Every finding on record at Creekside Health and Rehabilitation Center

Based on interview and record review, the facility failed to correctly document a resident's anti-psychiatric medication use on the annual Minimum Data Set assessment for 1 of 4 residents reviewed for use of accuracy of assessments. (Resident D) Findings include:The clinical record of Resident D was reviewed on 3-26-26 at 12:25 p.m. Her diagnoses included, but were not limited to delusional disorder (serious psychotic disorder characterized by the presence of one or more fixed, false beliefs that persist for at least one month) and anxiety. The annual Minimum Data Set (MDS) assessment (a tool to track, review, and report the high-risk medications a nursing home resident received), dated 2-6-26, indicated under the medication section, the resident had not received any anti-psychotic medications. A review of Resident D's physician orders, revised on 9/5/25, indicated the resident was prescribed, by the physician, risperidone .025 milligrams twice daily (an anti-psychotic medication) for a diagnosis of delusional disorder. The medication administration records (MAR) for January and February 2026, indicated Resident D had routinely received risperidone, twice daily, during the seven (7) day look back period prior to the MDS assessment period. During an interview with the MDS Coordinator on 3-26-26 at 2:19 p.m., she indicated she had worked at the facility for over 1 year and had worked in the area of MDS assessments for over 5 years. The resident's MDS assessment under the medication sections had an error It was nothing but human error, and she had corrected the error involving the medication section on 3/26/26. Resident D's was prescribed an anti-psychotic medication on a routine basis during the seven (7) day look-back period for the annual MDS assessment. In review of the Centers for Medicare and Medicaid Services Long Term Care Facilities Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, October 2025, section N, Medications, instructions, it indicated the MDS assessment should identify, by pharmacological category, any medication received in that category in the last seven (7) days. This citation relates to Intake 2807309. 410 IAC (Indiana Administrative Code) 16.2- 3.1-31(c)(1)410 IAC 16.2- 3.1-31(c)(6)

Based on observation, interview and record review, the facility failed to ensure the residents' dignity was maintained and respected by not using cell phones while assisting with eating (Resident ZZ), and staff turning off the call lights and not returning to the residents' room to provide the services that had been requested (Residents' C, D, E, F, G, H, J, K, L, M, N, P, Q, R, S, T, and V) for 18 of 109 residents reviewed for dignity. Findings include: 1.The Resident Council Minutes binder was provided by the Activities Director on 2/5/26 at 11:00 a.m. The council minutes, dated November 20, 2025, indicated staff were turning off the call lights and not providing the service requested. A resident council meeting was conducted on 2/5/26 at 1:36 p.m. The resident attendees were Residents' C, D, E, F, G, H, J, K, L, M, N, P, Q, R, S and T. During the meeting, they indicated call light response was a problem. It had been brought up in previous resident council meetings and had not been addressed. The staff would come into the room, turn the call light off and indicate they would let the Certified Nursing Assistant (CNA) that was assigned to them know. The staff notified would leave the room, and no one would return to the room often. An interview was conducted with Resident V on 2/5/26 at 3:44 a.m. He indicated the staff would turn the call light off, and the staff would say they would be back. The staff would not return or come back. 2. The clinical record for Resident ZZ was reviewed on 2/9/24 at 2:46 p.m. The resident's diagnosis included, but was not limited to, stroke (blood stopped flowing to a part of the brain). The resident required staff assistance with personal care. A Comprehensive Minimum Data Set (MDS) Assessment, dated 1/28/26, indicated Resident ZZ was cognitively impaired. Resident ZZ had an impairment on both upper extremities. She was dependent on the staff for assistance with eating. An Activities of Daily Living (ADL) care plan, revision date 10/28/25, indicated Resident ZZ required staff assistance with ADLs due to hemiplegia (one side paralysis or weakness) on the left side. An observation was made of Resident ZZ in the dining room with CNA 1 on 2/10/26 at 12:50 p.m. The resident was sitting in her wheelchair at a table with her lunch meal. CNA 1 was sitting in a chair next to Resident ZZ assisting her with eating. When CNA 1 was assisting the resident, she was observed holding her personal cell phone reading content from it at the same time. An interview was conducted with the Director of Nursing, Executive Director and the Nurse Consultant on 2/10/26 at 4:24 p.m. They indicated cell phones should not be used while assisting a resident with her meal. The staff should not be turning off the call lights without providing care and not return to the residents' rooms to provide care after knowledge of care needed. A resident's dignity policy was provided by the Director of Nursing on 2/11/26 at 9:49 a.m. It indicated, .Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.5. When interacting with a resident, pay attention to the resident as an individual. 6. Respond to requests for assistance in a timely manner. The citations are relates to Intakes 2727293, 2723240 and 2731292.

