/25. The last covered day of Part A services was 8/4/25. The SNF Notice of Medicare Non-Coverage (NOMNC) was reviewed with the resident's representative by phone on 8/1/25. The NOMNC indicated the resident had exhausted their Medicare A benefits.The clinical record lacked the SNF ABN.A 8/1/25, progress note indicated the resident was cognitively impaired and the resident representative was contacted. The resident's representative was advised of liability beginning on 8/5/25 and a copy of the NOMNC was available in the resident's room. 2. Resident 41 was admitted to Medicare Part A Skilled Services on 12/16/25. The last covered day of Part A services was 12/31/25. The SNF NOMNC was reviewed and signed with the resident on 12/16/25. The NOMNC indicated the resident had exhausted their Medicare A benefits. The SNF ABN was reviewed with the resident and signed on 12/26/25. The SNF ABN form was not completed in full. The section labeled F. Estimated Cost was left blank.A 12/26/25, progress note indicated the NOMNC was reviewed with the resident. The resident requested his family be contacted about the decision and a voicemail was left.During an interview, on 2/20/26 at 1:42 p.m., the Social Services Director (SSD) indicated when a resident was removed from Medicare A covered services, they were given a NOMNC and an ABN form to read and sign. She reviewed the information with them which included how to file an appeal, what services might not be covered, and an estimated cost of those services not covered. The SSD indicated Resident 104 should have received an ABN when discharged from Medicare A services. Resident 41's ABN should have been filled out completely with cost estimates, so the resident and/or resident representative could make an informed decision about the services moving forward. During an interview, on 2/20/26 at 3:29 p.m., the Regional Social Service Consultant indicated she has completed an audit reviewing the Medicare A NOMNC and ABN documents on 2/9/26. The audit tool was reviewed with the SSD and an action plan was put into place.A review of the Medicare A Discharge audit tool, on 2/20/26 at 4:02 p.m., indicated that Resident 104 should have received an ABN upon discharge from Medicare A services on 8/4/25.A review of the action plan, on 2/20/26 at 4:02 p.m., indicated the following: All residents with Medicare A services will be reviewed in the weekly Medicare meeting. Any resident with Medicare A services that intends to remain in the facility long term will be added to the ABN Required list. The SSD will verify resident costs with the Business Office Manager and deliver the NOMNC and ABN to the residents at least 48 hours prior to loss of coverage. The ABN will be uploaded into the resident's clinical record. The original document will be kept in the SS office.During a follow-up interview, on 2/20/26 at 4:02 p.m., the Regional Social Services Consultant indicated the ABN form needed to be filled out completely and provided to the resident and/or resident's representative so they have all the information needed to make an informed decision about services and care.An undated, current facility policy, titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage, provided by the Administrator on 2/20/26 at 3:18 p.m., indicated the following: .Medicare requires Skilled Nursing Facilities (SNFs) to issue the SNF ABN to Original Medicare.patients prior to proving care that Medicare usually covers, but may not pay for in this instance because the care is: not medically reasonable and necessary; or considered custodial.The SNF ABN provides information to the patient so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. D. In this section, the SNF enters the estimated cost of the corresponding care that may not be covered by Medicare. The SNF should enter an estimated total cost or a daily, per item, or per service cost estimate. SNF's must make a good faith effort to insert a reasonable cost estimate for the care. 3.1-4(f)(3)

Based on observation and interview, the facility failed to ensure insulin (a medication to treat diabetes mellitus) pens were labeled with resident identifiers, dated when opened, and disposed of when expired for 2 of 5 carts reviewed for medication storage. (300 south cart and 300 short cart)Findings include:1.During a medication storage observation, on 2/19/26 at 9:59 a.m., of the 300-hall south cart, accompanied by the Unit Manager, the following was observed:One open Lantus (long-acting) insulin pen dated 1/17/26; the pen had approximately 80 units remaining.One open Novolog (rapid-acting) insulin pen dated 1/10/26; the pen had approximately 175 units remaining.During an interview at the time of the observation, the Unit Manager indicated that insulin was good for 30 days and all expired insulin needed to be disposed of properly. The Unit Manager confirmed the open insulin pens had expired. She indicated only two residents received insulin from this medication cart.2.During a medication storage observation, on 2/19/26 at 10:18 a.m., of the 300-hall short cart, accompanied by QMA 6, the following was observed:One undated and unlabeled, open Novolog insulin pen with approximately 220 units remaining.During an interview at the time of the observation, QMA 6 indicated all medications should be labeled with resident identifier information. Insulin was good for 28 days and all expired medications should be disposed of properly. QMA 6 indicated two residents received insulin from this medication cart. An undated, current facility policy, titled, Drug Storage, provided by the Administrator on 2/20/26 at 12:39 p.m., indicated the following: . All expired, damaged and/or contaminated medications are removed from resident care areas and stored separately from medications available for administration. Discontinued and expired medications should be removed from medication carts, refrigerators and cupboards promptly. Insulin and other multi-dose injectable vials or pens must be discarded after 28 days or according to manufacturer's recommendations. Insulin and PPD (TB) vaccine and other multi-dose vials requiring refrigeration need to be dated when opened. All vials should be discarded within 28 days of the open date.An undated, current facility policy, titled, Cubex, provided by the Administrator on 2/20/26 at 1:17 p.m., indicated the following: . Multi-dose items. will need to have generic label affixed by the nurse staff that includes the following information; a. Patient name, b. Prescriber name, c. 1 additional patient identifier, such as a date of birth . 3.1-25(j)3.1-25(k)

Based on interview and record review, the facility failed to ensure staff followed resident care plan interventions and facility protocol while utilizing a mechanical lift during a transfer of a dependent resident for 1 of 4 residents reviewed for accidents. (Resident B) Findings include: Resident B's clinical record was reviewed on 4/11/25 at 10:40 a.m. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, diabetes mellitus, hypertension, dysphagia, and chronic kidney disease. The most current Significant Change Minimum Data Set (MDS) assessment, dated 3/18/25, indicated the resident was depended for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfer, and tub/shower transfer. A current care plan titled CNA Assignment Sheet Resident has specific needs related to their care, dated 11/09/22, had an intervention dated 11/09/22, of the resident is assisted with two person assist and hoyer (mechanical) [lift] with transfers. This intervention was last edited on 2/10/25. Review of a facility self- reportable, dated 2/9/25 indicated, on 2/8/25, the resident experienced pain and heard a popping sound. An x-ray was obtained and determined a subtle nondisplaced supercondylar fracture of the right elbow. The reportable did not mention any staff member or situation that may have been involved. A progress note, dated 2/7/25 at 9:34 p.m., indicated the resident complained of pain in the right shoulder while CNAs were utilizing a mechanical stand up lift for resident transfer to the bed. Range of motion resulted in no pain. The resident complained of pain while the shoulder was stationary. The facility investigation included an Administrator interview statement by QMA 1, dated 2/8/25, that indicated they had attempted to transfer the resident with the mechanical stand up lift without assistance of another staff member. The resident complained of pain in the right shoulder and the QMA immediately terminated the transfer and sought out assistance from CNA 2. The QMA informed LPN 3 of the resident's pain. QMA 1 was not available for interview during the survey on April 11, 2025 . Review of an Administrator interview statement by CNA 2, dated 2/10/25, indicated QMA 1 had requested assistance transferring the resident. When CNA 2 arrived to the resident's room, the resident was complaining of shoulder pain. QMA 1 and CNA 2 transferred the resident to a wheelchair and then to the bed. During the transfer, the resident did not complain. Once the resident was in bed they indicated the shoulder felt better while they were in bed. During an interview on 4/11/25 at 1:52 p.m., CNA 2 indicated QMA 1 had the resident in the lift before she requested her assistance. The resident said the QMA had put her in the stand up lift and her shoulder started hurting. QMA 1 put her back in the recliner and when CNA 2 came into the room, the resident was hooked up to the lift but was already in her recliner. I never saw [NAME] operate the lift or anything. CNA 2 indicate the resident preferred the stand up lift. CNA 2 indicated staff were supposed to have two people when operating any mechanical lift, as it had always been that way. During an interview on 4/11/25 at 3:16 p.m., CNA 4 indicated the resident required a mechanical lift because it became too difficult to stand. The resident used to use her left hand to hang on to the rails, but she could not do that any longer. CNA 4 had never used a stand-up lift for the resident's transfers, as she would feel safer using the mechanical lift. During an interview on 4/11/25 at 3:33 p.m., the DON indicated staff should always use two persons for any mechanical lifts. The facility did not have a policy dedicated to mechanical lift safety. A current copy of staff education related to mechanical lift transfers was provided by the DON on 4/11/25 at 2:00 p.m The education indicated the following: .REMINDER .All mechanical equipment such as Hoyer Lift or Stand Up Lift MUST be utilized with the assistance of at least 2 people. You cannot use these by yourself. Failure to comply will result in disciplinary action. This is for the resident and associate's safety .You must check your assignment sheets to verify resident transfer status. Theses can be found on the iPads. If you need assistance with this, please notify your supervisor or ADON (name). Do not solely go off what the resident or staff tell you. Verify by reviewing the assignment sheet. This citation relates to complaint IN00453043. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure completion of wound care treatment as ordered to promote healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 63) Finding Includes: Resident 63's clinical record was reviewed on 12/30/24 at 11:04 a.m. Diagnoses included an unspecified fracture of lower end of right femur, unspecified disorder of the skin and subcutaneous tissue, and end stage renal disease. A quarterly Minimum Data Set (MDS) assessment, dated 11/8/24, indicated the resident did not have any pressure injuries, was occasionally incontinent of bowel and bladder, required partial staff assistance for bed mobility, and did not transfer to utilize the toilet. A current care plan, dated 11/13/24, indicated Resident 63 was at risk for skin breakdown. Interventions included to assist with bed mobility (11/23/24), turn and reposition per resident's needs (11/13/24), and monitor skin for signs of breakdown (11/13/24). The clinical record lacked a care plan for pressure injury. A current physician order, dated 11/13/24, indicated to apply Resinol (a skin protectant and topical analgesic) to affected areas on each buttocks twice daily, upon rising and at bedtime. A wound management note, dated 12/4/24, indicated an abrasion to the coccyx measuring 1.0 centimeter (cm) length by 1.0 cm width. A late entry wound management note, dated 12/11/24 and initiated on 12/27/24, indicated an abrasion to the coccyx measuring 1.0 cm length by 1.0 cm width. The clinical record lacked additional wound management notes for the coccyx abrasion. A Skin Integrity Event, dated 12/7/24, indicated a pressure injury to the coccyx, measuring 0.5 cm length by 0.3 cm width by 0.1 cm depth. A current physician order, dated 12/7/24, indicated to clean the upper coccyx wound with normal saline and apply Medi-honey (to treat wounds) to wound bed and cover, daily on the day shift. A progress note, dated 12/25/24, indicated Resident 63 had a continued treatment to the coccyx wound. During a wound observation, on 12/31/24 at 2:16 p.m., LPN 2 and RN 3 entered the resident's room for wound care. LPN 2 and RN 3 utilized hand sanitizer and donned appropriate personal protective equipment (PPE). The resident independently rolled onto her right side. The coccyx wound was uncovered. LPN 2 applied Resinol to the open area, directly on a bony prominence, roughly the size of a #2 pencil eraser, circular, with a white edged open area. LPN 2 did not measure the area. The resident's buttocks had no visible redness. This observation is inconsistent with the previous wound management note dated 12/11/24. During an interview, at the time of the wound observation, LPN 2 indicated the DON had looked at the wound earlier that morning. The DON removed the dressing, measured the wound, and planned to document the wound was healed. Resident 63 indicated the DON had been in her room earlier and did measure her coccyx wound. During an interview, on 12/31/24 at 2:47 p.m., the DON indicated she saw Resident 63 today, removed her coccyx dressing and measured her wound. The current measurements were 0.2 cm length by 0.2 cm width with no depth, (roughly the size of a pencil point). The cream utilized by LPN 2 was just a barrier cream. The DON was not aware of the Medi-honey order. The staff member that completed the original skin integrity event and medication order was on vacation and unable to be reach by phone. The DON indicated the staff completed weekly skin assessments and but only completed Skin Integrity Events for new open areas. A current facility policy, revised on 1/29/21, titled, Skin Risk Policy, provided by the DON on 1/3/25 at 11:25 a.m., indicated the following: [NAME] & Associates, Inc. and its members are committed to providing quality care to our residents which includes identifying residents who are at risk for compromised skin integrity and preventing the development or worsening of skin issues . Addition interventions to prevent development or worsening of wounds/open area include: . Obtaining and following MD prevention/treatment order . A current facility policy, dated 4/3/17, titled, Protocol for Following Physician Orders, provided by the DON on 1/3/25 at 9:12 a.m., indicated the following: It is the policy of [NAME] and associates that we will provide the appropriate physician prescribed care to the residents in our communities .All licensed staff will verify and follow the physician orders as written. 3.1-40