Based on observation, interview, and record review, the facility failed to timely address a resident's skin condition; to ensure a resident's fall interventions were implemented; to obtain a resident's heart rate and medication hold perimeters were followed; address a resident's ear wax buildup; to ensure weights were obtained and the provider was notified of out of parameter weights for 5 of 10 residents reviewed for Quality of Care. (Residents BB, 86, 3, E, and V) Findings include: 1 The clinical record for Resident BB was reviewed on 2/5/26 at 2:52 p.m. The resident's diagnosis included, but was not limited to, quadriplegia (loss of sensation and function of all four limbs and torso). A Quarterly Minimum Data Set (MDS) Assessment, completed 11/10/25, indicated he was cognitively intact, frequently incontinent of urine, and dependent for toilet hygiene. He had no moisture associated skin damage (MASD). A shower sheet, dated 12/2/25, indicated Resident BB had a bed bath. There were no skin areas of concern marked on the shower sheet. A shower sheet, dated 12/9/25, indicated Resident BB had a bed bath. There were no skin areas of concern marked on the shower sheet. A Skin Sweep and Risk Assessment Tool, dated 12/11/25, indicated Resident BB had an open area on the left gluteal (buttock) that was moisture associated skin damage. There were no measurements or descriptions of the open area on the left gluteal. The clinical record did not indicate the physician had been notified and that a new treatment order had been obtained on 12/11/25. A physician's order, dated 12/15/25, indicated to cleanse left and right gluteus with normal saline, pat dry. Mix triad (cream for wound treatment) and collagen powder together and apply to wound bed and cover with a foam dressing. Change the dressing daily and as needed if soiled or dislodged. A Moisture Associated Skin Damage (MASD) evaluation, dated 12/16/25, indicated the open area on the left gluteus was a new wound, IAD Incontinence Associated Dermatitis acquired in-house (at facility). The measurements of the open area were 2.35 centimeters (cm) in length, 5.9 cm in width, and 0.1 cm in depth. During an interview on 2/5/26 at 2:52 p.m., Resident BB indicated he had an open area on his buttocks. The staff were caring for his wound. He took Lasix (diuretic) twice a day and urinated a lot. He did not feel he was getting changes as often as he needed to be. A care plan, last revised on 2/7/26, indicated Resident BB was at risk for developing pressure ulcers related to change in mobility. He had decreased sensory perception, incontinence, and one or more diagnosis that put him at higher risk. The goal was to be minimized to no open areas through care plan interventions. The interventions included, but were not limited to, staff to provide incontinent care and apply barrier cream as needed, observe for redness, tenderness, or changes in his skin, observe skin weekly and as needed. During an interview on 2/10/26 at 2:11 p.m., the Director of Nursing (DON) indicated the area on Resident BB's buttocks had been noted on 12/11/25. The nurse who identified the area was not sure if the area was open or scar tissue. The staff were using barrier cream as a protectant. The wound nurse assessed the wound on 12/15/25 and a new treatment was started. During an interview on 2/11/26 at 9:49 a.m., the DON indicated there was no care plan about Resident BB's buttock wound. 2.a. The clinical record for Resident 86 was reviewed on 2/5/26 at 3:27 p.m. The resident's diagnosis included, but was not limited to, hypotension (low blood pressure). A physician's order, dated 11/13/25, indicated the resident was to receive droxidopa (medication to treat orthostatic hypotension) 500 milligrams (mg) three times a day. The staff were to hold the resident's droxidopa for a systolic blood pressure (top number of blood pressure) greater than 140. A physician's order, dated 12/4/25, indicated the resident was to receive midodrine (medication to treat orthostatic hypotension) 10 mg three times a day. The staff were to hold the resident's midodrine for a systolic blood pressure greater than 140. The January and February 2025 Medication Administration Records (MAR) indicated Resident 86 had received droxidopa and/or midodrine when his systolic blood pressure was greater than 140 on the following days: 1/ 4, 1/10, 1/12, 1/15, 1/23, 1/24, 1/31, 2/1, 2/5, and 2/7/26. During an interview on 2/10/26 at 3:06 p.m., the DON indicated Resident 86's droxidopa and midodrine medications should have been held if his systolic blood pressure was greater than 140. 2.b. A care plan, last reviewed on 11/25/25, indicated Resident 86 was at risk for falls related to a history of falls, ataxia (lack of voluntary muscle coordination resulting in unsteady, clumsy, or awkward movements), and orthostatic hypotension (a sudden drop in blood pressure upon standing from a sitting or lying position). The goal was that his care plan interventions would minimize the risk for falls with serious injury. The interventions included, but were not limited to, medication review, remove pedals off resident wheelchair, and a soft touch call light in place. On 2/9/26 at 10:50 a.m., Resident 86 was observed in his room sitting in his wheelchair by his bed. His feet were on his wheelchair pedals. A push-button call light was present on his bed. On 2/9/26 at 3:16 p.m., Resident 86 was observed in his room sitting in his wheelchair. His feet were positioned on his foot pedals, and a push button call light was present on his bed. On 2/10/26 at 12:06 p.m., Resident 86 was observed sitting in his wheelchair in the dinning room with his foot pedals on and his feet resting on the foot pedals. During an interview on 2/10/26 at 12:21 p.m., Licensed Practical Nurse (LPN) 8 indicated the resident had a push-button call light in his room, which he was able to use. LPN 8 would check to see if he was supposed to have a soft touch call light. Resident 86 was using foot pedals on his wheelchair. During an interview on 2/10/26 at 3:06 p.m., the DON indicated Resident 86 had been moved closer to the nurses' station and his soft touch call light had not been moved with him. Resident 86 had started using foot pedals on his wheelchair after he had a fractured ankle in late January 2026. 3. The clinical record for Resident 3 was reviewed on 2/11/26 at 10:53 a.m. The resident's diagnosis included, but was not limited to, hypertension (high blood pressure). The hypertension care plan, revised on 10/31/25, indicated the resident's interventions, initiated on 1/12/26, was for staff to hold the resident's antihypertensive medication for a systolic blood pressure (SBP) below 110, a diastolic blood pressure (DBP) below 60, or a heart rate (HR) below 60. The physician's orders indicated staff were to administer one 25 mg tablet of Metoprolol Tartrate two times a day. The staff were to hold the resident's Metoprolol for SBP below 110, a DBP below 60, or HR below 60, starting 1/21/26. The February 2026 medication administration record (MAR) included documented blood pressures, but no documented heart rates for the resident's medication administration. The MAR indicated the resident's medication was administered twice daily from 2/1/26 through 2/10/26, except the a.m. administrations on 2/4/26 (refused) and 2/6/26 (blood pressure out of parameters.) Eight of the dates the resident received his Metoprolol administrations from 2/1/26 through 2/10/26, the resident's DBP's was under 60. The pulse rates in the vitals section of the resident's electronic health record lacked pulse rates documented on the following days: 2/2/26, 2/3/26, 2/4/26, 2/6/26, 2/7/26, and 2/8/26. An interview was conducted with the Director of Nursing (DON) on 2/11/26 at 12:25 p.m. She indicated she found verification of a pulse rate obtained on 2/2/26, but had no verification of any pulse rates for the administrations of Metoprolol on 2/3/26, 2/4/26, 2/6/26, 2/7/26, and 2/8/26. When the order was entered into the electronic health record, they set it up to include the blood pressures, but not the resident's heart rates. 4. The clinical record for Resident V was reviewed on 2/6/26 at 12:00 p.m. The resident's diagnosis included, but was not limited to, cerebral palsy (permanent, non-progressive neurological disorder). The ADL care plan, revised 8/26/25, indicated the resident required total staff assistance with his activities of daily living. The physician's orders indicated to provide a complete bed bath every shift, starting 2/11/20. An observation of Resident V was made with the Housekeeping Supervisor/Certified Nursing Assistant (HS/CNA) on 2/10/26 at 11:00 a.m. Resident V was lying in bed, the resident's right ear had shimmery wax easily observed inside of his ear. There was a thick amount of darker colored wax at the start of his ear canal. There was a ball of dry wax hanging, easily observed in the left ear. During the observation on 2/10/26 at 11:00 a.m., Licensed Practical Nurse (LPN) 3 entered the resident's room. The LPN indicated the CNAs should have informed the nurse when a resident had a large amount of ear wax so the nurse could inform the physician or audiology provider. She would have thought the CNAs would have notified the nurse if they recognized it. The LPN indicated she would reach out to the physician. The February, 2025 TAR (treatment administration record) indicated Resident V was provided a complete bed bath every shift from 2/1/26 through 2/10/26. 5.The clinical record for Resident E was reviewed on 2/6/25 at 2:46 p.m. The resident's diagnosis included, but was not limited to, acute kidney disease. A care plan, dated 11/4/25, indicated Resident E received furosemide medication for weight gain. The intervention indicated the staff were to administer the resident's medication as ordered. A physician's order, dated 11/5/25, indicated the staff were to provide 20 milligrams of furosemide as needed (PRN) if the resident's weight gain was over 2 pounds in 24 hours or 5 pounds in 1 week. A physician's order, dated 1/7/26, indicated Resident E was to receive 20 milligrams of furosemide daily for edema and weight gain. A physician's order, dated 12/2/25, indicated the staff was to obtain Resident E's weight in the morning for congested heart failure. The order was discontinued on 1/27/28. A physician's order, dated 1/28/26, indicated Resident E was to be weighed before breakfast. The staff were to notify the physician if the resident had a weight gain of 2 pounds over 24 hours or 5 pound weight gain in 1 week. If the resident refused, the staff were to provide education and document in the medical chart. The January 2026 and February 2026 Medication/Treatment (MAR/TAR) Records indicated the following days Resident E's weight was not obtained, the physician was not notified, or the PRN 20 milligrams of furosemide was administered as ordered: -On 1/4/26, the resident's weight recorded was 203.6 and on 1/5/26, the resident's weight recorded was 209 (5.4 pounds weight gain in 1 day); the physician was not notified and 20 milligrams of furosemide PRN was not administered. -On 1/18/26, the resident's weight was not obtained. -On 1/27/26, the resident's weight was not obtained. -On 2/5/26, the resident's weight recorded was 205.6 and on 2/6/26, the resident's weight recorded was 209 (3.4 pounds weight gain in 1 day); the physician was not notified and 20 milligrams of furosemide PRN was not administered. -On 2/8/26, the resident's weight was not obtained. An interview was conducted with the Director of Nursing on 2/10/26 at 2:27 p.m. She indicated she was unable to provide weights that had been obtained on 1/18/26, 1/27/26, and 2/8/26. She could not find any documentation the medical provider was notified when Resident E's weights were within the parameters of notifying the medical provider as ordered. A weight policy was provided by the Director of Nursing on 2/10/26 at 2:27 p.m. It indicated, Purpose.2. To provide an ongoing record of the resident's body weight as an indicator of the nutritional status and medial condition of the resident.Procedure: .5. The physician will be notified of significant weight changes by nursing. On 2/9/26 at 2:41 p.m., the Nurse Consultant provided the Accidents and Supervision Policy, last revised 10/8/24, that read .The resident environment will remain as free of accidents hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.3. Implementation of Interventions.e. Ensuring that the interventions are put into action.4. Monitoring and Modifications.Monitoring and modification process included: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new interventions. The Medication Administration policy was provided by the DON on 2/10/26 at 11:12 a.m. It indicated, Ensure blood pressure, pulse or other vital sign parameters are completed prior to administering medication(s) that require parameters. On 2/11/26 at 9:49 a.m., the DON provided the Skin Integrity and Pressure Injury Policy, last revised 2/2025, that read .After a wound or skin condition is identified: 1. Complete an assessment of the area. 2. Notify the physician and resident representative. 3. Recommend a treatment to the physician that is considered appropriate and n compliance with the current standards of practice for wound healing .4. Complete the treatment as ordered . 6. Document in the medical record . The Bed Baths policy was provided by the DON (Director of Nursing) on 2/11/26 at 11:15 a.m. It indicated, Wash the resident's ears (behind the ears and gently inside the ears) and neck, rinsing and drying the areas.Inspect the skin along the way noting any open areas, bruising, or other signs of skin breakdown and notify the nurse if noted. The citations relates to Intakes 2727293, 2723240 and 2731292. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure staff donned Personal Protective Equipment(PPE) prior to entering a room of a resident in contact isolation precautions and prior to performing tracheostomy care for a resident in enhanced barrier precautions, to ensure hand hygiene was performed after doffing (removing) gloves, and to ensure a resident's catheter bag was correctly positioned for 1 resident randomly observed for contact isolation, 1 of 1 resident reviewed for tracheostomy and 2 of 2 residents reviewed for urinary catheter care (Resident 22, Resident 1,and Resident 80).Findings include:1 The clinical record for Resident 22 was reviewed on 2/9/26 at 3:21 p.m. The resident's diagnosis included, but was not limited to, hypertension (high blood pressure). On 2/9/26 at 3:21 p.m., Resident 22's room was observed to have a sign posted on the door frame that indicated she was in Contact Isolation Precautions. An isolation cart was located outside of her door and contained disposable gowns and gloves. Registered Dietician (RD) 4 did not have an isolation gown or gloves on and was standing at Resident 22's bedside, assisting her to drink from a straw. During an interview on 2/9/26 at 3:25 p.m., RD 4 indicated she had not seen the contact isolation precaution sign prior to entering the room. She should have donned PPE prior to going into Resident 22's room to assist the resident. 2. The clinical record for Resident 1 was reviewed on 2/6/26 at 2:53 p.m. The resident's diagnosis included, but was not limited to, tracheotomy status (artificial airway to enable breathing). A care plan, last revised on 1/28/26, indicated Resident 1 required enhanced barrier precautions related to having a supra pubic catheter, tracheostomy, and wounds. An intervention was for staff to follow enhanced barrier precautions. On 2/11/26 at 9:50 a.m., the Respiratory Therapist (RT) was observed performing tracheostomy care for Resident 1. The RT prepared the supplies, performed hand hygiene (HH), and donned sterile gloves. The RT did not don an isolation gown when performing tracheostomy care for Resident 1. During an interview on 2/11/26 at 10:11 a.m., the RT indicated she should have donned a gown prior to providing tracheostomy care since Resident 1 was in enhanced barrier precautions. On 2/11/26 at 10:00 a.m., Licensed Practical Nurse (LPN) 5 was observed performing catheter care for Resident 1. LPN 5 gathered the supplies, performed HH, and donned an isolation gown and gloves. She removed the soiled dressing from Resident 1's urinary catheter site. LPN 5 doffed her gloves and donned a new pair of gloves without performing HH. She cleansed Resident 1's urinary catheter site and doffed her gloves. She did not perform HH and donned a new pair of gloves. LPN 5 rinsed the catheter site and doffed her gloves. LPN 5 did not perform HH and donned a new pair of gloves. LPN 5 then applied a new dressing to Resident 1's urinary catheter site. During an interview on 2/11/26 at 10:08 a.m., LPN 5 indicated she normally performed HH when changing her gloves. 3. The clinical record for Resident 80 was reviewed on 2/5/26 at 2:30 p.m. Her diagnoses included, but were not limited to, failure to thrive. She had been receiving hospice services in the facility since 3/1/25. The indwelling catheter care plan, revised 11/21/25, indicated an intervention was that she would receive teaching on proper positioning of the drainage bag. An observation of Resident 80, lying in bed in her room, was made on 2/5/26 at 2:39 p.m. Her bed was in a low position, and her catheter bag was hanging from the right side of her bed, resting on the floor. An observation of Resident 80, lying in bed in her room, was made on 2/9/26 at 11:37 a.m. Her bed was in a low position, and her catheter bag was hanging from the right side of her bed, resting on the fall mat on the floor. An interview was conducted with Family Member 7, who was visiting with Resident 80, on 2/9/26 at 11:37 a.m. He indicated Resident 80 had a couple of urinary tract infections recently. The last one was at Christmas time in 2025. Resident 80's catheter bag was always resting on the floor or on the fall mat when he visited. An observation of Resident 80, lying in bed in her room, was made with LPN (Licensed Practical Nurse) 3 on 2/9/26 at 11:49 a.m. An interview was conducted with LPN 3 at this time. Resident 80's catheter bag remained resting on the fall mat on the floor. LPN 3 indicated they kept the bag positioned on the floor or fall mat, because if they had her bed higher, she may fall out of bed, and she was a fall risk, so they had to have the bed in a low position with the catheter bag resting on the floor or fall mat. LPN 3 did not adjust the position of the catheter bag to not touch the fall mat. An observation of Resident 80, lying in bed in her room, was made on 2/10/26 at 10:43 a.m. Her bed was in a low position, and her catheter bag was hanging from the left side of her bed, resting on the fall mat on the floor. An interview was conducted with Resident 80's Hospice RN (Registered Nurse) on 2/10/26 at 3:34 p.m. He indicated he'd been Resident 80's hospice nurse since March of 2025. Resident 80's catheter bag should not be touching the floor. When he visited, he lowered her bed as low as it could go without her catheter bag touching the floor. If it touched the floor, her bed needed to be raised. Falling was a concern, but her catheter bag still should not touch the floor. He noticed it on the floor when he arrived, so he would reposition the bed and catheter bag, so that it would not be resting on the floor. Most times he arrived to visit, her catheter bag was resting on the floor. He ensured it was not on the floor every time he left. The Catheter Care policy was provided by the ED (Executive Director) on 2/10/16 at 4:00 p.m. It indicated, Ensure tubing and catheter bag does not touch the floor. Residents with low beds may require a different intervention/alternative to keep catheter bags and tubing from touching the floor such as: Put the [name brand of catheter] bag and any extra tubing into a new or clean wash basin and sit the basin on the floor next to the bed. Some residents move a lot at night, and the basin may slide, depending on your floors. The [name brand of catheter] bag could slip out. Use some no-slip or [name brand of no-slip material] on the floor under the basin to keep it from sliding around. There are also [name brand of catheter] bag floor stands to keep the bag from touching the floor. However, if the resident moves a lot, these can tip over easily. They also might require [name brand of no-slip material] to prevent sliding. This same product can mount to wheelchairs in several places. Some facilities also use a 'low profile' [brand name of catheter] bag. It's about half the size of the regular bag, about 1000 cc or less, so it may need to be emptied more often than a regular size bag, which can hold 2000 to 4000 cc, depending on the brand your facility uses. On 2/9/26 at 4:03 p.m., the ED provided the Transmission-Based (Isolation) Precautions Policy, last revised 6/11/25, that read .It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Contact Precautions.c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. On 2/11/26 at 11:30 a.m., the Director of Nursing (DON) provided the Enhanced Barrier Precautions Policy, last revised 2/5/25, that read . Definitions: 'Enhanced barrier precautions' [EBP] refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. 3.1-18(a)

Based on observation, interview, and record review, the facility failed to ensure a resident was provided with heel protective boots, as ordered, and ensure timely follow-up with podiatry services for 1 of 3 residents reviewed for foot care. (Resident V) Findings include: The clinical record for Resident V was reviewed on 2/6/26 at 12:00 p.m. The resident's diagnoses included, but were not limited to, cerebral palsy (neurological disorder that permanently affects body movement), seizure disorder (recurrent, unprovoked seizures), and aphasia (impaired ability to speak, write, and understand language). An interview was conducted with Family Member 4 on 2/6/26 at 12:01 p.m. The family member indicated there was an ongoing issue at the facility with them not trimming Resident V's toenails.The ADL care plan, with a revision date of 8/26/25, indicated Resident V required total staff assistance with his activities of daily living. The current physician's order, dated 3/24/20, indicated the resident was to always have Prevalon boots (a heel protection boot for pressure relief) on every shift for preventive measures. The February 2025 treatment administration record (TAR) indicated Resident V had his Prevalon boots on every day, every shift, including first shift on 2/10/26. An interview and observation of Resident V was made with the Housekeeping Supervisor/CNA (HS/CNA) on 2/10/26 at 11:00 a.m. Resident V was lying in bed with a blanket over him. The HS/CNA lifted the resident's blanket to reveal the resident's feet. The resident's feet were bare, and he was not wearing any Prevalon boots. His left big toenail was long and jagged. The first three toenails on his right foot were very long. The HS/CNA indicated his toenails needed filed or trimmed. During the observation on 2/10/26 at 11:00 a.m., LPN (Licensed Practical Nurse) 3 entered the resident's room. The LPN looked at Resident V's toenails and indicated, They need clipped. At that time, LPN 3 looked around Resident V's room, including in his drawers and closet and was unable to locate any Prevalon boots. The LPN indicated Resident V didn't have any boots and the resident would need to be referred to podiatry for his toenails. LPN 3 reviewed the resident's February 2026 TAR and indicated she had already signed off the resident's TAR to indicate Resident V had his Prevalon boots in place today. An interview was conducted with the Social Services Director (SSD) and LPN 3 on 2/10/26 at 11:21 a.m. LPN 3 informed the SSD that Resident V needed to see podiatry (foot specialist). The SSD indicated they needed to be notified by staff that a resident needed to be seen by podiatry for them to be placed onto the podiatry list. No one said anything prior about Resident V needing to be seen by podiatry services. The last time podiatry was in the facility was 1/7/26. During an interview, on 2/10/26 at 11:21 a.m., the SSD provided Resident V's last podiatry consultation note. The resident's podiatry note, dated 10/6/25, indicated Resident V met the qualifications for routine or at-risk footcare. The Assessment/Plan section indicated, Stressed importance of regular podiatry care and pedal hygiene. The Follow Up section indicated, At Risk Footcare established patient exam in 2 to 3 months. The SSD was unable to provide any follow up podiatry consultation notes after the 10/6/25 note for Resident V. Resident V had not received a 2-to-3-month follow-up as indicated in his assessment plan. The Podiatry Services policy was provided by the ED (Executive Director) on 2/10/26 at 4:00 p.m. It indicated, It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health.4. Employees should refer any identified need for foot care to the social worker or designee. 5. The social worker or designee will assist residents in making appointments and arranging transportation to obtain needed services. 3.1-47(a)(7)