Based on observation, interview, and record review, the facility failed to follow infection prevention and control procedures related to contact isolation (additional precautions used when standard precautions may not be enough to stop the spread of infection) precautions for 2 of 3 resident reviewed for transmission-based precautions. (Resident 61 and 227) Finding includes: 1. During an observation, on 12/27/24 at 2:09 p.m., Resident 227 was lying in bed and indicated she had been in the facility for roughly five days. She was going to the gym for therapy. On the door to Resident 227's room was an orange Contact Precautions sign, and three (3) signs with directions on putting on and taking off personal protective equipment (PPE). The PPE was hanging on the door inside plastic dividers. The dividers contained gowns, gloves, face masks, and face shields. During an observation, on 12/30/24 at 2:19 p.m., Resident 227 was being propelled in her wheelchair down the hallway towards her room, by PTA 4. PTA 4 and Resident 227 entered the room together. PTA 4 situated Resident 227 in her wheelchair at the foot of the bed, off to the side. PTA 4 retrieved wheelchair foot pedals from inside the room and using her bare hands attached them to the wheelchair. PTA 4 asked the resident to remain in her wheelchair for 20 more minutes and attached the call light to the mechanical lift pad underneath the resident. Resident 227 remained seated in the wheelchair. Resident 227 indicated she thought she needed to have a bowel movement and was not going to be able to wait until staff could help her. PTA 4 straightened the residents bed sheets. Without washing her hands, PTA 4 donned a gown and gloves. PTA 4 indicated she couldn't find a bed pad in the room. PTA 4 doffed the gown and gloves and exited the room. PTA 4, using her soiled hands, utilized the key pad to open the storage closet door across the hall. While in the hallway, PTA 4 was stopped by visitors wanting to exit, and walked the visitors to the exit doors at the end of the hallway. PTA 4, using her soiled hands, utilized the key pad to open the exit doors at 2:27 p.m. No hand washing or hand sanitization was observed at any time during these activities. During an observation, on 12/30/24 at 2:35 p.m., CNA 5 entered the room to answer the call light for Resident 227. Resident 227 asked for a tissue, the CNA grabbed the box of tissues on the dresser by the door and placed them on the resident's bedside table. CNA 5 moved the bedside table from the head of the bed to the foot of the bed, directly beside the resident as she sat bedside in her wheelchair. The resident requested assistance in getting back into bed. CNA 5 indicated she couldn't find bed pads in the room. CNA 5 exited the room and with her soiled hands, utilized the key pad to open the supply closet. CNA 5 removed two bed protection pads and closed the supply closet door. CNA 5 re-entered Resident 227's room and placed the pads onto her bed. CNA 5 indicated she would get the mechanical lift and someone to help her. CNA 5 exited the room. CNA 5 did not don PPE, nor performed hand sanitization or hand washing during these activities. During an interview, at the time of the observation, CNA 5 indicated the isolation sign required staff to wear PPE when entering a resident's room. This isolation sign could have been for different reasons and these reasons could have been found in the residents clinical record. Resident 227's clinical record was reviewed on 12/30/24 at 2:34 p.m. Diagnoses included recurrent enterocolitis due to Clostridium difficile (a germ that causes diarrhea and colitis [an inflammation of the colon] and can be life-threatening), unspecified diarrhea, and pneumonitis due to inhalation of food and vomit. A current physicians order, dated 12/13/24, indicated to follow contact isolation with meals, activities, therapy. All services must be provided in room with isolation precautions followed. An Admission Minimum Data Set (MDS), dated [DATE], indicated Resident 227 had a diagnosis of Clostridium difficile and was dependant on staff for personal and toileting hygiene and toilet transfers. A current care plan, dated 12/13/24, indicated the resident required contact isolation related to a diagnosis of Clostridium difficile. Interventions included provide contact isolation supplies (i.e. personal protective equipment etc.) and to provide staff, resident, and family education regarding contact isolation precautions as needed. During an interview, on 12/30/24 at 3:03 p.m., PTA 4 indicated when therapy staff worked with Resident 227 in the resident's room, they would wear a gown and gloves. When Resident 227 was brought to the gym, the staff did not wear PPE since the condition was able to be contained. During an interview, on 12/30/24 at 3:58 p.m., LPN 2 indicated contact precautions were used when a resident had an infection or open wound and the facility needed to prevent the spread of this infection. Resident 227 had a diagnosis of Clostridium difficile. This diagnosis required staff to wear PPE while in the resident's room and utilize soap and water for handwashing after exiting the resident room. 2. During an observation, on 12/30/24 at 10:48 a.m., Resident 61's room had an orange contact precautions sign, and three (3) signs with directions on putting on and taking off PPE. The PPE was hanging on the door inside plastic dividers. The dividers contained gowns, gloves, face masks, and face shields. During an observation, on 12/31/24 at 8:58 a.m., two staff members entered a room to deliver lunch meal trays. CNA 7 placed a tray to the bedside table of the resident farthest from the door. LPN 6 placed a tray onto the bedside table of Resident 61, closest to the door. LPN 6 utilized the resident's bed remote to lift the head of the bed to 90 degrees. LPN 6 placed her right hand on the right side grab bar attached to the resident's bed as she set up the lunch tray for Resident 61. CNA 7 and LPN 6 did not don PPE nor perform hand sanitization or hand washing upon exiting. During an interview, at the time of the observation, LPN 6 indicated she should have paid closer attention to the sign and recognized the difference between an Enhanced Barrier Precautions sign and the Contact Precautions signs. She and CNA 7 should have donned gowns and gloves prior to entering the room and when leaving should have doffed the PPE and washed their hands with soap and water immediately. Resident 61's clinical record was reviewed on 12/31/24 at 8:55 a.m. Diagnoses included Enterocolitis due to Clostridium difficile, unspecified diarrhea, and end stage renal disease. A current physician order, dated 12/27/24, indicated to follow contact isolation with meals, activities, and therapy. All services must be provided in room with isolation precautions followed. A quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 61 was incontinent of bowel and bladder and dependent on staff for toileting hygiene and showering. The resident did not transfer to utilize the toilet. A current care plan, dated 12/27/24, indicated the resident required contact isolation related to a diagnosis of Clostridium difficile. Interventions included provide contact isolation supplies (i.e. personal protective equipment etc.) and to provide staff, resident, and family education regarding contact isolation precautions as needed. During an interview, on 1/3/25 at 10:00 a.m., the Therapy Supervisor indicated a resident with a Clostridium difficile diagnosis or the possibility of Clostridium difficile could go to the therapy gym. The staff checked to ensure the resident was wearing a clean brief and the resident's clothing was clean. When therapy was completed, the staff utilized a 1:10 bleach solution to clean all the equipment used. If the resident become incontinent during the therapy session, the therapy session ended and the resident was returned to their room immediately. During an interview, on 1/3/25 at 11:45 a.m., UM 9 indicated when a resident had a diagnosis or had signs and symptoms of Clostridium difficile, they were placed in contact precautions to prevent the spread of infections. The staff were educated on how to enter and exit rooms with contact precautions. The signs and PPE were placed on the appropriate resident doors. Staff would don PPE prior to entering the room, when the care was completed, the staff removed the PPE inside the room, opened the door, and then used soap and water to wash their hands. The hand washing would take place inside the resident room as long as the outside door had been opened. The staff would utilize soap and water to wash their hands outside the room as well. The resident specific reason for contact precautions would be found in the resident medical record, but this information would also be exchanged during the walking rounds performed from shift to shift. Isolation precautions had been covered in facility in-services. During an interview, on 1/3/25 at 12:55 p.m., the DON indicated the expectation for staff was for the isolation precautions to be followed. When a resident had a diagnosis of Clostridium difficile, they would require contact isolation precautions and those included utilizing soap and water for handwashing. The information was covered in facility in-services. The last all staff in-service was in April 2024. The facility had started another staff education after the observations during the current survey. The facility followed the Contact Precautions policies and procedure found on the Centers for Disease Control and Prevention (CDC) website. An online reference titled, Transmission Based Precautions (4/3/24), retrieved on 1/6/25 from https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html indicated the following: . Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens . A facility policy, reviewed 1/2024, titled, Clostridioides Difficile (C-Diff) Policy, provided by the DON on 12/31/24 at 1:46 p.m., indicated the following: .A resident with a suspected or known active care of C-Diff that has been confirmed must be placed in contact isolation because C-Diff is transmitted by direct and indirect contact. This means the resident and the environment can cause others to contract the same infection . 3.1-18(b)(2) 3.1-18(l)

Based on interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation of resident property for 1 of 3 residents reviewed for misappropriation. (Resident B) Finding includes: Review of a facility investigation, on 9/9/24 at 3:20 p.m., indicated a statement signed on 8/2/24 by the Regional Marketing Consultant of a conversation held with the resident B's Family Member 2. It indicated Family Member 2 reported money was stolen from a plastic envelope out of the resident's purse in her nightstand. The statement lacked information regarding when it was identified missing, to whom it was reported, and who reported it missing prior to 8/2/24. The statement was not signed by Family Member 2. Five staff Abuse Allegation Questionnaires were included, but were not completed by direct staff members who were on duty when the alleged theft was reported. The investigation lacked how much money was reported missing, names or statements from staff who received the initial alleged reports of the resident's missing money on 8/1/24, indication of a timeline of events, nor a summary of the investigation. During an interview on 9/9/24 at 4:02 p.m., the Administrator indicated he was uncertain of the date and times he was notified of the allegation regarding the resident's missing money. He then indicated LPN 3 notified him sometime in the evening of 8/1/24 via telephone that the resident's Family Member 2 reported they could not find a gold envelope containing $300.00 that was missing from the resident's purse. The Administrator did not have a statement or interview from LPN 3 in the investigation file. He was the one responsible for completing a thorough investigation of the alleged misappropriation. The staff he questioned had never seen the resident with the envelope nor any money in her room. He did not have a statement/interview from Resident B because she was not interviewable. He did not have a statement/interview with the resident's representative because he felt the Regional Marketing Consultant had obtained all the information he would have asked during an interview. The resident's Family Member 2, who reported the misappropriation, was readily available in the building visiting her family member every day. He was unaware of any time frame of how long the money was missing. The Administrator notified the Police Department of the missing money on 8/2/24 and was provided an incident number but was uncertain if they ever came to the facility for a report. During an interview on 9/9/24 at 4:56 p.m., the DON indicated the provided copy of the facility's investigation of Resident B's alleged misappropriation included the entire investigation. Resident B's clinical record was reviewed on 9/10/24 at 12:58 p.m The resident admitted to the facility on [DATE]. Diagnoses included dependence on renal dialysis, unspecified atrial fibrillation, and anxiety. An admission Minimum Data Set (MDS) assessment, dated 7/22/24, indicated the resident was cognitively intact. She required moderate assistance with transfers and utilized a motorized wheelchair for mobility. Review of an Inventory of Personal Items, completed on 7/29/24 (14 days after admission), indicated the resident had a purse. The section that indicated to describe all contents in the purse/wallet was left blank. The clinical record lacked indication of the allegation of misappropriation of the resident's money from admission to discharge from the facility. Review of the police report, dated 8/2/24 at 10:54 a.m., provided by the Police Department, indicated the Administrator reported a resident advised him of missing money and did not want a report taken at this time. The amount of money was not included. During an interview on 9/10/24 at 3:06 p.m., LPN 3 indicated she was working on the 300 Unit on days shift on an unknown date when Family Member 2 reported Resident B had missing money in a specified amount. She thought she had made a progress note in the clinical record. LPN 3 was unable to recall how much money Family Member 2 alleged was missing from the shiny envelope that was in the resident's purse in her bottom drawer. The resident had been out of her room a large portion of the day getting her shower, attending activities, and then left for an appointment. Family Member 2 came to the facility before the resident returned from her appointment, but she was uncertain where Family Member 2 had been prior. RN 7, who also worked on the 300 unit that shift, told her she had observed the resident's family member go into the resident's room prior to the resident returning to the facility and reported the missing money. LPN 3 called the Administrator immediately when Family Member 2 reported the missing money. LPN 3 reported the details about alleged misappropriation of money to include the above mentioned details and the amount of money reported missing at the time. The Administrator instructed her to look everywhere for the resident's missing money and leave him a statement so he could do further follow-up. The Administrator did not tell her to get statements from anyone else. She went into the resident's room with the resident and Family Member 2 and the resident told her she usually took her purse with her for appointments, but she left in the facility that day because she was in a rush. LPN 3 was in a conversation with Family Member 3 on the phone while with the resident and Family Member 2 to ask how much money the resident had when Family Member 3 brought the resident money on Monday of that week. Family Member 3 provided a detailed description to LPN 3 of the amount the resident had when he brought the resident additional money and how much total money the resident had when he left the facility. LPN 3 could not recall those specific amounts since it had been quite some time, but it did not align with the amount of money Family Member 2 reported missing. After Family Member 3 discussed the amount of money the resident should have had in her envelope, Family Member 2 changed the amount of money she previously stated was missing. LPN 3 was uncertain if she had provided a statement for the investigation. During a telephone interview on 9/10/24 at 4:06 p.m., RN 7 indicated she was uncertain of the date, but she was working the day Resident B's $300.00 was reported missing by Family Member 2 to another nurse at the nurse station on the 300 Unit. Family Member 2 described the money was in Resident B's purse in the bottom drawer in her room. She had observed Family Member 2 entering Resident B's room twice before the resident returned to her room from an appointment that day. Family Member 2 had also changed her story about the amount of money missing on different times she came to the nurse station. RN 7 had been in the resident's room a couple of times to pick up the resident's meal trays that day because everyone assisted with meal trays throughout the unit. She mentioned this information when the other nurse at the nurse station called and spoke with the Administrator. No one had asked her to provide a statement/interview for an investigation of the alleged misappropriation. She worked on the 300 unit on a regular basis and Resident B nor any of her family members had reported they brought any money to the resident nor asked her to add any money to the resident's Personal Inventory Sheet. The resident's Personal Inventory Sheet lacked any listed money. RN 7 had not seen the resident with any money nor had the resident mentioned having any money with her when she had provided her care. She described Resident B's relationship with her family members tumultuous when they visited. During a telephone interview on 9/10/24 at 4:33 p.m., the Regional Marketing Consultant indicated Resident B's Family Member 2 was very chatty, so she provided a statement of what she heard Family Member 2 mention. Family Member 2 reported Resident B had money that was missing and there had been a time in the past when Resident B accused Family Member 3 of taking something that showed up later. The Regional Marketing Consultant could not recall any details about how much money was reported missing. During an interview on 9/11/24 at 1:15 p.m., LPN 4 indicated Resident B never mentioned anything in her purse until one day (uncertain of the date) on days shift, while in the resident's room, the resident reported to LPN 4 a gold envelope that contained money was missing from her purse. The resident had not seen anyone take it nor named anyone she thought may have taken it. She did not provide an amount of money that was missing. LPN 4 indicated she called the Administrator and reported the above information the resident reported to her. The Administrator told her he would look into it. LPN 4 could not recall if she was asked to provide a statement, but she would definitely have provided one if Administration requested one. She was uncertain if she had made any documentation in the resident's clinical record of the reported missing money. During an interview on 9/11/24 at 3:40 p.m., the Administrator indicated typically the individual who reported alleged misappropriation and the individual in which they reported to should have been included in an alleged misappropriation facility investigation. He had not requested additional pertinent information from the individual who reported the missing money. An investigation regarding missing money should have included how much money was reported missing. He did not have a reason for omitting staff interviews/statements who were knowledgeable of the situation for a complete and thorough investigation of alleged misappropriation. He followed the facility policy regarding the investigation of alleged misappropriation. A current facility policy, revised 6/4/19, titled Abuse, Neglect, and Misappropriation Prohibition and Prevention Policy, provided by the Administrator on 9/9/24 at 10:55 a.m., indicated the following: .POLICY STATEMENT . It is the policy . to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion and misappropriation of their property . No person under employment . shall knowingly: .d. Withhold information from law enforcement or other investigative agencies . III. 1. Preventing resident abuse is a primary concerns for this Community. It is our goal to achieve and maintain an abuse free environment. 2. Our abuse prevention/intervention program includes, but is not limited to, the following: . s. Thoroughly investigating each allegation regardless of source or credibility of information . V. ABUSE INVESTIGATIONS .1. Should an incident or suspected incident of . misappropriation of resident property be reported, the Administrator or designee . will appoint a member of management to investigate the alleged incident while retaining ultimate responsibility for ensuring a timely and thorough investigation .3. The individual conducting the investigation will, at minimum: .c. Interview the person(s) reporting the incident; d. Interview any witnesses or potential witnesses to the incident including staff, residents and visitors; e. Interview the resident (as medically appropriate); .g. Interview staff (on all shifts) who have had contact with the resident before, during, and immediately after the period of the alleged incident; .i. Interview the resident's . family members, and visitors; .l. Review all events leading up to the alleged incident and create a timeline . 6. The following guidelines will be used when conducting interviews: .c. The interview will be documented and, as appropriate, followed up with a written statement from the individual interviewed . 9. The known facts of each situation will be considered objectively in making decisions that best protect the residents and ensure ongoing Community operations . 12. The results of the investigation will be recorded and kept in a file for review This citation relates to Complaints IN00440157. 3.1-28(d)

Based on interview and record review, the facility failed to report an incident of a resident leaving the facility and the facility being unsure of her whereabouts for 1 of 1 resident reviewed for an unusual occurrence. (Resident C) Findings include: Resident C's clinical record was reviewed on 6/24/24 at 10:27 a.m. Diagnoses included unspecified severe protein-calorie malnutrition, adult failure to thrive, difficulty in walking, type II diabetes mellitus without complications, history of falling, attention and concentration deficit following other cerebrovascular disease, and other speech and language deficits following other cerebrovascular disease. Orders included insulin lispro (short acting) insulin per sliding scale three times daily, metformin (treat diabetes) 750 mg twice daily, mirtazapine (treat depression) 7.5 mg daily, acetaminophen (treat pain) 1000 mg three times daily, and cleanse coccyx wound with wound cleanser, pat dry, apply Medihoney (for wound healing) to wound bed and cover with a foam dressing every Monday, Wednesday and Friday. An admission Minimum Data Set (MDS) assessment, dated 6/5/24, indicated the resident was severely cognitively impaired. She required the assistance of two staff members for bed mobility, transfers and toilet use. She was frequently incontinent of bowel and bladder. She had two emergency contact relatives. She did not have a Power of Attorney (POA) or guardian. A nurses note, dated 6/20/24 at 1:58 a.m., indicated Resident C returned from the hospital at 1:30 a.m. via private automobile, accompanied by a family member. Resident C was treated for hyperglycemia (high blood sugar) and an altered mental status. The hospital administered insulin at 9:45 p.m., due to her blood sugar being over 400 mg/dL. She was assisted to her room, provided peri care and changed into a nightgown. Vital signs were obtained, and a head-to-toe assessment was completed with no new injuries or skin issues found. A social service note, dated 6/20/24 at 10:42 a.m., indicated the social worker met with Resident C for a psychosocial visit in the common area as she watched TV and ate breakfast. Resident C was asked how she was doing, and she stated good. She was able to carry a conversation and was very pleasant. A nurses note, dated 6/20/24 at 11:41 a.m., indicated Resident C stated she was afraid due to the incident that happened the day prior and asked staff not to hurt her. She was ensured she would not be hurt intentionally in the building by anyone. The clinical record lacked indication as to why the resident had been at the hospital, or when/how she had left the facility. During an interview with Resident C's Emergency Contact 2, on 6/24/24 at 11:22 a.m., he indicated on 6/19/24 around 3:30 p.m. to 4:00 p.m., a family member took Resident C out of the facility and intended to keep her. The family member told CNA 17 that she was going to take Resident C and CNA 17 realized something was wrong and reported it. Resident C was taken to the hospital because her blood sugar had spiked. The hospital released her between 1:00 a.m. to 1:30 a.m. and she came back to the facility. During an interview with the Administrator, on 6/24/24 at 12:19 p.m., he indicated Resident C's family member came into the facility on [DATE] and visited Resident C in the activity room for 5 to 10 minutes. The family member was going to take Resident C to her room but went to the parking lot instead. Another resident, sitting outside, saw the family member struggling to get Resident C into her car and let the receptionist know. The receptionist called the nurses station and CNA 17 was sent up front to help. CNA 17 asked Resident C's family member how long she was going to be gone and if she signed out. The family member indicated they were going for a drive a would be right back, which prompted CNA 17 to tell the ADON. The facility tried to contact the other family members and let them know that this family member had taken Resident C out of the building, and they indicated she was not supposed to leave with that family member. The facility contacted the family member who took Resident C in her car, and she indicated she had no intention of bringing Resident C back to the facility. The ADON called the police per the family request. He did not report the incident to the Indiana Department of Health because Resident C was with a family member. At the current time, no one was allowed to take Resident C out of the building until a POA was established. During an interview with CNA 17, on 6/24/24 at 2:02 p.m., she indicated around 4:00 p.m., on 6/19/24, Receptionist 9 called the nurses station to assist Resident C into the family member's car. CNA 17 went outside to the family member's car. The family member indicated her shoes were slippery and she couldn't get Resident C into the car. Resident C pointed to the facility and indicated she was going home. CNA 17 assisted Resident C into the car. The family member indicated to Resident C you don't have to take this sh-- anymore or sit in the activity room watching the f---king [NAME] of Hazard. CNA 17 observed that Resident C had been incontinent and she was wet. She asked the family member if she would like the CNA to provide care and the family member indicated she would change the residents' brief when she got her home. CNA 17 walked back into the facility and reported what the family member said to Receptionist 9 and the Director of Marketing and Admissions. During an interview with the Director of Marketing and Admissions, on 6/24/24 at 2:52 p.m., she indicated she had been in her office and CNA 17 was going out to the parking lot to assist Resident C in getting in a car. The person had taken Resident C from the activity room and took her outside. The way the family member took the resident outside and the comments about how she could take better care of the resident at home alerted her to do something about that person taking Resident C. Initially, they were not sure who had taken Resident C. They went back to Resident C's room to see if her belongings were still in her room, and they were. On her nightstand was a name and telephone number, so they looked up the name on social media and CNA 17 indicated that was the same person she helped get Resident C into her car. If it wasn't for finding the name and phone number on Resident C's nightstand, they would not had known who Resident C left with. She had seen a cognitive decline in Resident C since she was admitted to the facility. Herself, Receptionist 9 and the ADON called her two emergency contact relatives and the Administrator, who came to the facility. The ADON called the police. The police were able to identify the car Resident C left in, through video footage at a gas station, but the license plate did not match the car. A current facility policy, titled Incident Reporting Policy for Indiana Communities, indicated the following: .B. The following incidents must be reported to the Indiana State Department of Health as soon as possible after an allegation is made or the incident occurred, but minimally must be reported within 24 hours .4. Occurrences that directly threaten the welfare, safety, or health of a resident .d. Elopement of a resident .ii. Whose whereabouts had been unknown or whose return to the Community involves law enforcement or emergency personnel This citation relates to Complaint IN00437112. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure medication carts were kept locked when unattended, and failed to ensure proper labeling of medications for 2 of 3 carts observed for medication storage on the 200 Hall. Findings included: On 6/24/24 at 3:12 p.m., the two medication carts on the Southeast 2 unit were observed to be unlocked and unattended by staff. Residents were observed in the hallways and in the lounge area at this time. During an interview on 6/24/24 at 3:17 p.m., RN 1 indicated the nurse (LPN 2) responsible for the medication cart had stepped off the unit. She indicated the nurse also had the keys for the 2nd (overflow) medication cart. The overflow medication cart contained oral pills. The top drawer contained oral pills (identified as 19 melatonin (supplement for sleep) and 8 potassium chloride 10 meq) without resident indicators. RN 1 indicated she did not know why theses medications were not in a box with a resident's name or identifiers. During an interview on 6/24/24 at 3:22 p.m., LPN 2 she would normally lock the medication cart when she walked away from it. The top drawer of the medication cart contained breathing treatments, nasal sprays, eye drops, oral pills, insulin pen needles and lancets. Drawers 2-7 included all oral medications (pills). The 8th drawer (bottom drawer) contained patches, liquids, breathing treatments. The top drawer to the right contained insulin pens. The second drawer contained locked narcotic drawer. The 3rd drawer down on the right contained various liquid medications and powdered medications. The bottom drawer on the right contained povidone iodine solution (skin antiseptic) and cleaning wipes. A current undated policy, titled Drug Storage, and provided by the Administrator on 6/24/24 at 4:14 p.m., indicated the following: .Medications are dispensed in containers that meet or exceed official standards. These containers will be stored orderly in a secured area accessible to pharmacy personnel and to licensed nursing personnel designated by the facility per resident care policies. Procedure 3. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access 3.1-25(m)