Based on observation, interview, and record review, the facility failed to provide a resident's palm protector, per his functional maintenance program, for 1 of 1 resident reviewed for limited range of motion. (Resident V) Findings include: The clinical record for Resident V was reviewed on 2/6/26 at 12:00 p.m. The resident's diagnosis included, but was not limited to: contractures (a permanent or long-term tightening, shortening, and hardening of muscles, tendons, ligaments, or skin, causing joint deformity and reduced, painful range of motion). An observation of Resident V was made in his room on 2/5/26 at 3:00 p.m. He was sitting in his wheelchair in his room and his left hand was contracted. The resident had no splint, carrot, or pal protector in place. There were no physician's orders for a splint, carrot, or palm protector for the resident's left hand. The ADL care plan, revised 8/26/25, indicated the resident needed total assistance with his activities of daily living. The interventions were for staff to encourage him to wear his left-hand palm protector for up to 4 to 8 hours a day, wash his hands, dry his hands, and stretch his hands before applying hand splints. An observation of Resident V was made with the Housekeeping Supervisor/Certified Nursing Assistant (HS/CNA) on 2/10/26 at 11:00 a.m. During an interview the HS/CNA indicated in the past, at one time, she had seen a palm protector for Resident V. The resident was observed lying in bed and no left-handed palm protector was in place. On 2/10/26 at 11:00 a.m., Licensed Practical Nurse (LPN) 3 entered the resident's room. During an interview, at that time, the LPN indicated she had worked the hall full time since November, 2025 and she did not know anything about the resident using a palm protector or having an order for it. She had never seen him with a left-hand palm protector. LPN 3 looked in Resident V's drawers and closets and was unable to locate a palm protector. An interview was conducted with the Therapy Manger (TM) on 2/11/26 at 10:35 a.m. She indicated Resident V had a functional maintenance plan (FMP) created when he was discharged from therapy in February of 2024. On 2/11/26 at 11:10 a.m., the TM provided the 2/23/24 FMP for Resident V. The FMP indicated the problem/needs were contractures to both hands. His current functional status was that he tolerated a left-hand palm protector for up to 4 to 8 hours. The goal was to maintain tolerance of splint, wear to maintain skin hygiene and integrity, and prevent further contractures. The recommendations/approaches were to encourage wear of bilateral hand splints for up to 4 to 8 hours. The Use of Assistive Devices policy was provided by the ED (Executive Director) on 2/10/26 at 4:04 p.m. It indicated, The facility will provide assistive devices for residents who need them.Direct care staff will be trained on the use of the devices as needed to carry out their roles and responsibilities regarding the devices.A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. 3.1-42(a)(2)

Based on interview and record review, the facility failed to timely implement provision of a resident's nutritional supplements for 1 of 1 resident reviewed for nutrition. (Resident 25) Findings include:The clinical record for Resident 25 was reviewed on 2/6/26 at 12:30 p.m. Her diagnosis included, but was not limited to, dementia (mental decline). An interview was conducted with Family Member 2 on 2/6/26 at 12:38 p.m. The family member indicated Resident 25 hadn't been eating very well lately and had lost weight. The weights in the vitals section of the electronic health record indicated the resident had the following weights on the following dates: -On 1/12/26, the resident weighed 145.8 pounds-On 1/22/26, the resident weighed 149.8 pounds-On 1/26/26, the resident weighed 150 pounds-On 2/01/26, the resident weighed 142.8 pounds-On 2/02/26, the resident weighed 142.4 pounds The nutrition care plan, revised on 1/13/26, indicated the resident's intervention was for her to receive her diet, as ordered. The hospital discharge instructions, dated [DATE], indicated the resident's discharge diet was regular with ensure supplements. The facility physician's orders and medication administration records (MAR) indicated the resident's ensure supplement did not begin until 2/05/26. The 1/13/26 nutrition assessment indicated Resident 25 was malnourished due to decreased appetite/intakes, recent weight loss, reduced mobility, recent acute illness, and dementia. The recommendations were for her to have a magic cup with lunch and dinner. The facility physician's orders and MAR indicated the magic cup supplements did not begin until 2/05/26. An interview was conducted with the Assistant Director of Nursing (ADON) on 2/11/26 at 11:00 a.m. The ADON indicated the resident's ensure and magic cup supplements were not starting until 2/5/26, and it was an oversight. The Nutritional and Dietary Supplements policy was provided by the ED (Executive Director) on 2/10/26 at 4:00 p.m. It indicated, The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs. 3.1-46(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity and respect for 1 of 4 residents reviewed for dignity. (Resident B)Findings include: The clinical record for Resident B was reviewed on 8/21/25 at 12:10 p.m. The diagnoses included, but were not limited to, depression and pain in the right knee. A Quarterly Minimum Data Set assessment, completed 8/5/25, indicated he was moderately cognitively impaired and had severe signs and symptoms of depression.A Psychological Progress Note, dated 8/12/25, indicated he was oriented to person, place, and had mild impairment in thought process. On 8/21/25 at 12:40 p.m., Resident B was observed in his room. He was sitting in his wheelchair by his bed, and the room door was closed. Certified Nurse Aide (CNA) 2 opened the door without knocking. CNA 2 asked Resident B if he was okay and if he had his call light. Resident B responded that he was fine. CNA 2 exited the room, closing the door behind her. Resident B indicated the staff come into his room often without knocking and it bothered him. He wished they would knock before coming in. Resident B then began speaking about his pain medications and indicated the staff did not administer his pain medication correctly. Qualified Medication Aide (QMA) 3 knocked and entered the room as Resident B was discussing his pain medication and sternly told Resident B No we don't. QMA 3 indicated she had Resident B's methadone (routine pain medication). Resident B asked about having his oxycodone (narcotic pain medication). QMA 3, in a sharp tone, informed him that he had his oxycodone earlier in the day and did Resident B want his methadone, if not she would put refused and throw it away. Resident B indicated he would take his methadone and QMA 3 administered the medication to him. QMA 3 then left the room. Resident B became tearful and indicated the staff spoke to him that way all the time. He felt that it was disrespectful. The staff would talk to him like there was something wrong with him and respond like he (the resident) did not know what he was talking about. During an interview on 8/21/25 at 1:00 p.m., CNA 2 indicated she was sorry for busting in the door without knocking. CNA 2 had been worried Resident B did not have his call light and should have knocked before entering. During an interview on 8/21/25 at 1:06 p.m., QMA 3 indicated Resident B asked every day about the pain medications and thought he was getting the wrong medications. She educated him on his medications before giving them.During an interview on 8/22/25 at 12:39 p.m., the Director of Nursing and the Executive Director indicated they expected staff to knock before entering a room and staff should speak to and treat residents with dignity and respect. On 8/21/25 at 11:04 a.m., the Director of Nursing provided the Resident Rights Policy, implemented 3/5/24, which indicated . The resident has a right to be treated with respect and dignity .This citation relates to Complaint 2580039. 3.1-3(a)3.1-3(t)

Based on interview and record review, the facility failed to timely notify a resident's representative of a medication change for 1 of 3 residents reviewed for changes of condition. (Resident C) Findings include: The clinical record for Resident C was reviewed on 5/27/25 at 10:55 a.m. The diagnoses included, but were not limited to, dementia and rheumatoid arthritis. A Quarterly Minimum Data Set (MDS) assessment, completed 4/9/25, indicated Resident C was cognitively intact. A progress note, dated 1/15/25, indicated nursing staff had reported increased confusion and lethargy since taking Baclofen (a muscle relaxant) 10 milligrams (mg). Due to the resident's fatigue, there was a concern for the use of multiple medications at the same time, and several medications were discontinued, including Baclofen. A progress note, dated 5/6/25, indicated Resident C was experiencing chronic muscle spasms and was taking Tizanidine (medication used to treat muscle spasms) to manage her pain. The resident continued to experience muscle spasms and pain despite the use of the medication. Due to the ineffectiveness of the Tizanidine, Baclofen was to be restarted. A physician's order, dated 5/5/25, indicated to give Baclofen 5 mg, three times a day for muscle spasms. The clinical record for Resident C did not contain documentation of notification to the resident's representative of the new order for Baclofen 5 mg. A physician's order, dated 5/7/25, indicated to increase the dosage of Baclofen to 10 mg, three times a day for spasms. The clinical record for Resident C did not contain documentation of notification to the resident's representative of the new order for Baclofen 10 mg. The clinical record included special instructions on the resident profile that indicated to notify the family of any medication changes for Resident C. A nursing note, dated 5/9/25 at 3:30 p.m., indicated Resident C appeared confused and semi-conscious throughout the shift. The on-call physician, Director of Nursing (DON), and family were notified, and orders were received to decrease the resident's Baclofen to 5 mg, three times a day. A nursing note, dated 5/10/25 at 7:50 a.m., indicated Resident C's daughter wanted the resident sent to the emergency room (ER) due to slurred speech she had witnessed via phone call. Licensed Practical Nurse (LPN) 4 went to the resident's room and found the resident in bed making clear, but repetitive statements, and seemed confused. The resident's vital signs were taken, and she was transferred to the ER at a local hospital. The physician, DON, and family were notified. A nursing note, dated 5/10/25 at 3:00 p.m., indicated Resident C was being admitted to the local hospital for poly pharmaceuticals (the concurrent use of multiple medications), acute encephalopathy (altered mental status), and hypertensive urgency (severely elevated blood pressure). Hospital records, dated 5/10/25, indicated Resident C was admitted to the ER for acute metabolic encephalopathy (altered mental status) in relation to increased Baclofen dosing. During a confidential interview on 5/27/25 at 1:46 p.m., an anonymous source indicated Resident C's family had not been notified of the resident being restarted on Baclofen on 5/6/25 or of the dosage increase on 5/7/25. During an interview conducted on 5/27/25 at 2:55 p.m. with LPN 4, she indicated Resident C's representative was not notified of the medication (Baclofen) being started on 5/6/25. The resident continued to have pain after starting Baclofen, on 5/6/25, so the dosage was increased. It was LPN 4's understanding that the Nurse Practitioner was to notify the family of medication changes. During an interview on 5/27/25 at 3:15 p.m., the DON indicated nursing staff was to notify resident's family of medication changes when the resident was not their own person. A Notification Changes Policy, last revised 10/21/24, was provided by the DON on 5/27/25 at 3:44 p.m. It indicated .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include: .3. Circumstances that require a need to alter treatment. This may include: a. New treatment b. Discontinuation of current treatment due to: i. Adverse consequences ii. Acute condition. iii. Exacerbation of a chronic condition . This citation relates to Complaint IN00459359. 3.1-5(a)(3)