Based on interview and record review, the facility failed to provide notification of Medicare non-coverage for 3 of 3 residents reviewed for beneficiary protection notifications. (Resident 68, 185, and 71) Findings include: On 11/28/23 at 2:25 p.m., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed, and indicated the following: 1. Resident 68 had admitted to the facility on [DATE] under Medicare Part A Skilled Services. The last covered day of Part A Services was 8/5/23. The resident remained in the facility. The clinical record lacked both Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-coverage (NOMNC) notices. 2. Resident 185 had admitted to the facility on [DATE] under Medicare Part A Skilled Services. The last covered day of Part A Services was 10/12/23. The resident discharged home on 10/13/23. The clinical record lacked a NOMNC notice. 3. Resident 71 had admitted to the facility on [DATE] under Medicare Part A Skilled Services. The last covered day of Part A Services was 10/31/23. The resident remained in the facility. The clinical record lacked both SNF ABN and the NOMNC notices. During an interview on 11/30/23 at 1:47 p.m., the Social Services Director (SSD) indicated the residents 68 and 71 should have received the SNF ABN and NOMNC form, and a NOMNC form should have been provided to Resident 185. Review of Beneficiary Notices Really Can Be Understood (April 6, 2021), retrieved on 12/5/23 at 12:31 p.m. from the American Association of Post-Acute Care Nursing (AAPACN) website indicated the following: .The Basics Under federal and state laws, Medicare beneficiaries have rights while residing in the nursing home, to help ensure that a beneficiary receives the care and services they need. One of these rights is to be informed when care and services will most probably not be covered by their Medicare benefits. The nursing home must inform the resident of the decision to end skilled care and the option to appeal 3.1-4(f)(2) 3.1-4(f)(3)

Based on interview and record review, the facility failed to resolve resident council concerns related to call lights being turned off prior to assistance and long call light wait times. (Residents 2, 9, 10, 16, 20, 38, 49, 54 and 73) Findings include: During the Resident Council meeting on 11/29/23 at 2:35 p.m., Residents 2, 9, 10, 16, 20, 38, 49, 54 and 73 indicated the wait for call lights to be answered was long, and staff would turn off the call light without completing care. During an interview on 11/27/23 at 10:58 a.m., Resident 67 indicated the call light wait time ranged from 1 to 2 hours, with the average being around an hour. During review of the resident council minutes, on 11/28/23 at 9:57 a.m., the following was observed: The 8/23/23 minutes indicated residents were concerned about the call light issues not being addressed, and the resident council meeting was the only place to voice a grievance. The record lacked a facility follow-up. The 9/25/23 minutes indicated residents were concerned about staff turning call lights off prior to providing care and long call light wait times of over an hour. The record lacked a facility follow-up. The 10/25/23 minutes indicated residents were concerned about long call light wait times. Resident 10 indicated wait times over 1 hour. The record lacked a facility follow- up. During an interview on 12/1/23 at 2:03 p.m., the Social Services Director (SSD) indicated she had not received grievance forms from the resident council meetings, as Resident Council concerns were handled during the meetings. During an interview on 12/1/23 at 2:55 p.m., the Administrator indicated the facility did not have a call light time log or any print out indicating call light response times. During an interview on 12/4/23 at 10:56 a.m., the Activities Director (AD) indicated she utilized the Resident/Family Concern/Grievance Form, when resident council members present concerns during the meeting. She provided the Administrator with these forms for review and completion. During an interview on 12/4/23 at 10:59 a.m., the Administrator indicated the resident council grievances or concerns were not documented on grievance forms, and the concerns voiced in the resident council meetings were handled immediately and documented on the Resident Council Minutes forms. A current, revised 12/06, facility admission policy, provided by the Administrator on 11/30/23 at 11:46 a.m., titled Resident Council, indicated the following: .7. A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible to address the item(s) of concern 3.1-3(1)

Based on record review and interview, the facility failed to educate resident council members on the facility grievance process. (Residents 9, 16, 20, 38, 54, and 73) Findings include: During the Resident Council meeting on 11/29/23 at 2:30 p.m., residents 9, 16, 20, 38, 54, and 73 indicated they did not know the grievance process or how to file a grievance. During a record review on 11/28/23 at 9:57 a.m., the resident council binder lacked a record of grievances filed. During an interview on 11/30/23 at 9:25 a.m., the Administrator indicated there were no grievances from the resident council meetings and the Social Services Director (SSD) was the facility's grievance designee. During an interview on 12/1/23 at 2:03 p.m., the SSD indicated she has not received grievance forms from the resident council meetings, as Resident Council concerns were handled during the meetings. During an interview on 12/4/23 at 10:56 a.m., the Activities Director (AD) indicated she utilized the Resident/Family Concern/Grievance Form, when resident council members present concerns during the meeting. She provided the Administrator with these forms for completion. During an interview on 12/4/23 at 10:59 a.m., the Administrator indicated the resident council grievances or concerns were not documented on grievance forms, and the concerns voiced in the resident council meetings were handled immediately and documented on the Resident Council Minutes forms. A current, revised 12/06, facility admission policy, provided by the Administrator on 11/30/23 at 11: 46 a.m., titled Resident Council, indicated the following: .b. Assisting in the development of resident grievance and complaint procedures; . 7. A Resident Council Response Form will be utilized to track issues and their resolution 3.1-7(b)

Based on record review and interview, the facility failed to ensure comprehensive assessments were completed per the Resident Assessment Instrument (RAI) specified timeline. (Resident 63, 38, 47, 79 and 287) Findings include: 1. Resident 63's clinical record was reviewed on 11/28/23 at 2:10 p.m. Current diagnosis included acute renal failure, aphasia, and dysphagia. The resident had a 10/17/23 significant change Minimum Data Set (MDS). The assessment was signed by the MDS Coordinator on 11/08/23 (22 days after the assessment date). This resulted in the assessment being signed eight days late. During an interview on 12/4/23 at 10:57 a.m., the MDS Coordinator indicated Resident 63's MDS was signed late due to the lack of an MDS assistant during that time period and the inability to complete all tasks in a timely manner. 2. Resident 38's clinical record was reviewed on 11/28/23 at 2:14 p.m. Current diagnosis included end stage renal disease, complete traumatic amputation of left lower leg, and diabetes mellitus. The resident was readmitted to the facility 9/25/23. The resident had a 9/28/23 Admission MDS which was not signed until 10/18/23 (20 days after the assessment date). The signature was six days later than the required 14 day period. During an interview on 12/4/23 at 10:58 a.m., the MDS Coordinator indicated she had needed assistance completing all the tasks of the MDS process due to the loss of her assistant. At times during that time period, MDS assessments were signed late. 3. Resident 47's clinical record was reviewed on 11/30/23 at 9:09 a.m. Current diagnosis included unspecified cerebral infarction, influenza virus with other respiratory manifestations, attention and concentration deficit following other cerebrovascular disease, memory deficit following other cerebrovascular disease, and obstructive and reflux uropathy. The resident had a 10/19/23 Admission MDS which was not signed until 11/7/23 (20 days after the assessment date). The signature was six days later than the required 14 day period. 4. Resident 79's clinical record was reviewed on 11/30/23 at 11:24 a.m. Current diagnosis included cellulitis of left lower limb, Methicillin Resistant Staphylococcus Aureus (MRSA) infection as the cause of diseases classified elsewhere, and morbid (severe) obesity due to excess calories. The resident had a 10/30/23 Admission MDS which not signed until 11/9/23 (16 days after the assessment date). The signature was two days later than the required 14 day period. 5. Resident 287's clinical record was reviewed on 11/30/23 at 2:08 p.m. Current diagnosis include acute and chronic respiratory failure with hypoxia, weakness, other chronic pain and chronic obstructive pulmonary disease with (acute) exacerbation (COPD). The resident has a 11/13/23 Admission MDS which was not signed until 11/29/23 (17 days after the assessment date). The signature was three days later than the required 14 day period. During an interview on 11/30/23 at 3:56 p.m., the MDS Coordinator indicated she utilized the RAI manual found online and was aware some of the assessments where completed late. She was the only employee in this role and required an assistant to be able to complete the MDS tasks on time. Review of the current online RAI manual (November 23, 2023) retrieved from www.cms.gov on 12/5/23 indicated the following: .MDS completion date no later than the 14th calendar day from the assessment reference date (ARD) 3.1-31(d)(1)

Based on observation, interview, and record review, the facility failed to ensure narcotics were reconciled per facility policy for 2 of 3 medication carts reviewed for medication storage. (41 South cart and 41 North cart) Findings include: 1. During a medication storage observation of the 41 South cart, accompanied by LPN 6 on 12/4/23 at 11:10 a.m., the Nurse's Narcotic Sign In/Out Sheet record was reviewed and the following dates lacked shift to shift reconciliation of controlled medications: In November 2023- 11/2 on day and evening shifts, 11/3 on day shift, 11/4 on night shift, 11/8 on day and night shifts, 11/13 on night shift, 11/15 on day and evening shifts, 11/16 on day and evening shifts, 11/18 on evening and night shifts, 11/19 on day shift, and 11/30 on day shift. 2. During a review of the 41 North cart, Nurse's Narcotic Sign In/Out Sheet record, provided by the DON on 12/4/23 at 12:10 p.m., the following dates lacked shift to shift reconciliation of controlled medications: In November 2023- 11/1 on day shift, 11/4 on all three shifts, 11/5 on day shift, 11/10 on day shift, 11/11 on day shift, 11/12 on day shift, 11/14 on evening shift, 11/16 on day shift, 11/18 on evening and night shifts, 11/19 on day shift, 11/23 on evening shift, 11/26 on day shift, and 11/29 on day shift. During an interview on 12/4/23 at 12:07 p.m., the DON indicated the expectation of the nursing staff was the narcotic sign in/sign out sheet to be completed at any time the medication cart keys change hands. An undated, current facility policy titled Controlled Substance Reconciliation, provided by the Corporate Nurse Consultant on 12/4/23 at 12:45 p.m., indicated the following: .1. Each facility should verify the quantity of controlled substance(s) on hand as well as the number of accompanying count sheets at the end of each nursing shift 3.1-25(b)(3)

Based on observation and interview, the facility failed to appropriately label medications brought in to the facility by the resident or resident family and stored in the medication cart in 1 of 3 medication carts. (34 South Hall medication cart) Findings include: On 12/4/23 at 11:30 a.m., during observation of the 34 South Hall medication cart, accompanied by LPN 5, the following was observed: a. Four bottles of Omega XL 300 mg (milligram) (dietary supplement), lacked a resident name or pharmacy label. b. On bottle of D3 5000 units (vitamin supplement), lacked a resident name or pharmacy label. c. Sleep XL (dietary supplement), lacked a resident name or pharmacy label. During an interview at the time of observation, LPN 5 indicated there was no resident name or prescribing information on the bottles. Review of current, undated facility policy titled, Medication Labeling, provided by the Nurse Consultant on 12/4/23 at 12:34 p.m., indicated the following: .Procedure .8. Over the counter medications used for a specific resident must identify that resident and have an appropriate pharmacy label applied 3.1-25(j)

Based on observation and interview, the facility failed to develop and implement a method of communication with the [CONDITION(S)] provider for 2 of 2 residents reviewed with [CONDITION(S)] services (Resident 15 and Resident 33). Findings include: 1. Resident 15's clinical record was reviewed on 10/3/22 at 2:20 p.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current care plan problem/need regarding the need for hemodialysis due to [CONDITION(S)]. This care plan was originated 7/19/22. The clinical record for August and September 2022 indicated the resident left the facility to received [CONDITION(S)] 24 days as follows: 9/30/22, 9/28/22, 9/21/22, 9/19/22, 9/16/22, 9/14/22, 9/12/22, 9/9/22, 9/5/22, 9/2/22, 8/31/22, 8/29/22, 8/26/22, 8/24/22, 8/22/22, 8/19/22, 8/17/22, 8/15/22, 8/12/22, 8/10/22, 8/8/22, 8/5/22, 8/3/22, and 8/1/22. The clinical record lacked communication documents from the resident's [CONDITION(S)] provider for the 24 days listed above. During an interview on 10/3/22 at 3:25 p.m., the DON indicated the facility did not have any communication forms completed by Resident 15's [CONDITION(S)] provider during the months of August and September 2022. She indicated the facility would call the [CONDITION(S)] provider if they believed they needed additional information, but there was not a routine standard method of communication completed by the [CONDITION(S)] provider to ensure continuity of care. A current, undated, facility document titled SNF [CONDITION(S)] Services Agreement, which was provided by the DON on 10/3/22 at 3:57 p.m., indicated the contracted was established with the [CONDITION(S)] provider where Resident 15 received services. The contract included, but was not limited to the following: D, Mutual Obligation 1. Collaboration of Care. Both partied shall ensure that there is documented evidence of collaboration of care and communication between the Nursing facility and [CONDITION(S)] [CONDITION(S)] Unit. 2. Resident 33's clinical record was reviewed on 9/28/22 at 2:22 p.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current health care plan, dated 5/31/22 and revised 9/2/22, indicated the resident received hemodialysis due to [CONDITION(S)]. The clinical record for August and September 2022, indicated the resident left the facility to received [CONDITION(S)] 20 times as follows: 8/3/22, 8/8/22, 8/10/22, 8/12/22, 8/17/22, 8/19/22, 8/22/22, 8/24/22, 8/29/22, 8/31/22, 9/2/22, 9/9/22, 9/12/22, 9/14/22, 9/19/22, 9/21/22, 9/23/22, 9/26/22, 9/28/22 and 9/30/22. The clinical record lacked communication documents from the resident's [CONDITION(S)] provider for the 19 of the 20 days listed above. A review of a Nurse Practitioner progress note, dated 9/19/22, indicated the resident's [CONDITION(S)] provider reported the resident had severe [CONDITION(S)] with a hemoglobin blood level of 5.9. The provider indicated the resident had a hemoglobin of 6.1 on Monday, 9/12/22 with a repeat hemoglobin of 5.9 on Wednesday 9/14/22. The facility had not been notified. The resident was sent to the emergency department for evaluation and treatment regarding his low blood hemoglobin levels. During an interview on 10/03/22 at 3:26 p.m., the DON indicated the resident's [CONDITION(S)] provider had not sent information back with the resident. The staff completed a pre-assessment and sent the information with the resident. The provider had called before to inform staff the resident did not complete his [CONDITION(S)] cycle or had been sent to emergency room , but the facility doid not receive any information in writing regarding his treatments. A current facility policy, dated 6/4/19, titled, Hemodialysis Policy, provided by the DON on 10/3/22 at 4:09 p.m., included, but was not limited to, the following: Policy Statement [Facility] will ensure that residents who require [CONDITION(S)] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the individual resident's goals and preferences. 3.1-37(a)

Based on record review and interview, the facility failed to provide notice of transfer to residents or their representative for 2 of 4 residents reviewed. (Resident 20, and Resident 33) Findings include: 1. A review of Resident 20's clinical record was completed on 10/3/22 at 2:10 p.m. He was transferred to the emergency roiagnom on [DATE] for aggressive and uncooperative behaviors. He was admitted with a urinary tract infection. There was no record of transfer/discharge information having been given to the resident or his legal representative at the time of the transfer. 2. A review of Resident 33's clinical record was completed on 9/28/22 at 2:22 p.m. He was transferred to the emergency roiagnom on [DATE] due to low hemoglobin blood level as reported by the [CONDITION(S)] provider. There was no record of transfer/discharge information being provided to the resident or his legal representative at the time of transfer. During an interview on 10/3/22 at 2:18 p.m., the Director of Nursing (DON) indicated the record lacked transfer/discharge information for Resident's 20 and 33 related to their transfers to the emergency room . She indicated the information should have been completed. A current facility policy, dated 6/4/19, titled, Discharge Planning, provided by the Corporate Nurse Consultant on 9/30/22 at 4:24 p.m., included, but the following: Policy Interpretation and Implementation: XIV. If a resident is discharged to the care of another health care entity such as a hospital , the community shall providde the receiving entitiy with the following F. All other necessary information to ensure a safe and effective transistion of care. 3.1-12(a)(21)

Based on interview and record review, the facility failed to develop a discharge summary to ensure a safe discharge and continuity of care for 2 of 3 residents reviewed. (Resident 58 and Resident 60) Findings include: 1. Resident 58's clinical record review was completed on 9/30/22 at 11:37 a.m. The resident was discharged on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked a discharge summary and discharge instructions. An order, dated 8/3/22, indicated to discharge the resident with physical therapy, occupational therapy, and home health care. A Nurse's Note, dated 8/5/22, indicated the resident discharged home with his daughter. A care plan to return home after rehabilitation, dated 7/12/22, indicated the resident would have discharge arrangements made prior to the discharge date . Interventions included, resident would have services or equipment arranged prior to/upon discharge per physician order. During an interview on 9/30/22 at 11:18 a.m. the Director of Nursing (DON) indicated the discharge summary and discharge instructions were under observations in the clinical record. During an interview on 9/30/22 at 3:08 p.m., the DON indicated she did not know of any other location to find the discharge summary and discharge instructions. A copy of the resident's discharge summary and discharge instructions were requested at this time. During an interview on 9/30/22 at 3:35 p.m., the Registered Nurse (RN) Consultant indicated the resident's discharge summary was not developed and the clinical record lacked a discharge summary or discharge instructions. A second request was made for the resident's discharge summary and discharge instructions. Further documentation was not provided. During an interview on 9/30/22 at 4:20 p.m., the RN Consultant indicated since the discharge summary and discharge instructions were not in the clinical record, the facility did not have a record of what documents were provided at discharge. During an interview on 10/3/22 at 11:01 a.m. the RN Consultant indicated the resident did not discharge against medical advice. 2. Resident 60's clinical record review was completed on 9/30/22 at 9:49 a.m. The resident was discharged on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked a discharge order, discharge summary, and discharge instructions. Review of a Social Service Note, dated 8/11/22 at 11:31 a.m., indicated the resident was discharging home with his sister and father on 8/11/22. The planned discharge time was 4:00 p.m. A Nurse's Note, dated 8/11/22 at 5:47 p.m., indicated the resident was discharged . A care plan to return home independently after rehabilitation, dated 8/8/22, indicated the resident would have discharge arrangements made prior to the discharge date . Interventions included the resident would have services or equipment arranged prior to/upon discharge per physician order. During an interview on 9/30/22 at 3:08 p.m., the DON indicated the discharge summary and discharge instructions were not availabe for review. A copy of the resident's discharge summary and discharge instructions were requested at this time. During an interview on 9/30/22 at 3:35 p.m., the Register Nurse (RN) Consultant indicated the resident's discharge summary was not developed and the clinical record lacked a discharge summary or discharge instructions. A second request was made for the resident's discharge summary and discharge instructions. Further documentation was not provided. During an interview on 9/30/22 at 4:20 p.m., the RN Consultant indicated since the discharge summary and discharge instructions were not in the clinical record, the facility did not have a record of what documents were provided at discharge. During an interview on 10/3/22 at 11:01 a.m. the RN Consultant indicated the resident did not discharge against medical advice and the clinical record lacked an order to discharge the resident. A current policy, titled Discharge Planning, provided by the RN Consultant on 9/30/22 at 4:24 p.m., indicated the following: . I. When the community anticipates a resident's discharge to a private residence . a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her living environment. II. The discharge summary will include a recapitulation of the resident's stay at this community and a final summary of the resident's status at the time of the discharge in accordance with established regulations . XIII. A copy of the following will be provided to the resident and any receiving provider and a copy will be filed in the resident's medical records: A. An evaluation of the resident's discharge needs; B. The post-discharge plan; and C. The discharge summary 3.1-36(a) 3.1-36(b)