Based on interview and record review, the facility failed to document the reason for transferring a resident to a local hospital and ensured communication to the receiving health facility for 1 of 3 residents reviewed for discharge rights. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/27/25 at 10:30 a.m. The diagnoses included, but were not limited to, multiple sclerosis and hypertension. A care plan, last revised on 4/15/25, indicated Resident B's plan was to discharge home with her spouse. The goal was for her to be discharged home. The interventions included, but were not limited to, arrange for and set up community resources and to educate her on her clinical condition and medications as needed. A Medicare Part A Discharge Minimum Data Set (MDS) assessment, completed 5/5/25, indicated Resident B's Medicare Part A payment coverage ended on 5/5/25. A physician's order, dated 5/5/25, indicated Resident B was to be evaluated and treated by hospice services. A physician's order, dated 5/5/25, indicated she was not to be resuscitated (DNR). A Physician's Narrative Progress Note, effective 5/5/25 at 9:18 a.m., indicated Resident B had been seen for lethargy, difficulty swallowing medications, and having hallucinations. Resident B was no longer able to participate in therapy. A discussion was held with Resident B's family member and an acute work up in the facility was offered verses a palliative (end of life) care and hospice option were offered. Resident B's family member would like to make her mother comfortable. New orders were discussed with nursing staff and a plan for hospice care was discussed with social services. A physician's order, dated 5/6/25, indicated to admit Resident B to a local hospice service. A Nursing Progress Note, dated 5/6/25, indicated Resident B had staples removed from her left below the knee amputation site and the surgical incision was proximal (together). There were no open areas noted and the skin around the incision site was dry and flakey. Resident B had tolerated the procedure with no difficulty. A Nursing Progress note, dated 5/6/25 at 11:30 p.m., indicated Registered Nurse (RN) 3 had been instructed to send Resident B to the emergency room due to a decline in her condition. The clinical record did not contain a physician's order to send Resident B to the hospital, on 5/6/25, and did not contain a Situation, Background, Assessment, and Recommendation (SBAR) form indicating the decline in her condition. A Nursing Progress note, dated 5/7/25 at 1:38 a.m., indicated the emergency room (ER) nurse had contacted the facility to ask why Resident B was sent to the ER. A Nursing Progress note, dated 5/7/25 at 2:02 a.m., indicated the acute care hospital social worker had called with questions about Resident B and requested to speak to the Director of Nursing. The Director of Nursing was notified. A Nursing Progress note, dated 5/7/25 at 10:24 a.m., indicated Resident B had returned from the hospital. She was conscious but not alert. There were no new orders received from the hospital. During an interview on 5/27/25 at 11:15 a.m., Family Member (FM) 10 indicated Resident B had been sent to the ER, the night of 5/6/25, due to an outstanding bill with the facility. Resident B had a change in condition and was unable to return home when her therapy was over. The facility's Social Services Director (SSD) and Business Office Manager (BOM) had spoken with FM 10 about an outstanding balance. FM 10 had made the facility aware that she was attempting to contact an attorney to obtain guardianship of Resident B so she could access Resident B's funds and pay the outstanding balance. The facility had informed FM 10 that if the balance was not paid by midnight, on 5/6/25, that Resident B would be discharged to an inpatient hospice program. During an interview on 5/27/25 at 12:14 p.m., Licensed Practical Nurse (LPN) 5 indicated normally when a resident was sent to the hospital, an SBAR form was completed to communicate the reason for the transfer or the change in condition. Resident B did not have an SBAR in her medical record for the transfer on 5/6/25. During an interview on 5/27/25 at 3:00 p.m., the SSD indicated Resident B had not been issued a 30-day discharge notice. Her stay at the facility had been financially covered by Medicare Part A. Her condition had declined, and she was no longer able to participate in therapy. The Nurse Practitioner had approached the SSD, on 5/5/25, and requested that Resident B be referred to hospice. The SSD had made contact with a hospice company that provided services at the facility about a referral. The SSD had also spoken with Resident B's family about hospice and about an outstanding balance. The SSD had suggested that an inpatient hospice may be an option for Resident B due to her outstanding balance. Resident B's family had been working with the facility to provide payment. The SSD was unsure why Resident B had been sent to the ER at the late hour on 5/6/25. During an interview on 5/27/25 at 3:07 p.m., the Director of Nursing (DON) indicated Resident B had been transferred to the ER, on 5/6/25, so that she could be admitted to the hospital's inpatient hospice. Resident B had experienced a gradual change in condition and the DON was expecting Resident B to be transferred to an inpatient hospice. The DON had been made aware that Resident B was still at the facility in the late evening, on 5/6/25, and had instructed the nurse on duty to send Resident B to the ER department so that she could be admitted to an inpatient hospice. The DON was not sure of the admission process for inpatient hospice and had been concerned that transportation had not come to transport Resident B. During an interview on 5/27/25 at 3:07 p.m., the BOM indicated that a 30-day notice had not been issued to Resident B. There was an outstanding balance on Resident B's account. During an interview on 5/27/25 at 3:07 p.m., the Executive Director (ED) indicated the facility was attempting to assist the family from accruing a large bill. During an interview on 5/28/25 at 9:22 a.m., RN 3 indicated she had been Resident B's nurse during the night shift of 5/6/25. She had been instructed by the DON to send Resident B to the ER right after she had started her shift. RN 3 was not sure why Resident B was sent to the hospital. The hospital nurse and the hospital social worker called the facility after Resident B arrived at the hospital to ask why she had been sent to the hospital. Resident B returned to the facility on 5/7/25 at around 5:00 a.m. During an interview on 5/28/25 at 10:00 a.m., LPN 2 indicated she had cared for Resident B during the evening shift on 5/6/25. There were no acute changes in Resident B on the evening of 5/6/25. LPN 2 had been informed that Resident B may be transferred out of the building to an acute inpatient hospice service but had not been transferred during the evening shift. Resident B had been stable when LPN 2 ended her shift on 5/6/25. Nothing acute happened during the shift. During an interview on 5/28/25 at 11:05 a.m., the ED indicated there was some confusion with Resident B's transfer on 5/6/25. The facility was trying to do the right thing so that the family would not accrue a large bill. During an interview on 5/28/25 at 11:13 a.m., FM 10 indicated she had not had a formal discharge meeting. While FM 10 was visiting with Resident B, the evening of 5/6/25, a nurse had informed her that if payment of the outstanding balance was not received by midnight that night, Resident B would be discharged . During an interview on 5/28/25 at 12:35 p.m., the DON indicated the clinical record did not include information about what information was sent to the hospital with Resident B on 5/6/25. On 5/27/25 at 3:44 p.m., the DON provided the Transfer and Discharge (including AMA) Policy, last reviewed 2/5/25, that indicated .Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility. c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. d. The health of the individuals in the facility would otherwise be endangered. e. The resident has failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his or her stay at the facility .f. The facility ceases to operate .4. Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. 10. a. The facility will obtain a physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis .f. Document assessment findings and other relevant information regarding the transfer in the medical record . This citation relates to Complaint IN00459914. 3.1-12(a)(4)(A) 3.1-12(a)(4)(E) 3.1-12(a)(5) 3.1-12(a)(6)(B)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for pressure ulcers had a baseline care plan developed and implemented within 48 hours of admission. (Resident D) Findings include: The clinical record of Resident D was reviewed on 3-12-25 at 9:25 a.m. His diagnoses included, but were not limited to metabolic encephalopathy, atherosclerotic heart disease, high blood pressure and cognitive impairment following cerebrovascular disease. His admission Minimum Data Set (MDS) assessment, dated 2-26-25, indicated he had severe cognitive impairment and was admitted with a stage 2 pressure ulcer. A review of his admission nursing assessment, dated 2-21-25, indicated he was admitted to the facility with a pressure ulcer to the coccyx. A review of Resident D's care plans indicated there was not a baseline care plan developed for Resident D related to skin concerns or pressure ulcers. In an interview with the Wound Nurse on 3-12-25 at 1:05 p.m., she indicated she and the MDS staff were responsible for developing care plans for any skin related issues. In an interview with the Director of Nursing on 3-12-25 at 2:15 p.m., she indicated a month or so ago, she identified an issue with care plans, including baseline care plans, not being conducted routinely by the floor nurses. She shared this issue was put into QAPI (Quality Assurance and Performance Improvement, a process to improve the quality of care and safety in nursing homes) and yesterday, 3-11-25, the facility held an in-service educational offering, dealing with baseline care plans, in addition to other issues. I tell the nurses that all of them can put care plans into the record, not just the MDS staff. She indicated baseline care plans were a part of the admission nursing assessment document and only required the nurse to electronically click on the areas of concern. She added when she reviewed Resident D's chart, the staff had obtained an assessment of the wound to his coccyx, notified the doctor and family and had care orders, but there was an absence of baseline care plans. It looks like they did everything they should have, except for the [baseline] care plans. In an interview on 3-12-25 at 2:53 p.m., with the Executive Director, she indicated the facility held an in-service educational offering on 1-14-25, with the licensed nurses on Admission Assessment and Care Plans, and yesterday, 3-11-25, another in-service educational offering addressed baseline care plans. She provided an attendance sign-in sheet, from 1-14-25, which indicated it was attended by 11 nursing staff persons. On 3-12-25 at 2:53 p.m., the Executive Director provided a copy of a policy and procedure, dated 12/2022, entitled, Admission of Resident. It indicated its purpose as, To facilitate a smooth transition into a healthcare environment, to help alleviate concerns and answer questions the resident and family may have [and] to gather comprehensive information as a basis for the planning of care .Conduct the initial interview and nursing history .Conduct a head-to-toe observation/assessment. Identify functional abilities, needs, or problems .initiate a plan of care. On 3-12-25 at 1:33 p.m., the Executive Director provided a copy of a policy, dated 10/2022, entitled, Care Planning. This policy indicated, It is the policy of this facility to develop a comprehensive plan of care that is individualized, and reflective of the resident's goals, preferences, and services that are to be provided to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being .A baseline plan of care will include at a minimum and will be completed within 48 hours of admission: physician orders, dietary orders, therapy services, social services .initial goals based on admission orders . This citation relates to Complaint IN00454080. 3.1-30(a)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for pressure ulcers had a comprehensive care plan developed and implemented. (Resident D) Findings include: The clinical record of Resident D was reviewed on 3-12-25 at 9:25 a.m. His diagnoses included, but were not limited to metabolic encephalopathy, atherosclerotic heart disease, high blood pressure and cognitive impairment following cerebrovascular disease. His admission Minimum Data Set (MDS) assessment, dated 2-26-25, indicated he had severe cognitive impairment and was admitted to the facility with a stage 2 pressure ulcer. A review of his admission nursing assessment, dated 2-21-25, indicated he was admitted to the facility with a pressure ulcer to the coccyx. A review of Resident D's care plans indicated there was not any type of care plan developed for Resident D related to skin concerns or pressure ulcers. In an interview with the Wound Nurse on 3-12-25 at 1:05 p.m., she indicated she and the MDS staff were responsible for developing care plans for any skin related issues. In an interview with the Director of Nursing on 3-12-25 at 2:15 p.m., she indicated a month or so ago, she identified an issue with care plans not being conducted routinely by the floor nurses. She shared this issue was put into QAPI (Quality Assurance and Performance Improvement, a process to improve the quality of care and safety in nursing homes). I tell the nurses that all of them can put care plans into the record, not just the MDS staff. She indicated baseline care plans are a part of the admission nursing assessment document and only requires the nurse to electronically click on the areas of concern. She added when she reviewed Resident D's chart, the staff had obtained an assessment of the wound to his coccyx, notified the doctor and family and had care orders, but there was an absence of baseline care plans. It looks like they did everything they should have, except for the care plans. In an interview on 3-12-25 at 2:53 p.m., with the Executive Director, she indicated the facility held an in-service educational offering on 1-14-25, with the licensed nurses on Admission Assessment and Care Plans, and yesterday, 3-11-25, another in-service educational offering addressed baseline care plans. She provided an attendance sign-in sheet, from 1-14-25, which indicated it was attended by 11 nursing staff persons. On 3-12-25 at 2:53 p.m., the Executive Director provided a copy of a policy and procedure, dated 12/2022, entitled, Admission of Resident. It indicated its purpose as, To facilitate a smooth transition into a healthcare environment, to help alleviate concerns and answer questions the resident and family may have [and] to gather comprehensive information as a basis for the planning of care .Conduct the initial interview and nursing history .Conduct a head-to-toe observation/assessment. Identify functional abilities, needs, or problems .initiate a plan of care. On 3-12-25 at 1:33 p.m., the Executive Director provided a copy of a policy, dated 10/2022, entitled, Care Planning. This policy indicated, It is the policy of this facility to develop a comprehensive plan of care that is individualized, and reflective of the resident's goals, preferences, and services that are to be provided to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being .The facility may utilize a completed comprehensive plan of care, if present in the initial 48 hours, in place of a Baseline Plan of Care/Summary. The comprehensive care plan will include a summary of the assessment of the Resident's: needs, strengths, goals, life history, personal and cultural preferences, MDS findings .The resident's care plan will contain measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .A baseline plan of care will include at a minimum and will be completed within 48 hours of admission: physician orders, dietary orders, therapy services, social services .initial goals based on admission orders . This citation relates to Complaint IN00454080. 3.1-35(a) 3.1-35(b)(1) 3.1-35(b)(2) 3.1-35(c)(1)