Based on interview and record review, the facility failed to assist a resident with oral intake of meals for 1 of 1 resident reviewed with tube feeding. (Resident 17) Finding includes: Resident 17's clinical record was reviewed on 9/28/22 at 2:28 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A CNA (Certified Nursing Assistant) Assignment Sheet, dated 9/28/22, provided by the Corporate Nurse Consultant on 9/28/22 at 3:20 p.m., indicated the resident had a prescribed diet of regular food with pureed texture and nectar thick liquids and indicated the resident was to be fed per staff. A quarterly Minimum Data Set (MDS) assessment, dated 7/21/22, indicated the resident had severe cognitive impairment, had no rejection of care, required extensive assistance of one staff for eating, had a feeding tube and mechanically altered diet, and received 26-50% of total calories through her feeding tube. The resident had a health care plan, revised 9/8/22, with an indicated problem of, resident receives a tube feeding with pureed diet. Goals included, but were not limited to, provide pureed diet and tube feeding and encourage compliance. A Registered Dietician Assessment, dated 8/5/22, indicated the resident had a current diet order for a regular diet, pureed texture, nectar-thick liquids and tube feeding. The average percent of oral intake was recorded as less than 50%. Interventions included, but were not limited to, continue to encourage oral food and fluid intake. Review of the resident's intakes for meals, indicated Nothing-By-Mouth (NPO) for the following meals: a. Breakfast on 9/28/22, 9/25/22, 9/23/22, 9/23/22, 9/16/22, 9/9/22, 8/31/22, 8/15/22, 8/14/22, and 8/8/22. b. Lunch on 9/25/22, 9/23/22, 8/31/22, 8/15/22, 8/14/22, and 8/8/22. c. Dinner on 9/4/22, 8/15,22, 8/14/22, and 8/13/22. During an interview on 9/29/22 at 9:32 a.m., CNA 3 indicated she did not feed Resident 17 by mouth every meal because she has her tube feedings also and sometimes pockets food in her mouth. When the resident's family fed her, she would enter the amount consumed for the resident's intake. When she entered NPO she was indicating the resident was not assisted to eat by her. During an interview on 9/29/22 at 9:36 a.m., the Assistant Director of Nursing (ADON) indicated the resident should have been offered assistance with every meal. She had been educating CNA's on proper documentation. She indicated NPO should only be documented when a resident was unable or ordered to have nothing by mouth. Resident 17 was to be offered oral intake as well as tube feeding. A current facility policy, revised 3/2018, titled, Activities of Daily Living (ADL), Supporting, provided by the Director of Nursing (DON) on 10/3/22 at 3:50 p.m., included, but was not limited to, the following: Policy Statement Residents will be provided with care, treatment and services as appropriated to maintain or improve their ability to carry out activities of daily living (ADLs) . Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .d. Dining (meals and snacks . 3.1-37(a)

Based on record review and interview, the facility failed to transcribe an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was given at an incorrect dose, which resulted in a critically elevated PT (prothrombin time) and INR (international normalized ratio) level, which resulted in hospitalization for rectal bleeding due to a critically elevated PT/INR level of 9.9 for 1 of 3 residents reviewed for medication errors. (Resident B) The Immediate Jeopardy began on 7/12/21 when the facility failed to correctly enter a physician order, and Resident B received the wrong dose of medication and was transferred to the emergency room and required hospitalization for stabilization and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: The record for Resident B was reviewed on 8/12/21 at 10:42 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE] at 4:19 p.m., from a rehabilitation hospital with discharge information including, but not limited to, the following: 1. [MEDICATION(S)] 2 mg (milligram), one tablet every day via g-tube at 6:00 p.m. 2. INR should be drawn per skilled nursing facility protocol. INR on 7/12/21 was 2.76 with INR goal of 2.5 to 3.5. During admission to the facility, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 6 mg, one tablet every day at 6:00 p.m. The order was dated 7/12/21. The July 2021 Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A nurse practitioner note, dated 7/16/21 at 9:42 a.m., indicated resident had rectal bleeding noted with no external hemorrhoids noted and no history of hemorrhoids. She was currently on [MEDICATION(S)] 6 mg daily. After discussion with patient and significant other, resident was sent to the emergency room for evaluation. The hospital history and physical, dated 7/16/21 at 5:49 p.m., indicated .arrival workup in the ER revealed an INR of 9.9 .ED course: Given 2.5 mg of vitamin K [given to [MEDICATION(S)] [MEDICATION(S)]] orally. During an interview on 8/12/21 at 2:01 p.m., the Director of Nursing (DON) indicated Resident B admitted to the facility on [DATE] and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She indicated the order entered into the EHR's and on the eMAR upon admission was for [MEDICATION(S)] 6 mg, one tablet daily and this was incorrect. The DON indicated she reviewed the admission assessment that indicated the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a phone interview on 8/13/21 at 10:25 a.m., LPN 3 indicated she did not recall or know why she had entered the order for [MEDICATION(S)] as 6 mg when the written discharge paperwork indicated a 2 mg dose. During a phone interview on 8/13/21 at 2:26 p.m., the Provider Representative indicated the protocol when a resident admitted to the facility was for the admitting nurse to call the on-call provider to review orders. The nurse practitioner would then review the written admitting orders and reconcile the entered orders upon next visit to the facility. He indicated the nurse practitioner had seen the dose of [MEDICATION(S)] 6 mg somewhere in the discharging facilities paperwork, but was unable to provide further information regarding the dosage difference. A current facility policy, revised 2016, titled, Admission Assessment and Follow Up: Role of the Nurse, provided by the Administrator on 8/13/21 at 9:34 a.m., included, but was not limited to, Steps in the Procedure .11. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (ifavailable) {SIC}, and the discharge summary from the previous institution, according to established procedures. The Immediate Jeopardy that began on 7/12/21 was removed on 8/13/21 when the facility began staff education/in-services, audits of all residents on blood thinner therapies and creation of an audit form for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This federal tag relates to Complaint IN 504. 3.1-48(c)(2)

Based on interview, record review and observation, the facility failed to ensure infection control practices for COVID-19 were followed to prevent the spread of [MEDICAL CONDITION]. A systemic infection control failure was found related to cohorting residents, use of PPE and screening staff prior to working their shifts. The facility failed to have a designated area for residents with confirmed COVID-19, with designated staff and equipment and designated entrance and exit. Staff cared for both residents with confirmed COVID-19 and residents who were not confirmed COVID-19, then went to other areas of the facility to take a break or exit the facility. Staff were observed exiting rooms of residents with confirmed COVID-19, with their PPE on and with both used and clean PPE in the hallway. The facility also failed to appropriately screen staff at the beginning of their shifts. These deficient practices had the potential to affect 28 residents who were unconfirmed COVID-19 and residing on the yellow zone on the West unit as well as residents throughout the facility. The Immediate Jeopardy began on 9-24-2020 when the facility cohorted residents with confirmed COVID-19 with residents who were not confirmed COVID-19 on the same hallway in rooms across from each other. The confirmed COVID-19 residents were not in a separate, designated area with designated staff, equipment and entrance/exit. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 9-26-2020 at 6:16 p.m. The Immediate Jeopardy was removed on 9-27-2020, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: Upon entering the facility on 9-26-2020 at 11:00 a.m., RN 11 was at the entrance and was unsure of how to sign in the surveyor or screen for COVID-19. She was unaware there was no staff member at the front desk to assist with visitors. The surveyor took their own temperature and no screening sheet was available. During a facility tour on 9-26-2020 at 11:03 a.m., the West Unit was observed to have three hallways: one hallway was a red zone for residents with confirmed COVID-19, another hallway was a yellow zone for residents who were exposed or symptomatic but not confirmed COVID-19, and the third hallway housed confirmed COVID-19 residents on one side (red zone) and unconfirmed COVID-19 residents across the hall on the other side (yellow zone). There were four rooms, with a total of 6 unconfirmed COVID-19 residents on one side, and four rooms with a total of 8 confirmed COVID-19 residents on the other side. One nurse was passing medications to residents on both sides of the hallway. There was one nursing station for this area. Nurses and Certified Nursing Assistants (CNA) were observed exiting resident rooms on the red side of the hallway, and removing their reusable gowns and hanging them on hooks located on the wall beside the residents' room doors. Each resident door on the red side of the short hallway was covered with a plastic barrier that had a zipper for closure. Each staff member working in that area had a reusable gown for each resident. Staff were observed donning their PPE in the hallway before entering the resident rooms and were observed removing their PPE in the hallway after exiting the resident rooms for both confirmed and unconfirmed residents. Gloves were placed in the trash container located in the hallway next to the soiled linen container after staff exited the residents' rooms. The clean, unused PPE was located inside a separate room. Resident rooms also had face masks located in isolation caddies hanging on the doors of the COVID-19 positive resident rooms. At the end of the shift, the staff members placed their gowns inside a soiled linen container. During an observation on 9-26-2020 at 11:43 a.m., LPN 8 was observed leaving a room with a confirmed COVID-19 resident on the third hall of the West unit. LPN 8 was assigned to be working the yellow hall of the West unit at that time. During a facility tour on 9-26-2020 at 11:43 a.m., RN 11 was observed wheeling an electronic blood pressure machine down the West unit hallway with both red zone and yellow zone residents. The employee indicated the equipment was shared between the red and yellow zoned residents and the staff cleaned it with bleach between uses. RN 11 was later observed moving the equipment from the red/yellow zone to the yellow zone and using it on residents in that area. During an observation on 9/26/2020 at approximately 12:00 p.m., CNA 8, who was working on the yellow zone, entered the red zone to assist with passing meal trays. The employee was called back to the yellow unit by a nurse and told she could not go between the red and yellow units. CNA 8 indicated she was not assigned to the red zone but went back to help because they needed the help. During an interview on 9-26-2020 at approximately 1:00 p.m., the Corporate Consultant indicated due to possible exposure all residents and staff had been tested on [DATE] and by cohorting the confirmed and unconfirmed residents on one unit, the facility attempted to keep all possible infections on one side of the facility. Confidential interviews of staff working 9-26-2020 through 9-27-2020 were completed. Exact times and dates were withheld to maintain anonymity. During an interview, Employee 9 indicated staff had been told it was safe to work between the red and yellow zones. The employee indicated staff were responsible for screening themselves prior to their shifts. Staff received their assignments at the nursing stations after entering the facility. During an interview, Employee 8 indicated staff had been told it was safe to work between the red and yellow zones. The employee indicated they received their assignments from the schedule posted at the nursing station. If their normal area had been the unit with the yellow and red zone, they looked there first. If they were scheduled to work the green zone, they would walk through the facility to arrive at the green zone. During an interview, Employee 7 indicated staff were allowed to work between the red and yellow zones. The employee indicated staff who worked on the red zone were allowed to pick up extra shifts on the yellow zone for consecutive shifts. Staff received their assignments at the nursing stations after entering the facility. If a staff member believed they were working on the yellow or red zone, they would go to that nursing station. If, after seeing the schedule, they were assigned to the green zone, they would leave the yellow/red zone and go to the green zone. During the interviews, staff indicated staff working on the red zone had to exit the facility through an outside door at the end of the red zone hallway. Staff working on the red zone could enter the facility from the all staff entrance and screen themselves then report for their assignment on the red zone. Staff working on the red/yellow zone took their breaks in the common break area or outside. Staff working in the green zone also took their breaks in the common break area or outside. During an interview on 9-27-2020 at 1:18 p.m., the Corporate Consultant and Executive Director indicated the staff who worked the yellow/red zone hall and the yellow zone hall took their breaks in the common break area or outside, as well as the staff who worked on the green zone. The yellow/red hall and the yellow hall could share staff. They indicated staff screening was done at point of entry and was not supervised. Review of the CDC guidance, Responding to Coronavirus (COVID-19) in Nursing Homes, dated as updated 4/30/20, indicated the following: Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19 - Determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP (healthcare personnel) to work on this unit. Facilities that have already identified cases of COVID-19 among residents but have not developed a COVID-19 care unit, should work to create one unless the proportion of residents with COVID-19 makes this impossible (e.g., the majority of residents in the facility are already infected). Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. Assign environmental services (EVS) staff to work only on the unit. If there are not a sufficient number of EVS staff to dedicate to this unit despite efforts to mitigate staffing shortages, restrict their access to the unit. Also, assign HCP dedicated to the COVID-19 care unit (e.g., NAs) to perform cleaning and disinfection of high-touch surfaces and shared equipment when in the room for resident care activities. HCP should bring an Environmental Protection Agency (EPA)-registered disinfectant (e.g., wipe) from List into the room and wipe down high touch surfaces (e.g., light switch, doorknob, bedside table) before leaving the room. Ensure that HCP have been trained on infection prevention measures, including the use of and steps to properly put on and remove recommended personal protective equipment (PPE). If PPE shortages exist, implement strategies to optimize PPE supply on the unit, such as: Bundle care activities to minimize the number of HCP entries into a room. Consider extended use of respirators (or facemasks if respirators are not available), eye protection, and gowns. Limited reuse of PPE may also be considered. Assign dedicated resident care equipment (e.g., vitals machine) to the cohort unit. Cleaning and disinfection of shared equipment should be performed between residents and the equipment should not leave the cohort unit. The Immediate Jeopardy that began on 9-24-2020 was removed on 9-27-2020 when the facility began inservicing staff on the proper donning and doffing of PPE, screening prior to the start of their shifts, appropriate exit and entrances to the facility and changed the facility layout to decrease the risk of the spread of infection, but the noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced. This federal tag relates to Complaint IN 072. 3.1-18(a) 3.1-18(b)(2)

Based on observation, record review and interview the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for medication administration. This deficient practice resulted in a resident being given the wrong mediations and being admitted to the hospital for a [DIAGNOSES REDACTED]. Findings include: The clinical record of Resident B was reviewed on 2/11/2019 at 11:15 AM. [DIAGNOSES REDACTED]. Review of most recent Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact. The resident was easily understood and could make his needs known. The resident ate independently with assistance for set up. Review of a facility event dated, 2/3/2019, indicated Resident B had received the following medications intended for another resident (Resident E) at 2:30 PM: [MEDICATION NAME] 7.5/325 mg x 2 (narcotic [MEDICATION NAME]) and [MEDICATION NAME] 0.5 mg (anti-anxiety). At 3:00 PM Resident B was found to be lethargic. The physician was notified and an ordered for the resident to receive [MEDICATION NAME] (opioid antagonist) injection and to send the resident to the hospital for evaluation and treatment was obtained. Vital signs at the time of incident were as follows: blood pressure 95/60, pulse 58 and oxygen saturation 92% on room air. The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]. During an observation on 2/11/2019 at 12:32 PM, the resident was observed sitting in the dinning room and required assistance to eat. The resident was unable to be understood. During an interview on 2/11/2019 at 1:37 PM., LPN 1 indicated she placed Resident E's medication in a cup with a piece of paper with the resident's name on it. The resident was not in his room when she went to administer his medications. She indicated the cup was placed in the top drawer of the medication cart. LPN 1 indicated she continued her medication pass and later found the cup with the medications in the medication cart. I saw the cup with the name of Resident B on it. I gave the meds to (name of Resident B). Later that afternoon Resident E requested his medications and LPN 1 realized she had given Resident B the wrong medications. The paper that had been placed in the cup had Resident B's written on one side and Resident E's name on the other side. Resident B was assessed and the physician called. an order for [REDACTED]. I gave it immediately. The physician also gave an order to send the resident to the hospital for evaluation and treatment. Confidential interviews for staff were completed. Exact times and dates withheld to maintain anonymity. During an interview Employee 2 indicated the resident's cognition has declined since his readmission to the facility on [DATE]. Employee 2 indicated the resident had been able to hold a conversation prior to the incident but he is unable to at this time. During an interview on 2/11/2019 at 4:36 PM the Corporate Consultant indicated medications prepared for administration but not given should be destroyed and not kept in the medication cart for later administration. The facility did not have a policy for this aspect of medication administration but did provide a copy of the Licensed Nurse Med Pass Clinical Skills Validation which indicated the following: . Medication Administration Skills Validation . 9. Read order entirely to check for right resident, right medication, right route, right dose, right time, right documentation . 22. Identify resident by their picture on e-mar or photograph with MAR and identified (sic) resident by name . This federal tag relates to Complaint IN 220. 3.1-25(b)(7) 3.1-48(c)(2)

Based on interview and record review, the facility failed to properly monitor daily blood pressure as ordered by a physician (Resident D). The facility also failed to ensure laboratory specimens were collected promptly following a physician's orders [REDACTED]. Findings include: 1. During closed record review on [DATE] at 12:40 p.m., the clinical record indicated Resident D was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 30-day assessment dated [DATE], indicated Resident D was cognitively intact. During review of a progress note, dated [DATE] at 3:12 p.m., LPN #1 noted Resident does complain of pain in upper right quadrant of abdomen. On [DATE] at 7:42 p.m., LPN #2 indicated B/P (blood pressure) was low today. [MEDICATION NAME] (diuretic) held per (name of medical group) order. During review of the physician order's, no order was documented as having been obtained to hold [MEDICATION NAME] for 2 doses on [DATE]. A progress note, dated [DATE] at 6:45 p.m., LPN #1 indicated Complains of abdominal pain. Medicated PRN (as needed) .B/P was low today. Review of the vital signs record, on [DATE] (Friday) at 1:33 a.m., Resident D had a blood pressure reading of ,[DATE] mmHg (millimeters of mercury). On [DATE] at 2:08 p.m., Resident D had a blood pressure reading of ,[DATE] mmHg. On [DATE] (Saturday) at 7:40 a.m., Resident D had a blood pressure reading of ,[DATE] mmHg. On [DATE] (Sunday) at 9:50 p.m., Resident D had a blood pressure reading of ,[DATE] mmHg. On [DATE] (Monday) at 2:43 p.m., Resident D had a blood pressure reading of ,[DATE] mmHg. On [DATE] (Wednesday) at 1:57 a.m., Resident D had a blood pressure reading of ,[DATE] mmHg. On [DATE] at 2:55 p.m., Resident D had a blood pressure reading of ,[DATE] mmHg and a pulse of 54 beats per minute. No blood pressure readings were documented on the vital sign record for the following dates: [DATE] (Thursday), [DATE] (Fridat), [DATE] (Tuesday), [DATE] (Thursday), [DATE] (Friday), [DATE] (Saturday), [DATE] (Tuesday), [DATE] (Wednesday), [DATE] (Thursday) or [DATE] (Tuesday). A progress note dated [DATE] at 7:44 a.m., LPN #2 indicated very 'air hungry' and pale. B/P was ,[DATE] -02 Sats are 93% on 3L (liter). MD paged. 911 called and resident sent to (name of hospital). A progress noted dated [DATE] at 2:56 p.m., indicated Resident was admitted to (name of hospital) [MEDICAL CONDITION]. Review of the physician order's dated [DATE] through [DATE], a general order to monitor for signs and symptoms of bleeding, positive [MEDICATION NAME], bruising and [MEDICAL CONDITION] was noted. Staff were to monitor vital signs every shift. Another order, indicated for staff to complete vital signs daily during the day shift Review of a current health care plan dated [DATE], indicated a fall risk problem related to [MEDICAL CONDITION] and hypertension. Interventions included, but were not limited to, observe for and report any noted functional changes. Another health care plan dated [DATE], indicated a problem with potential fluid volume excess related to [MEDICAL CONDITION]. Interventions included, but were not limited to, monitor lung sounds and vital signs as clinically indicated. During an interview on [DATE] at 11:45 a.m., LPN #1 indicated they (staff) review the vital signs and notify the physician or nurse practitioner if the resident is on a blood pressure medication or diuretic. She indicated they (staff) were recently given parameters by the Director of Nursing (DON) to notify the physician. She indicated staff were to notify the physician if a resident's diastolic blood pressure was less than 60. She indicated she could not remember the systolic level to notify. During an interview on [DATE] at 12:05 p.m., the DON indicated the staff see the abnormal vital signs in the computer colored as red. She indicated the computer had preset parameters of a systolic blood pressure being abnormal if the level was greater than 179 mmHg or less than 100 mmHg. The diastolic pressure to notify the physician if it was less than 60 mmHg or greater than 80 mmHg. She indicated if a resident had a normal range of a blood pressure being higher or lower, the computer parameters could be changed to reflect their normal range. 2. The clinical record for Resident E was reviewed on [DATE] at 2:30 p.m. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 10-day assessment, dated [DATE], indicated Resident E was cognitively intact. A progress note dated [DATE] at 12:57 p.m., indicated NP (nurse practitioner) in to see resident this shift, new orders received, res and family aware. A progress note dated [DATE] at 1:42 p.m., indicated res alert c (with) increased confusion this am, NP notified, in to see resident, new orders received. Review of a physician's verbal order, dated [DATE] and written by RN #3, indicated the following: a. BMP (basic metabolic panel), CBC (complete blood count) with differential today secondary to altered mental status. b. Obtain chest X-ray 2 views today secondary to shortness of breath. c. Monitor vital signs every 8 hours for 72 hours secondary to fever. Review of a physician's progress note dated [DATE], indicated to obtain a BMP, CBC with diff today Obtain Chest X-ray 2 views today Obtain UA and C&S today A progress note dated [DATE] at 3:13 a.m., indicated ' .on floor beside bed. Res confused et (and) asking for biscuits et gravy A progress note dated [DATE] at 2:09 p.m., indicated resident resting in chair on 2 lpm (liters per minute) nc (nasal cannula), pt (patient) appears lethargic, pt is mildly alert w/ noted confusion, NP asked writer for assessment A progress note dated [DATE] at 2:27 p.m., indicated Decline noted in activity critical lab result received, NP aware Report called to (name of hospital) ER. A progress note dated [DATE] at 7:38 p.m., indicated Resident E was admitted to the hospital with [REDACTED]. Resident E expired [DATE]. Review of the laboratory results collected [DATE] at 6:17 a.m., indicated the following: 1. GFR (Glomerular Filtration Rate) (assess kidney filtration) 28 mL/mm (milliliters/minute). The normal range is greater than 60 mL/mm. 2. Creatinine (to assess kidney function) 1.86 mg/dL (milligram per deciliter). The normal range is 0XXX,[DATE].03 mg/dL. 3. BUN (basic urea nitrogen) (to monitor kidney function) 27 mg/dL. The normal range is ,[DATE] mg/dL. 4. WBC (white blood cell) 12.18 K/uL (kilo per microliter). The normal range is between 4XXX,[DATE].00. Review of the laboratory results collected [DATE] at 12:42 p.m., indicated the following: A. [MEDICATION NAME] 2.4 mmol/L (millimole per liter). The normal range is 0XXX,[DATE].20 mmol/L. The range was a toxic level of [MEDICATION NAME]. Resident E received [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]) 450 mg twice daily. Review of the Lab Log, the following labs were scheduled: Labs Ordered: BMP, CBCD, UA. The labs were listed to be drawn on [DATE]. Review of a current, dated [DATE], indicated Resident E had a problem for potential altered cardiac output related to hypertension. Interventions included, but were not limited to, monitor labs per physician and notify physician of results. During an interview on [DATE] at 10:34 a.m., RN #3 indicated the NP did not write stat on the order. She indicated the NP knew the facility lab draws were done on Monday and Thursday of each week. She indicated when the NP wrote today it did not mean stat. She indicated she put the order in [DATE], but the labs were not drawn until [DATE]. During an interview on [DATE] at 10:40 a.m., the Director of Nursing (DON) indicated today and stat meant the same thing. She indicated the NP wanted the labs done today ([DATE]). Review of a current facility policy, dated ,[DATE], titled Physician Medication Orders provided by the DON on [DATE] at 1:30 p.m., indicated the following: Policy Statement Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state. Policy Interpretation and Implementation .3. Verbal orders for drugs and treatments shall be received only by 3XXX,[DATE](a)