Based on observation, interview, and record review, the facility failed to provide a resident with adequate assistance of two staff members for bed mobility during perineal care resulting in a fall from bed, and ensure a transfer from the wheelchair to the toilet was performed in accordance with the plan of care for 2 of 4 residents reviewed for accidents and 1 of 5 residents reviewed for Activities of Daily Living (ADLs). This deficient practice resulted in Resident 60 falling and sustaining a fracture of the left upper arm. (Resident 1, Resident 60, and Resident B) Findings include: 1a. The clinical record for Resident 60 was reviewed on 1/9/25 at 9:55 a.m. The diagnoses included, but were not limited to, bone density disorder, abnormalities of gait and mobility, muscle weakness, difficulty in walking, and stroke with hemiplegia (paralysis one side of body) affecting left non-dominant side. The Annual Minimum Data Set (MDS) assessment, dated 8/7/24, indicated Resident 60 was cognitively intact. The resident had impairment on upper and lower of one side of the body. The resident's functional status of toilet transfers and sit-to-stand function was substantial maximal assistance. The caregiver does more than half of the assistance. The Quarterly MDS assessment, dated 11/4/24, indicated the resident was cognitively intact. The resident's functional status of toilet transfers was dependent. The caregiver does all the effort. A fall care plan, date initiated 2/1/19, indicated, I am at risk for falls related to Lt. [left] sided hemiparesis, history of falls .Goal. My care plan interventions will minimize my risk for falls resulting serious injury . An ADLs care plan, dated 6/25/24, indicated, I need assistance with my ADLS; bed mobility, eating, toileting, transferring, dressing and grooming and bathing, related to activity intolerance, muscle weakness, lack of coordination, left side hemiplegia/hemiparesis . The resident's interventions included, but were not limited to, gait belt utilized with transfers, date initiated of 5/1/24, and assistance with transfers utilizing two staff members initiation date of 8/2/21. A care plan, dated 6/25/24, indicated, I am at risk for pathological fractures d/t [due to] dx [diagnosis] of osteopenia [bone density is lower than normal/bone loss]. A progress note, dated 10/10/24 at 11:15 a.m., indicated Resident 60 had fallen. Description of fall: Seen resident accompanied by Physical Therapist [PT] in the bathroom, Per PT, they were transferring resident from toilet to her wheelchair when she lost her balance and fell hit her head in the door [sic]. Per resident she lost her balance and hit her head in the door. Range of motion; mental status, neurochecks if unwitnessed or hit head; injuries: witnessed fall, ROM [range of motion] wnl [within normal limits], swelling on forehead noted, Per resident she lost her balance and fell hit her head in the door [sic]. Immediate intervention: Assisted back resident to her chair, vital signs and neuro [neurological] checks initiated, noted to have swelling on resident forehead, ice pack applied over forehead. Physician notification . informed and recommend having CT [medical image scan] head for the resident since she was on blood thinner [sic] A nursing note, dated 10/10/24 at 8:27 p.m., indicated, Res. [Resident 60] returned from hospital visit r/t [related to] fall with head contusion [bruise]. CT of head & spine with no findings, no new orders received. Res. alert & orientated x3 [times 3], extensive assist x 2 [two] to bed .Will continue to observe with 3 [three] day follow up fall observation. An Interdisciplinary Team fall note, dated 10/11/24 at 9:25 a.m., indicated .Summary of the fall: Patient [Resident 60] lost footing during the fall. Root cause of fall: Patient lost footing while being transferred to toilet. Intervention and care plan updated: OT [Occupational Therapy] to evaluate and treat for transfers to/from toilet. An Occupational Therapy evaluation, dated 10/11/24 at 12:56 p.m., indicated .Patient [Resident 60] demonstrates decreased strength and indep [independence] with toilet transfer. Recommend 2 [two] person assist with gait belt and one step cues for proper foot placement .Pt [patient] had a fall on 10/10 during transfer off toilet . A nursing note, dated 10/20/24 at 2:00 p.m., indicated, Resident was transferring from w/c [wheelchair] to toilet, her foot was buckled and staff had to put resident down on floor. Fall was witnessed, resident didn't touch the floor. VS [vital signs] WNL [within normal limits], no injuries noted after fall . A nursing note, dated 10/21/24 at 7:31 a.m., indicated, .Resident seen in bed, complain of left shoulder pain, swelling noted .[medical provider] informed with order for Left shoulder X-ray requested. A radiology report for Resident 60, dated 10/21/24 at 9:25 a.m., indicated, .Findings: There is an acute fracture proximal left humerus. There is mild displacement . A nursing note, dated 10/21/24 at 11:20 a.m., indicated, Left Shoulder x-ray: Conclusion: Acute Fracture Proximal left humerus. [name of medical providers] informed and order to send resident to ER [emergency room ] . A Facility Reported Incident [FRI] was reported to the Indiana Department of Health, dated 10/21/24, indicated an incident had occurred, on 10/20/24, with Resident 60. The resident's knees gave out during a transfer from wheelchair to toilet resulting with an acute fracture and displacement of the proximal humerous. The follow up on the report indicated, Resident returned from the ER [emergency room ] with orders to follow up with orthopedics for treatment .Resident pain assessed every shift and scheduled and PRN [as needed] pain medications administered as ordered. Resident was previously noted as requiring assistance of two for transfers. An IDT review of the resident's fall history and mobility determined that the resident is unable to safely transfer to the toilet with an assist of two. As a result, a new intervention was put in place for toileting with a bedpan and assistance of two for bed mobility, along with the use of a hoyer lift [mechanical lift] for transfers . A care plan, dated 10/22/24, indicated, I have a traumatic fracture/pathological fracture of the left proximal humerus [the top portion of the upper arm bone] . The investigation into Resident 60's fall was provided by the Director of Nursing (DON), on 1/15/25 at 10:55 a.m., and included, but was not limited to, the following: A written statement by Certified Nurse Aide (CNA) 1, dated 10/20/24, indicated, I [CNA 1] went to take [Resident 60] to bathroom. She had stated she was ok [okay] to stand she stood .but her foot gave out as she was standing she fell on my leg. I made sure she was off my foot after she fell on my foot and went to get nurse. She was already complaining about pain on her left arm when we was [sic] getting her up for morning care we let nurse know she was complaining asap. A staff education form for CNA 1, dated 10/21/24, indicated .Safe transfers. This includes the following areas: 1. Area for Improvement: a) following resident plan of care. b) using a gait belt with all transfers .2. Necessary Steps for Improvement: a) Use the Kardex located in [electronic medical chart] dashboard to find resident transfer/care information. b) Get report from the Charge nurse to stay informed of resident changes . Hospital records, date of arrival on 10/21/24, and discharged on [DATE], indicated .[Resident 60] presenting today with concerns of left arm pain and a fall. Report from EMS [Emergency Medical Services] which he received from the facility states that they were attempting to move patient in bed when they pulled on her left arm. X-ray at facility confirmed she had a broken humerus. However patient tells me that she fell in the bathroom either today or a few days ago on the wet tile. She reports since then her arm has been hurting. Patient arrives with left arm pain .She has some bruises that appear to be in late stages of healing on her face so we will obtain basic CT head and neck imaging as well. Admission was considered so further work-up was obtained. Please refer to ED [emergency department] course for additional details on this work-up .Workup here notable for a mildly displaced fracture through the proximal neck of the left humerus. Patient was placed in a sling here and referred to orthopedic for further observation. Basic labs with no emergent abnormalities .At this point I do think she is safe and stable for discharge at this time. We need to follow-up closely with orthopedics .Clinical Impression 1. Fall, initial encounter 2. Other closed nondisplaced fracture of proximal end of left humerus . An interview was conducted with the Therapy Director on 1/15/25 at 11:41 a.m. She indicated the staff should be utilizing gait belts while transferring residents. Resident 60 did have a fall with a PT in the bathroom on 10/10/24. After that fall, the resident's ability to safely transfer was evaluated. It was determined Resident 60 was a two person assist with transfers. After the resident's fall with the nursing staff on 10/20/24; the resident was evaluated. Resident 60 transfers now utilizing a mechanical lift due to her decline and unable to safely transfer. During an interview on 1/15/25 at 12:47 p.m., Resident 60 indicated she fell in the bathroom when a CNA was transferring her to the toilet. There was only one staff person assisting her with the transfer, and the resident was not wearing a gait belt. Resident 60 had lost her balance and fell . The CNA called for help, and a nurse came into the bathroom to assist. During that time, the nurse had pulled on her left arm to help the CNA get her up. The fall resulted with a broken left arm. She was sent to the hospital. She did not have to have surgery, but she did have to be seen by an orthopedic specialist for a while. An interview was conducted with CNA 1 on 1/15/25 at 1/15/25. She indicated she was transferring Resident 60 when she had fallen while transferring her to the toilet. During that time, CNA 1 was the only staff person conducting the transfer. She had utilized the back of the resident's pants to assist with the transfer. The resident's leg gave out, and Resident 60 fell on CNA 1's leg and her foot. The resident did not fall on the floor. After, CNA 1 had called for the nurse, and she came into the bathroom to assist with the removal of the resident off CNA 1's foot and leg. The nurse had placed her arms underneath the resident's arm to assist the resident to stand up. CNA 1 had not worked with Resident 60 prior to that day. She did receive report by staff prior to working on the hallway, but she was not told the resident was a two person assist with transfers until after the resident had fallen. She would have never transferred Resident 60 without assistance of another staff person if she had known. 1b. The clinical record for Resident B was reviewed on 01/10/25 at 1:35 p.m. The diagnoses included, but were not limited to, hemiplegia (a condition causing paralysis or weakness on one side of the body) secondary to a CVA (cerebral vascular accident). A random observation of Resident B being transferred from his wheelchair to the toilet was made with CNA 2 and the Wound Nurse on 1/13/25 at 11:23 a.m. During the observation, a gait belt was not utilized during the transfer. Resident B indicated at that time; he was not having a good day with transferring. An interview was conducted with the DON on 1/15/25 at 3:25 p.m. She indicated the nursing staff were to utilize gait belts when transferring residents. A Use of Gait Belt policy was provided by the DON, on 1/15/25 at 10:55 a.m., and it indicated the following, .Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety .Compliance Guidelines: 1. Each nursing department employee will be given a gait belt during orientation. 2. All employees will receive education on the proper use of gait belt during orientation and annually. 3. It will be the responsibility of each employee to ensure they have it available for use at all times when at work. 4. Any and all repairs needed or issues with gait belt will be reported to the supervisor immediately for replacement. 5. Failure to use gait belt properly may result in termination. The Indiana State Department of Health Nurse Aide Curriculum, revised November 19, 2015, indicated the following, .PROCEDURE #24: USING A GAIT BELT TO ASSIST WITH AMBULATION .3. Place belt around resident's waist with the buckle in front and adjust to a snug fit ensuring that you can get your hands under the belt .4. Assist the resident to stand on count of three .6. Stand to side and slightly behind resident while continuing to hold onto belt .PROCEDURE #26: TRANSFER TO WHEELCHAIR .2. Place wheelchair on resident's unaffected side .4. Stand in front of resident and apply gait belt around the resident's abdomen 40287 2. The clinical record for Resident 1 was reviewed on 1/8/25 at 3:01 p.m. The diagnoses included, but were not limited to, cerebral palsy and aphasia (inability to speak). A care plan, last revised on 7/1/24, indicated he required total assistance with activities of daily living due to his diagnosis of cerebral palsy. The goal was for him to allow staff to render needed care daily. The interventions included, but were not limited to, total assist of two staff members for bed mobility. A care plan, last revised on 6/19/23, indicated he was at risk for falls related to cerebral palsy and total assistance with all transfers. The goal was the care plan interventions would minimize the risk to no serious injuries. The interventions included, but were not limited to, place in the center of the bed for positioning. A Quarterly MDS assessment, completed 11/10/24, indicated he rarely/never made himself understood. He was dependent on staff for bed mobility and toilet hygiene. A progress note, dated 12/10/24 at 6:43 p.m., indicated Resident 1 had a witnessed fall. The CNA was turning Resident 1 while changing him when he slipped from the bed. There was no change in his assisted range of motion, no pain with passive range of motion, neurological checks were initiated, and there was no change in his mental status or consciousness. A Fall Interdisciplinary Team Note, dated 12/11/24 at 9:49 a.m., indicated the summary of the fall was Resident 1 slid from the bed when turned by the CNA to provide perineal care. The root cause of the fall was one person assisting with perineal care. The interventions and care plan update included the staff were educated on providing care. During an interview on 1/14/25 at 3:30 p.m., the Director of Nursing indicated the CNA was changing Resident 1, who had a low air loss mattress. He got too close to the side of the mattress and just slid out. There should have been two staff members providing care. On 1/15/25 at 10:15 a.m., the Director of Nursing provided the Fall Investigation and Risk Evaluation, last revised June 2022, which read .It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents .The residents will have a care plan developed that includes the resident's complications and risks, an attainable and measurable goal, and individualized interventions to decrease their risk of falls .'Avoidable Accident' means that an accident occurred because the facility failed to .Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of and accident .Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice .'Supervision/Adequate Supervision' refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 5 of 6 residents reviewed for dignity. (Residents' 13, 24, 37, 43, and 95) Findings include: 1. A resident council meeting was conducted on 1/09/25 at 11:05 a.m. The resident attendees in the meeting were the following: Residents' 13, 16, 17, 33, 34, 39, 43, 55, 65, 79, 85, and 94. During the meeting the resident council indicated the staff do not respect and/or maintain the residents' dignity. The staff need sensitivity training. They do not have any compassion for the residents. The staff were rude with bad attitudes and disrespectful. During sleeping hours, the staff speak to one another in loud voices along with laughing and yelling down the hallway. The residents overhear inappropriate comments made by the staff as the following, I don't want to work on 200 hall. I don't get paid enough for this. I only get 20 minutes per resident to assist with getting residents up, so no I don't have time to wash your hair. I am the only one here. The staff turn off call lights and never return to provide the service that had been requested. The residents' feel they do not have a choice if they eat in his or her room or dining room. The staff walk in and report the resident will have to go to the dining room to eat his or her meal. 2. During an interview on 1/09/25 at 9:58 a.m., Resident 24 indicated one of the Certified Nurse Aides (CNAs) had told him to have a bowel movement in the bed, because they did not want to get him up to the toilet. The clinical record for Resident 24 was reviewed on 1/13/25 at 10:00 a.m. The Quarterly Minimum Data Set (MDS) assessment, dated 10/25/24, indicated Resident 24 was cognitively intact. 3. During an interview on 1/09/25 at 10:46 a.m., Resident 95 indicated she had issues with the third shift turning off her call light and not providing the incontinent care she needed. The clinical record for Resident 95 was reviewed on 1/13/25 at 10:05 a.m. The Quarterly MDS assessment, dated 10/9/24, indicated Resident 95 was cognitively intact. 4. During an interview on 1/9/25 at 2:19 p.m., Resident 13 indicated during shift changes it sounded like there was a party going on. The staff talk too loudly, socializing with each other. The staff will turn off the call light and do not do what was initially requested. The clinical record for Resident 13 was reviewed on 1/13/25 at 10:10 a.m. The Annual MDS assessment, dated 11/4/24, indicated Resident 13 was cognitively intact. 5. During an interview on 1/09/25 at 3:42 p.m., Resident 43 indicated the nursing staff had attitudes when they talk with her and that they don't like to help her in her wheelchair. The clinical record for Resident 43 was reviewed on 1/13/25 at 10:15 a.m. The Quarterly MDS assessment, dated 11/26/24, indicated Resident 43 was cognitively intact. 6. During an interview with Resident 37 on 1/10/25 at 11:40 a.m., she indicated at times, if she hits her call light the staff will come in turn off the call light and walk out of the room. They do not return to provide the service she had requested. The clinical record for Resident 37 was reviewed on 1/13/25 at 10:20 a.m. The Annual MDS assessment, dated 11/11/24, indicated Resident 37 had moderate cognitive impairment. An interview was conducted with the Director of Nursing on 1/15/24 at 2:47 p.m. She indicated she has been working with staff on providing good customer service. She has been conducting in-service training related to dignity and customer service since October of 2024. A resident rights policy was provided by the Executive Director on 1/14/25 at 2:37 p.m. It indicated, .Policy .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .4. Respect and dignity. The resident has a right to be treated with respect and dignity, including . c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do would endanger the health or safety of the resident or other residents .5. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to .b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . 3.1-3(t)

Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 2 of 2 residents reviewed for care plan meetings (Resident 63 and Resident 95). Findings include: 1. The clinical record for Resident 63 was reviewed on 1/9/25 at 2:46 p.m. The diagnosis included, but were not limited to, depression and hypertension. An Annual Minimum Data Set (MDS) assessment, completed 10/25/24, indicated he was cognitively intact. The clinical record contained a Multidisciplinary Care Conference Summary, dated 2/26/23. A Social Services Assessment, dated 11/19/24, indicated that Resident 63 was invited to his scheduled care plan meeting. During an interview on 1/9/25 at 2:46 p.m., Resident 63 indicated that he was unsure of the last time he was invited to a care plan meeting, it may have been over a year ago. During an interview on 01/14/25 at 10:42 a.m., the Social Service Director (SSD) indicated a care plan meeting was held on 2/14/24 and 11/19/24. There were no other care plan meetings held between 2/14/24 and 11/19/24. 51750 2. The clinical record for Resident 95 was reviewed on 01/10/25 12:45 p.m. The diagnoses included, but were not limited to, hypertension, cocaine abuse, hemiplegia and hemiparesis following a cerebral infarction, and diabetes. A Quarterly Minimum Data Set assessment, completed 10/09/24, indicated she was cognitively intact. During an interview on 01/09/25 at 10:53 a.m., Resident 95 indicated she did not know what a care plan meeting was, and she had not been invited to one since she had been at the facility. Records regarding Resident 95's care plan meetings were provided by the Director of Nursing (DON) on 01/14/25 at 9:07 a.m. Records included a multidisciplinary care conference summary dated 04/02/2024, a social services assessment dated [DATE], and a progress note, dated 01/13/25, indicating a care plan invitation had been extended to Resident 95's daughter. During an interview on 01/14/25 at 10:42 a.m., the SSD indicated care plan meetings were supposed to occur quarterly. They have not occurred timely due to excess workload in the facility. On 01/10/25 at 2:00 p.m., the Executive Director provided a Care Planning-Resident Participation Policy, date implemented 11/01/2023. It indicated, .This facility supports the resident's right to be informed of, participate in, his or her care planning and treatment (implementation of care) . 10. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident/resident's representative . 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to provide routine oral care and appropriate incontinence care timely to 1 of 5 residents reviewed for Activities of Daily Living (ADL) care (Resident B). Findings include: The clinical record for Resident B was reviewed on 01/10/25 at 1:35 p.m. The diagnoses included, but were not limited to, hemiplegia (a condition causing paralysis or weakness on one side of the body) secondary to a CVA (cerebral vascular accident). A Quarterly Minimum Data Set (MDS) assessment, completed 10/25/24, indicated he was cognitively intact, had impairment on one side of the upper extremity, required supervision or touching assistance from staff with oral care, and required substantial/maximal assistance with toileting hygiene. A care plan, created on 02/06/24, indicated Resident B had a problem with oral health related to carious (decayed), and missing teeth. The goal was his oral health will not decline. The interventions, created on 02/06/24, were to assist him with oral care two times a day with a.m. and p.m. care. He was to receive his medications as ordered. He would report oral pain, bleeding gums, red inflamed tongue, white patches in oral cavity, or change in his ability to chew food. He would be referred to the dentist as needed. A care plan, created on 02/06/24, indicated Resident B was incontinent of bowel and bladder at times related to functional incontinence, decreased mental awareness, mobility, and personal unwillingness. The goal was for his functional incontinence to be managed through the care plan as evidenced by Resident B would continue to have continent episodes. The interventions, created on 02/06/24, were to assist resident with clothing adjustment, cleansing, and transfers during toileting. The staff would encourage/remind resident to wear his incontinence products for management of his incontinence. Staff would assist resident with incontinence care and apply barrier cream as needed. During an interview on 01/09/25 at 9:47 a.m., Resident B indicated the staff do not help brush his teeth. On 01/09/25 at 9:58 a.m., Resident B indicated one of the aides told him to have a bowel movement in his brief in the bed because she didn't want to get him up. During an interview on 01/13/25 at 9:41 a.m., Resident B indicated staff did not help brush his teeth when they had provided a.m. care that morning or the morning before. Visible white debris was observed on the resident's lower teeth. Resident B indicated he put his call light on last night, and nobody came. My brief wasn't changed until this morning before breakfast. On 01/13/25 at 11:20 a.m., Resident B indicated his brief had not been changed since that morning before breakfast, record review of the task administration record indicated the last time Resident B had been toileted was on 1/13/2025 at 6:56 a.m. On 01/13/25 at 11:23 a.m., Certified Nurse Aide (CNA) 2 was observed providing incontinent care for Resident B. Resident B was wheeled into his shared bathroom by CNA 2. Hand hygiene was performed, and gloves were donned. CNA 2 assisted Resident B to stand (by holding onto back of waistband), pivot, and sit gently onto the toilet. His brief was removed and was visibly heavily saturated with urine. CNA 2 used a wet wash rag and soap to wipe the resident's perineal area and then applied barrier cream. Significant moisture was present on scrotum. Licensed Practical Nurse (LPN) 4 was present to assess a moisture associated skin damage wound on the coccyx. CNA 2 and LPN 4 assisted Resident B to stand from toilet and moisture was observed dripping from Resident B's scrotum onto the floor. A new brief was applied without the cleansing of or drying of the resident's genitalia. During an interview on 01/13/25 at 2:05 p.m., CNA 2 indicated the process for providing perineal care was to pull foreskin of the penis back and clean around it, and to use wipes or a wash rag when a resident has a bowel movement. During an interview on 01/13/25 at 2:10 p.m., CNA 3 indicated the residents get changed every two hours. On 01/14/25 at 10:26 a.m., Resident B indicated his teeth had not been brushed that morning. During an interview on 01/14/25 at 10:36 a.m., CNA 2 indicated she had not brushed Resident B's teeth, and that night shift should have done it because he was a get-up. Night shift was supposed to get them up and prepare them for the day every morning. During an interview with the Director of Nursing (DON) on 01/14/25 at 3:01 p.m., she indicated residents should receive oral care assistance in the mornings if needed. She also indicated staff should be checking every two hours to see if incontinent residents are wet or need changed. A perineal care policy was provided by the DON on 01/13/25 at 3:49 p.m. It indicated, .12. Males . g. Cleanse the shaft of the penis, using downward strokes toward the scrotum . h. cleanse the scrotum, using a clean portion of the washcloth, new washcloth or new disposable wipe with each stroke . i. pat dry . On 1/14/25 at 3:28 p.m., the DON provided the Personal Hygiene Policy, last revised 6/2021, which read .1. Personal hygiene will be performed 2 times daily in the morning and before bed . 4. Personal hygiene may include, but is not limited to . a. Oral care . This citation relates to Complaint IN00446265. 3.1-38(a)(3)(A) 3.1-38(a)(3)(C)

Based on interview and record review, the facility failed to ensure pre and post assessments were conducted for a resident receiving dialysis for 1 of 1 resident reviewed for dialysis. (Resident 43) Findings include: The clinical record for Resident 43 was reviewed on 1/9/25 at 1:55 p.m. The diagnoses included, but were not limited to, end stage renal disease. A dialysis care plan, dated 10/25/24, indicated I [Resident 43] have end stage kidney disease requiring dialysis. I no longer have any urinary output. I have a fistula in my left arm. The goal was to remain free of infection through the next review utilizing my care plan interventions. The interventions included I will report and you will observe for side effects of dialysis such as change in level of consciousness, cramping, fatigue, headaches, itching, and bleeding . A physician order, dated 12/31/21, indicated the resident received dialysis Mondays, Wednesdays, and Fridays at 10:30 a.m. The November 2024, December 2024, and January 2025 pre and post dialysis assessments for Resident 43 were reviewed. The following day(s) indicated the pre and/or post dialysis assessments were not located in the clinical record: 11/20/24 - pre dialysis assessment, 11/24/24 - post dialysis assessment, 11/26/24 - post dialysis assessment, 12/6/24 - pre dialysis assessment, 12/11/24 - post dialysis assessment, 12/16/24 - post dialysis assessment, and 1/13/25 - post dialysis assessment. An interview was conducted with the Director of Nursing (DON) on 1/14/25 at 2:57 p.m. She indicated she was unable to locate the missing pre and post dialysis assessments for Resident 43 in November 2024, December 2024, and January of 2025. The staff should be doing pre and post dialysis assessments for residents' receiving dialysis. A dialysis policy was provided by the DON on 1/14/25 at 2:00 p.m. It indicated, .Policy: It is the desire of this facility to provide appropriate care for end stage renal disease (ERSD) residents receiving dialysis. Staff caring for residents receiving dialysis outside the facility will be trained and educated in the special needs of these residents . Residents receiving hemodialysis will receive appropriate monitoring and care from the facility and the dialysis provider in order to coordinate care. To set appropriate guidelines for monitoring the health and safety of residents receiving dialysis care .Pre and Post Dialysis: 1. A [name of corporation] pre-dialysis assessment will be completed before dialysis. This includes . a. level of consciousness, b. vital signs, c. breath sounds, d. skin, vascular access, f. edema, g. signs and symptoms of infection, h. Complaints such as chest pain, shortness of breath, cough, i. Assess resident for nausea, vomiting, constipation, diarrhea, abdominal pain, itching, bleeding, change in urine output amount or appearance, or falls. Any abnormalities will be communicated by the charge nurse to the dialysis center. The facility will communicate any prn [as needed] medications given before dialysis. 2. A [name of corporation] post dialysis form will be completed after dialysis and compared to the pre-assessment. Any abnormal assessment findings will be reported to the physician or NP [Nurse Practitioner] 3.1-37(a)