Based on observation, interview and record review, the facility failed to prevent the development of a pressure ulcer resulting in a stage 3 wound for 2 of 5 residents reviewed for pressure wounds (Residents B and I). The facility also failed to ensure a resident received continued treatment for [REDACTED]. (Resident H) Findings include: 1. The clinical record of Resident I was reviewed on 7/22/16 at 10:20 a.m. [DIAGNOSES REDACTED]. A review of Resident I's Minimum Data Set (MDS) Quarterly Review dated 5/12/16, indicated the resident was severely cognitively impaired and required extensive assistance and two plus person physical assistance with bed mobility and transfers. Review of a Skin Condition assessment dated [DATE], Resident I was noted to have an abrasion to the right outer gluteal area. The area measured 1.8 cm x 0.5 cm. The area was obtained in the facility. The area was noted as healed on 4/8/16. Review of an Event Report for Resident I dated 6/1/16, an open area to the left gluteal area was noted. The Nurse Practitioner was notified and gave new orders for Santyl (wound ointment) 250 unit/gram nickel sized amount to the wound and then cover with [MEDICATION NAME] (foam dressing), change daily and as needed. On 6/2/16, a Skin Condition Assessment indicated a shearing on the left outer proximal gluteal area. The area measured 2.0 cm x 2.0 cm. Another Skin Condition assessment dated [DATE], indicated a left outer distal gluteal area listed as shearing. The wound measured 1.0 cm x 0.5 cm. The date of origin was 5/31/16. On 6/9/16, a Skin Condition Assessment indicated a shearing on the outer gluteal area. The area measured 1.0 cm x 0.5 cm and was a stage 2 pressure area. A Skin Condition Assessment on 6/16/16, indicated a shearing on the left. No other mention of the area was noted. The area measured 1.5 cm x 1.0 cm. No staging was noted. On 6/22/16, a Skin Condition Assessment indicated a left gluteal fold area. The area measured 2.8 cm x 0.6 cm x 0.2 cm. The area was now listed as a stage 3 pressure ulcer. (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed). On 6/30/16, a Skin Condition Assessment indicated a pressure sore on the left gluteal fold. The area measured 1.9 cm x 0.9 cm x 0.1 cm. The area was listed as a stage 3 pressure area. The Skin Condition assessment dated [DATE], indicated a pressure sore on the left gluteal fold that measured 1.5 cm x 2.2 cm x 0.2 cm. No stage was noted. The Skin Condition assessment dated [DATE], indicated the same area measured 2.7 cm x 1.1 cm x 0.2 cm. The pressure area was a stage 3 wound. The Skin Condition assessment dated [DATE], indicated the same area measured 1.8 cm x 0.5 cm x 0.2 cm. The pressure area was a stage 3 wound. Review of a physician's orders [REDACTED]. .Order Description: Apply border foam dressing to wound of L (left) buttock Frequency: Once A Morning Every 3 Days . Special Instructions: Clean wound with normal saline, apply scant amount of silva kollagen (antimicrobial gel) and apply border foam daily. PRN as needed d/t (due to) soilage. The order was received by LPN #1. During an interview on 7/22/16 at 3:35 p.m., the Director of Nursing (DON) indicated the order for Resident I was not correct. She indicated the order should have been done daily, not every 3 days as listed. Review of the Treatment Administration History from 3/30/16 through 6/20/16, the treatment was done every 3 days. On 6/22/16, an order was received from the Nurse Practitioner to have Resident I evaluated and treated by the wound nurse. The order was received after the wound increased from a stage 2 to a stage 3 wound. Review of a current care plan dated 6/2/16, indicated Resident I had a problem with an open area to the left outer proximal and distal gluteal area. Interventions included, but were not limited to, administer medications as prescribed by MD (medical doctor) and administer treatments as prescribed by MD. The care plan indicated on 6/9/16, the left outer proximal and distal gluteal now formed one area. Wound care and dressing change was observed on 7/25/16 at 11:25 a.m. by LPN #2. During an interview on 7/25/16 at 3:23 p.m. with the DON, LPN #1 and Corporate Nurse, the DON indicated the wound was not initially classified as a pressure area. LPN #1 indicated Resident I had two areas, one on the left gluteal and one on the coccyx that combined into one pressure area. She indicated the nurses do a weekly skin assessment and if there are any skin concerns, she follows up with them weekly as unit manager. 2. The closed clinical record of Resident B was reviewed on 7/21/16 at 11:20 a.m. [DIAGNOSES REDACTED]. Resident B was admitted to the facility on [DATE]. A review of Resident B's MDS 60-day review dated 7/6/16, indicated the resident was severely cognitively impaired and required extensive assistance and two plus person physical assistance with bed mobility and transfers. Review of a Skin Condition assessment dated [DATE], Resident B was noted to have a pressure wound to the coccyx area. The area measured 2.0 cm x 1.0 cm x 0.1 cm. The area was listed as a stage 2 wound. The area was not present on admission. An order was received on 5/17/16 to start DermaSeptine (barrier cream) around the wound area the apply [MEDICATION NAME] (foam dressing) over open area. The dressing was to be changed daily for 7 days then re-evaluated. The treatment was done 5/18/16 through 5/24/16. Review of a Skin Condition assessment dated [DATE], indicated a pressure area to the coccyx that measured 1.0 cm x 1.0 cm. No staging was listed. Review of a Skin Condition assessment dated [DATE], indicated a pressure area to the coccyx that measured 3.5 cm x 3.5 cm x 0.1 cm. The wound was noted as a stage 2 wound. Review of the Treatment Administration History from 5/25/16 through 6/4/16, Resident B did not receive any treatment for [REDACTED]. A physician's orders [REDACTED]. The order was discontinued on 6/7/16. A new order was received on 6/6/16 to place [MEDICATION NAME] ([MEDICATION NAME] dressing gauze) to the right gluteal area and cover with [MEDICATION NAME] daily. The treatment was done 6/6/16 through 6/22/16. Review of a Skin Condition assessment dated [DATE], indicated a pressure area to the coccyx that measured 4.0 cm x 3.0 cm x 0.1. The wound was noted as a stage 2 wound. On 6/15/16, a Skin Condition Assessment indicated the coccyx wound measured 3.75 cm x 2.25 cm x 0.1 cm. The wound was noted as a stage 2 wound. On 6/15/16, physician's orders [REDACTED]. On 6/22/16, a Skin Condition Assessment indicated the coccyx wound measured 4.0 cm x 3.2 cm x 0.1 cm. No wound stage was noted. A Wound Nurse Progress Note dated 6/22/16, indicated a right coccyx, stage 3 pressure wound that measured 3.0 cm x 4.0 cm x 0.1 cm. An order to clean the wound with saline, apply SilvaKollagen to wound bed and cover with border foam dressing daily was received. Resident B was seen on 6/29/16 by the wound nurse. The wound measured 3.0 cm x 2.0 cm x 0.1 cm. No new order was received. A Skin Condition assessment dated [DATE], indicated the pressure area to the coccyx measured 3.0 cm x 2.0 cm x 0.1. The wound was noted as a stage 3 wound. A Skin Condition assessment dated [DATE], indicated the pressure area to the coccyx measured 3.2 cm x 1.4 cm x 0.1. The wound was noted as a stage 3 wound. Resident B was seen on 7/6/16 by the wound nurse. The wound measured 3.2 cm x 1.4 cm x 0.1 cm. No new order was received. Review of a current care plan dated 5/18/16, indicated the following: Resident has a pressure ulcer R/T (related to) res (resident) chooses not to turn and reposition Interventions included, but were not limited to, turn as reposition as resident allows. During an interview on 7/22/16 at 1:56 p.m., the DON indicated she could not find any re-evaluation from the order dated 5/17/16. The DON also indicated she could not find any documentation of a refusal to turn and reposition from 5/1/16 through 5/31/16 for Resident B. During an interview on 7/25/16 at 10:43 a.m., LPN #4 indicated the gluteal wound and the coccyx wound were the same wound. She indicated there was no contact with the physician related to the follow-up care for the wound. She indicated clearly an order to re-eval should not happen again. She indicated staff were still using the DermaSeptine, but were not documenting it. She indicated she was not sure why Resident B had a care plan stating refusal to turn and reposition dated the same day as the wound was noted. 3. The clinical record of Resident H was reviewed on 7/22/16 at 11:03 a.m. [DIAGNOSES REDACTED]. Review of Resident H's Quarterly MDS dated [DATE], indicated the resident was cognitively intact and required extensive assistance and two plus person physical assistance with bed mobility. Review of an Event Report dated 7/1/16, Resident H was noted to have an open area to the right ankle. The area measured 1.0 cm x 1.0 cm. The area was not present on admission. The physician was notified on 7/1/16 and a new order for [MEDICATION NAME] (antibacterial ointment) was received. The medication was to be applied to the right ankle for 10 days. The ointment was applied from 7/1/16 through 7/11/16. A Skin Condition assessment dated [DATE], indicated a right ankle pressure wound that measured 1.0 cm x 1.0 cm. The wound was listed a a stage 2. A Skin Condition assessment dated [DATE], indicated the wound measured 1.0 cm x 0.5 cm. A Skin Condition assessment dated [DATE], indicated the wound measured 0.8 cm x 0.8 cm. On 7/21/16, a Skin Condition Assessment indicated an abrasion that measured 0.5 cm x 0.5 cm x 0.1 cm. The wound was listed as unstageable. Review of Progress Notes from 7/1/16 through 7/25/16, indicated the following: 7/13/16 at 9:44 p.m.- .o/a (open area) to ankle 7/14/16 at 10:00 p.m.- .denies pain to oa to ankle 7/15/16 at 12:40 p.m.-Treatment continues to open area 7/16/16 at 10:43 p.m.-Treatment continues to open area . 7/17/16 at 11:20 a.m.-Treatment continues to open area . 7/17/16 at 10:37 p.m.-No longer receiving treatment to OA A physician's orders [REDACTED]. Cover with [MEDICATION NAME] dressing and change on Monday, Wednesday and Friday. Review of the Treatment Administration History from 7/1/16 through 7/25/16, Resident H received [MEDICATION NAME] from 7/1/16 through 7/11/16 and [MEDICATION NAME] from 7/21/16 through 7/25/16. No treatment was obtained for the documented open area from 7/12/16 through 7/19/16. Review of a current care plan dated 7/1/16, indicated Resident H had pressure area to the right ankle. Interventions included, but were not limited to, conduct a systematic skin inspection every shift and report any signs of further skin breakdown. Wound care and dressing change was observed on 7/25/16 at 11:05 a.m. by LPN #2. Review of a current facility policy dated 1/15/15, titled Skin risk policy, which was provided by the DON on 7/22/16 at 3:54 p.m., indicated the following: Policy Statement Policy: Residents within a CarDon community will have a head-to-toe skin assessment completed by a licensed nurse upon admission and weekly thereafter. The head-to-toe skin assessment will be charted as completed by the licensed nurse. The nurse doing the assessment will document any abnormal findings affecting the skin. .The licensed nurse that discovers a new open area will perform the following actions: 1. Notify the MD and obtain a treatment order 2. Apply the initial treatment 3. Notify the immediate nursing supervisor 4. Notify the family 5. Inform the other caregivers to ensure preventative actions are put into place to promote healing. 6. Document these items in the patient medical record. This Federal tag relates to Complaints IN 669 and IN 639. 3.1-40(a)(1)(2)