Based on interview and record review, the facility failed to ensure residents' respect and dignity was maintained by staff not being respectful and ensuring a resident was able to exercise her right to vote for 1 of 23 residents reviewed for activities and 26 of 104 residents reviewed for dignity. (Residents' B, C, D, E, F, G, H, J, K, L, M, N, P, Q, R, S, T, V, W, X, Y, Z, BB, CC, DD, EE, and FF) Findings include: 1a. A resident council meeting was conducted on 11/28/23 at 2:30 p.m. The residents that attended the meeting was the following: B, C, D, E, F, G, J, K, L, M, N, P, Q, R, S, T, V, W, X, Y, Z, BB, and CC. During the meeting, the council indicated they do not feel the staff are respectful. Some staff use foul language and are on their personal cell phones during care. They do not respond to the call lights timely. The staff will come into the residents' rooms turn off their call lights and then immediately leave the room without providing the service that was needed. 1b. A Quarterly Minimum Data Set (MDS) assessment, dated 10/2/23, indicated Resident FF was cognitively intact. An interview was conducted with Resident FF on 11/29/23 at 11:20 a.m. She indicated the Certified Nursing Assistants (CNA)s staff are rude and disrespectful. They will be in the room providing care and always on their cell phones. They are very inconsiderate. The CNAS will come into the room turn off the call light, and leave the room without provided the assistance needed. 1c. A Quarterly Minimum Data Set (MDS) assessment, dated 9/4/23, indicated Resident H was cognitively intact. An interview was conducted with Resident H on 11/29/23 at 2:16 p.m. She indicated some nurses are hateful. She had spoken to one of the nurses regarding propping her feet up due to swelling in her feet. She didn't feel she was being mean about it, but she really wanted assistance with getting her feet up. The nurse did not assist and stated to her in a hateful tone, she was speaking mean to her and left the room. She called and told her family about the attitude of that nurse. The family then called and spoke to that nurse. The nurse reported to her family she was the one that was being mean. After, the resident stopped a male staff person coming down the hallway, and he assisted with raising her bed. The resident indicated that's all she wanted assistance with. I don't want to be fussing and arguing with the staff. 1d. A Quarterly Minimum Data Set (MDS) assessment, dated 11/15/23, indicated Resident EE was moderately impaired. An interview was conducted with Resident EE on 11/29/23 at 2:34 p.m. She indicated there are long delays in call light response times by the staff. The staff turn their name badges around, so the residents' are unable to identify who assist them. One evening the week of Thanksgiving, a staff member had stated to her that she had put her call light on 3 times in the past 15 minutes, and she wasn't going to keep coming into her room to answer her call light. 1e. A Quarterly Minimum Data Set (MDS) assessment, dated 10/18/23, indicated Resident DD was severely impaired. An interview was conducted with Resident DD's Representative on 11/29/23 at 4:11 p.m. The resident's family had come in to visit Resident DD. Resident DD was observed sitting in the dining room with her dinner tray in front of her, but not eating. A staff member was sitting next to the resident eating a meal. At that time, the staff member requested the family assist the resident with her dinner meal while the staff member sat there eating. 1f. A quarterly Minimum Data Set (MDS) assessment, dated 8/9/23, indicated Resident G was moderately cognitive impaired. An interview was conducted with Resident G on 11/30/23 at 9:32 a.m. He indicated one day the week of Thanksgiving, he was told by a nurse the CNA staff were arguing about who was going to come down to his room to feed him. The nurse stated aides don't want to feed you, so she had come to assist him. 2. During the resident council meeting conducted on 11/28/23 at 2:30 p.m., the council indicated some residents were not given the opportunity to vote for the November 7, 2023 election for the mayor. Resident B indicated she had wanted to vote, but was unable to do so. She had asked about it and was told she needed to get down to activities, because they were doing it right then. She was never told when or where to go to vote. At that time, a CNA staff member was pushing her down to the activities, and then she was told by another staff member it was too late to vote. She missed out on voting that day. An interview was conducted with the Resident Council President (RCP) on 11/29/23 at 11:48 a.m. she indicated the process in place for residents to have the opportunity to vote was not organized, and some residents missed out on the opportunity. She can recall being told about the election a few weeks prior the election was coming, but no follow up was done to where, when or what to do if a resident chose to vote. She had asked the Assistant Executive Director (AED) when and where, and if she had not asked the AED she wanted to vote; she believed she would not have gotten to do it. An interview was conducted with AD at 12/1/23 at 11:30 a.m. She indicated she had a few weeks prior her activity staff and herself went to each resident room and asked if they would like to participate in voting in the election for mayor. All the residents denied wanting to participate in voting due to it was for the mayor, and they didn't know who was running. The residents voiced since the election was not to vote for the president they did not wish to vote. Since she did not have anyone that wanted to vote; she did not make arrangements for anyone to come to the facility. The AD indicated the activities staff asked the residents verbally about voting. She was unable to provide any documentation the activities staff spoke to all the residents in the facility about voting. An interview was conducted with the Executive Director (ED) and the AED on 12/1/23 at 2:03 p.m. They had heard from the AD there was no residents wished to vote for the election. The AED indicated the day before the election there was a couple of residents that inquired about voting. He called and received by email applications for absentee ballots for those residents that decided to vote. ED and AED went around that day to all the residents rooms and asked verbally all the residents if they wanted to vote. AED and ED was unable to provide documentation they asked all the residents to vote. The AED provided residents' applications for absentee ballots filled out to vote on 12/1/23 at 2:30 p.m. Resident B did fill out an application for absentee ballot for November 7, 2023 election. An interview was conducted with Resident B with AED on 12/1/23 at 2:45 p.m. She indicated she was unable to vote that day. She was told by staff it was too late when she was headed down there. AED was unsure why she was unable to vote that day. A Voting and Absentee Ballots policy was provided by the ED on 12/1/23 at 12:19 p.m. It indicated .It is the policy of this facility to assist and inform all residents of any upcoming elections and offer assistance in obtaining needed materials to vote, however the resident must make all voting choices on his/her own accord. Procedures - .2. Determine which residents wish to vote and compile a list of names. 3. Provide assistance to ensure that the residents are currently listed with the local voter's registration office. 4. Periodically reassess residents' interest in active voting. 5. Request absentee ballots and check to ensure that each resident receives his/her ballot .9. Coordinate assistance at polls as per residents' needs or requests. A Resident Rights policy was provided by the ED on 12/1/23 at 12:19 p.m. It indicated .The resident has right to exercise his or her rights as a citizen or resident of the facility and as a citizen of the United States .Dignity. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality . This citation relates to complaint IN00411851. 3.1-3(t)

Based on interview and record review, the facility failed to follow up with resolutions to grievances reported in resident council for 3 of 3 resident council minutes reviewed. (Residents' B, C, D, E, F, G, J, K, L, M, N, P, Q, R, S, T, V, W, X, Y, Z, BB, and CC) Findings include: The September 2023, October 2023, and November 2023 Resident Council Minutes were provided by the Executive Director on 11/28/23 at 1:10 p.m. The minutes indicated the following grievances discussed: September 2023 Resident Council Minutes: A resident stated she wanted her name removed from the scheduled exercise class on the activity's calendar. A resident had not received her prizes she won from bingo activity. October 2023 Resident Council Minutes: Old business: Nursing: Staff talking about residents in the hallway and the conversations are overheard by residents. Activities: Residents want their winnings after playing bingo. Kitchen: Residents requesting breakfast for dinner Housekeeping: Request for staff utilize bleach to clean rooms. New business: Nursing: Certified Nursing Aides (CNA)s leave without finishing their jobs. Maintenance: Gnats flying in the dining room. November 2023 Resident Council Minutes: Old Business: Nursing: Staff are on their phones a lot. Kitchen: Food not appealing, residents' want breakfast for dinner, and residents' want to invite dietitian at the next meeting Activities: Resident wants her name removed from the exercise class on the activity calendar and a resident had not received her prizes from bingo. New business: Nursing: CNAS in resident's room looking out window while resident sleeping. Staff are not available at nurse's station when residents need help. A resident council meeting was conducted on 11/28/23 at 2:30 p.m. The residents that attended the meeting was the following: B, C, D, E, F, G, J, K, L, M, N, P, Q, R, S, T, V, W, X, Y, Z, BB, and CC. The resident council indicated the council meets monthly, and the Activities Director (AD) attends the meetings. The AD documents the content discussed in the meetings. During the meetings, grievances are reported, but they do not receive any follow up with resolutions to their grievances discussed in the meetings. The council indicated they do not feel the staff are respectful. Some staff use foul language and are on their personal cell phones during care. They do not respond to the call lights timely. The staff will come into the residents' rooms turn off their call lights and then immediately leave the room without providing the service that was needed. An interview was conducted with the Resident Council President on 11/29/23 at 11:48 a.m. She indicated grievances discussed in the resident council monthly meetings are turned in to the appropriate person by the AD. The council does not receive follow up with resolutions to grievances/concerns discussed in the council meetings. An interview was conducted with the Activities Director on 12/1/23 at 11:30 a.m. She indicated she does sit in and write down the discussions at the monthly resident council meetings. After the meetings, she fills out the grievance forms and gives the forms to the appropriate department the grievances are referring to. She does not provide follow up to the grievances that were discussed in the council. The September 2023 and October 2023 resident council grievances were provided by the Executive Director on 12/1/23 at 2:00 p.m. The following grievances were the following: September 2023: A resident council grievance dated 9/22/23 indicated the council had concerns with staff gossiping, talking on cell phones in rooms, and call light response times. The conclusion to the investigation of the concern indicated no specific details regarding staff or hallway provided. Staff education provided. Upon observation not able to confirm concern. The resident response to resolution indicated no further concerns note. A resident council grievance dated 9/22/23 indicated the grievance was the residents want breakfast once a month for dinner. The conclusion to the investigation of the concern indicated The dietary department provides a resident choice meal monthly that is chosen during resident council. The request for a breakfast meal to be provided for dinner will be provided for the October 2023 resident choice meal .The resident/resident representative response to resolution: No further concerns . October 2023: A grievance by Resident F dated 10/20/23 indicated a resident was asked to leave the resident council meeting and Resident F did not feel it was right. During investigation, the resident was rude and yelling out during resident council meeting and was asked to leave. The conclusion to the investigation the resident apologized for her behavior. The Executive Director did not provide any additional grievances that were reported by the resident council in September 2023, October 2023 or November 2023. A Resident Council policy was provided Executive Director on 12/1/23 at 12:19 p.m. It indicated Purpose: to establish guidelines for assisting residents with the development and facilitation of a Resident Council in order to voice concerns, make recommendations, and participate in resolution of concerns .Policy: It is the policy of the facility to encourage and support a Resident Council for the purpose of protecting and preserving resident rights and to afford residents a forum to voice and discuss alleged concerns, resident rights or other problems and to participate in the resolution. The Resident Council shall also be encouraged to make recommendations regarding facility operations, quality of life issues and resident care .Any suggestions, concerns or view of the Resident Council presented to the Administrator or other facility staff will be reviewed and acted upon. The Administrator/Executive Director will respond to all written recommendations and concerns of the council, in writing, and in accordance with the facility grievance policy . A grievance policy was provided by the Nurse Consultant on 12/4/23 at 2:30 p.m. It indicated .Policy: It is the policy of this facility to thoroughly investigate all grievances and provide a prompt resolution regarding the resident's rights. The facility respects the resident's/resident representative's right to file a grievance and can do so without the fear of reprisal or mistreatment . This citation relates to complaint IN00421422. 3.1-3(l)

Based on interview and record review, the facility failed to ensure a resident had a care plan to address his seizure diagnosis for 1 of 5 residents reviewed for unnecessary. (Resident 74) Findings include: The clinical record for Resident 74 was reviewed on 11/30/23 at 9:55 a.m. His diagnoses included, but were not limited to: bilateral above knee amputation, type 2 diabetes mellitus, and congestive heart failure. The 9/21/23 Quarterly MDS (Minimum Data Set) Assessment indicated he had a BIMS (brief interview for mental status score) of 15, indicating he was cognitively intact. An interview was conducted with Resident 74 on 11/30/23 at 10:00 a.m. He indicated he went to the hospital because he had a seizure. The seizure was a few days after falling backwards in his wheel chair and hitting his head. He was now taking medication to address his seizures and hadn't had any since. The 9/5/23 hospital notes read, .presented on 9/5/2023 c/o [complaints of Seizures (Seizure today during rehab [rehabilitation]at ECF [extended care facility,] EMS [emergency medical services] report postictal [period that begins when a seizure subsides and ends when the patient returns to baseline] upon arrival, 2nd seizure en route resolved with 5 mg Versed [medication used to treat anxiety and cause drowsiness .] Assessment/Plan 1. Seizures: Presented from facility after having a seizure. He also seized en route to ED [emergency department ]a. New this morning, patient reports having fallen and hit his head twice in the past 2 weeks (most recently on Sunday.) b. EEG [electroencephalography-recording of brain activity] results pending. c. Cont [Continue] Keppra d. Seizure precautions. The physician's orders and December, 2023 MAR (medication administration record) indicated he was receiving 500 mg of levetiracetam (anticonvulsant medication) twice a day for seizures, effective 9/7/23. The 9/22/23 neurology note indicated he had a past medical history of seizures and was currently taking 500 mg of Keppra (name brand for leviteracetam) twice a day without issue. Resident 74's care plans did not address his seizure diagnosis. An interview was conducted with the NC (Nurse Consultant) on 12/5/23 at 12:40 p.m. She reviewed Resident 74's care plans and 9/22/23 neurology note and indicated he did not currently have a care plan to address his seizure diagnosis, but he should, and she was going to create it now. The NC provided the Comprehensive Care Plans policy on 12/5/23 at 1:35 p.m. It read, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3.1-35(a)

Based on interview and record review, the facility failed to implement their Behavior Management policy and review and revise behavioral health care plans, which had not been effective, for a resident's behavior of rummaging for linens and combativeness, which resulted in escalating physical behaviors and the resident being sent to the emergency room for due to pain and swelling of her left ankle and arm. (Resident 55, 30 and 37). Findings include: 1. The clinical record for Resident 55 was reviewed on 8/3/22 at 10:04 a.m. The Resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS (Minimum Data Set) Assessment, completed 3/11/22, indicated she had unclear speech, and was usually able to understand what was said to her. She was sometimes able to make herself understood and was severely cognitively impaired. A care plan, last revised on 4/26/22, indicated she had behavioral symptoms such as rummaging through linen closets, yelling, agitation, combativeness such as hitting, kicking, and slapping, disrobing, throwing bed linens, refusal of care and medications, refusing to allow staff to take meal trays or clean her room, and only allowing certain certified nursing assistants to provide care for her. She had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions were to allow her to express her feelings, created 4/20/21, approach her from the front and make sure to have her attention, created 4/20/21, not to rush her and allow her time to express her wants, created 6/14/21, explain that my behaviors are not appropriate, created 4/20/21, if she was choosing not to have care to come back at a later time and re-approach, created 4/20/21, offer her alternative care choices to achieve the same outcome, created 4/20/21, Offer to change her brief using the stand-up lift rather than in bed, created 6/14/21, implement her communication care plan, created 4/20/21, medications as ordered, created 4/20/21, mental health services as indicated, created 4/20/21, and when agitated allow her time to calm and reapproach at a later time, created 4/20/21. A psychiatric provider behavioral health follow up evaluation, dated 5/24/22, read .HPI [sic]: Patient is seen on this date .the patient continues to refuse all medications per staff report. Staff reported the patient has refused all of her medications both tablet and liquid for several months. Staff reported family is aware of this .Patient was calm today, unable to elaborate on issues or concerns. Patient is aggressive at times, refuses all medications. She often isolates to herself/[sic] room. Discussed discontinuing psychotropics with the treatment team as she has refused them for several months and family is aware. Treatment team was aggregable to this today .Plan: 1) Discontinue [CONDITION(S)] medications as the patient continues to refuse all medications .3) If the patient becomes explosive/[sic] unable to redirect her, please consider having admitted to an inpatient psychiatric unit . A behavior sheet, dated 5/26/22 at 4:03 p.m., indicated she had displayed the behaviors of hitting others, scratching others two to three times. The intensity of the behaviors was severe. The interventions used to decrease the behavior were to approach in a calm manner, which did not change the behavior. The interventions of not arguing or confronting her and replacing the certified nursing assistant with additional staff had shown an improvement in the behavior. The comments were that the behavior had occurred when she was being washed on the toilet. She had expressive [CONDITION(S)] and continued to attempt nonsensical communication. A nurse note, dated 6/9/22 at 6:01 p.m. read resident went behind the wall of nurses station,[sic] to remove linen off of cart,[sic] cna[sic] told resident that she could not remove anything off of cart,[sic] resident started pulling linen cart in hallway,[sic] cart leaning[sic] resident grab[sic] cart and cna[sic], another cna[sic] had to assist cna[sic], resident had pad in her hand swung[sic] around and hit this nurse in the face, resident seen earlier removing several sheets[sic] gowns and pads of[sic] linen closet and taking to her room,[sic] placed call to unit manager to inform of situation. placed[sic] call to daughter had[sic] to leave message to call facility as soon as possible. unit[sic] manager called this writer after speaking with director of nursing 911[sic] was called to transport resident to hospital for evaluation. daughter[sic] returned call was[sic] informed of situation, stated that she was on her way. 911[sic] arrived resident[sic] would not let this writer or 911[sic] entered[sic] room, daughter arrived [sic] would not let her in at first [sic] eventually allowed daughter in room, eventually resident placed on stretcher and transported to .emergency room . A behavior sheet, dated 6/9/22, at 9:55 p.m., indicated she had displayed the behaviors of hoarding, hitting others, scratching others, and grabbing others. The intensity of the behaviors was severe. The interventions used to decrease the behaviors were to approach in a calm manner, identify self, establish eye contact, call her by name, use simple sentences, not to argue or confront, and talk with her. The behaviors remained unchanged using these interventions. The comment were that she was sent out for a psychiatric evaluation. An acute care hospital emergency department provided notes, dated 6/9/22 at 6:18 p.m., indicated Resident 55 presented to the emergency department for evaluation of pain in her right ankle and right shoulder. She was in an altercation with her staff from her facility. She had mild swelling over her right ankle. The Xray results did not show acute fracture or dislocation. She returned to the facility from the Emergency Department visit. An Individualized Mental Health Safety Plan, dated 6/9/22, indicated she had been seen by a behavioral health crisis center. Her early warning signs that a crisis may be developing were communication issues. She had both expressive and receptive limits due to a history of a stroke and [CONDITION(S)] and conflicts with staff who are not skilled at solving problems or resolving conflict amicably. Her coping strategies were deep breathing, removing herself from the stress or conflict, listening to music, and distraction. The coping strategies had not been added to the care plan for behaviors. A nurse note, dated 6/28/22 at 10:15 p.m., indicated she was in the linen closet and was told staff would get her what she wanted. She was not to go into the linen closet. She started to swing at the nurse and nursing assistants in an aggressive manor. She refused care from all staff. A nurse note by LPN (Licensed Practical Nurse) 22, dated 7/25/22 at 4:30 a.m., read Pt[sic] was upset about it[sic] not being any pads on the unit and having a sheet on her bed instead. She was in[sic] chair and proceeded to go to the linen closet and both linen bins in hall to look[sic] herself. I went over to 100 hall to get pads out the closet for her,[sic]she wasn't happy with me getting the pads. [sic]And proceeded to go in other patients rooms looking for pads. I found her in another residents room, room number .taking there[sic] pad and i[sic] took the pad from her and she proceeded to swing and try and[sic] fight me. I was trying to get her out[sic] the residents room and she proceeded to hit and swing on[sic] me as i[sic] pulled her wheelchair from the back to removed her from his room. She stood in front of his door turning[sic] knob trying to reenter[sic], I was holding the door so she couldn't enter. I had to end up going through the residents bathroom and coming out of another room, room . to get away from her. She kept going into different residents rooms and when i[sic] was pulling her out she was fighting and swinging at me. I ended up having to go into another residents room . to keep her from being violent with me,[sic] I went through the bathroom and came out . to get away from her. I myself [sic]and the other aides tried to accommodate her and she refused care from everyone. I tried to talk and accommodate[sic] to her but she was chasing me and being violent. A nurse note, dated 7/25/22 at 10:59 a.m., indicated a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Emergency Department Provider Note, dated 7/25/22 at 10:08 a.m., indicated Resident 55 was seen for evaluation of arm injury that was first noticed this morning. EMS (Emergency Medical Services) reports picking her up at her nursing home where she was found on her bed and complained of right wrist swelling, left ankle pain, and left ring finger pain. According to the EMS the nursing home does not know what transpired. The clinical impression was left ankle swelling, left hand pain, swelling of right wrist, and alleged assault. On 8/8/22 at 10:33 a.m., the Executive Director provided the Behavior Management Record for Resident 55 for June and July 2022 which indicated she had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The behaviors she was known to exhibit were combativeness, refusal of care and medications, rummaging and hoarding, yelling, and screaming, and throwing objects. Behaviors of rummaging, hoarding, and combativeness were documented as occurring on the following days: 6/9/22- behavior of combativeness, refusal of care or medications, rummaging and hoarding. The reason for the behavior was unknown. The approaches uses were to identify self, approach calmy. make eye contact, talk calmly, and leave and then return, which were not effective. She was sent out 911. 6/13/22- behaviors of combativeness and refusal of care or medications. The reason for the behavior was unknown. The approaches used were to approach and speak calmly and call daughter, which were not effective. 6/29/22- behaviors were noted to occur at 3 different times of day. the behaviors displayed were combativeness and refusal of care or medications. The reasons for the behaviors were unknown. The approached used were to call daughter, leave and reapproach in a few minutes, approach calmly, which was effective 1 of the 3 times. 7/6/22- behavior of combativeness. The reason was toileting. The approaches used were to talk calmly and review care being given, which were effective. During an interview on 8/3/22 at 9:36 a.m., FM (Family Member) 20 indicated that Resident 55 had begun having behaviors about linen when the facility rules changed, and she was no longer able to go to the linen closets to get her own linens. Resident 55 did not understand why she could not continue to get the linens on her own. She had been sent to the emergency room after a tussle about linens in June 2022. The facility had called the police on her that time, and she was sent for a psychiatric evaluation. On 7/25/22 there was another tussle over linens. They had taken the pad she had found from her. Resident 55 had said they were physical with her and were pulling her wheelchair back. Her hand and ankle were swollen. The morning after it happened, she was in pain and had one of the nursing assistance call me, during the conversation she complained of pain in her arm. FM 20 then requested the nursing assistant to tell the nurse to send Resident 55 to the hospital. The nurse called FM 20, wondering why Resident 55 needed sent to the hospital. FM 20 told her about Resident 55's pain in her hand. Resident 55 was then sent to the emergency room . While she was at the hospital Resident 55 expressed, she was afraid to return to the facility. FM 20 had reached out to find out answers about what happened in June but is seemed to her that the facility was blaming Resident 55 for the problem. If her bed wasn't made the way she wanted it, what was she expected to do. During an interview on 8/4/22 at 11:02 a.m., LPN 22 indicated she was the nurse caring for Resident 55 on the night of 7/25/22. She had went to another unit to get a pad for Resident 55's bed. When she returned, Resident 55 did not want the pad she had brought. Resident 55 had gone into another resident's room and had found a pad. LPN 22 had noticed that Resident 55 had some of the other resident's clothes in her hand along with the pad. LPN 22 took the pad and clothing out of Resident 55's hand. Resident 55 targeted LPN 22 after taking the items. Resident 55 started swinging her left hand and came after LPN 22. LPN 22 was attempting to pull Resident 55's wheelchair from behind to remove her from another resident's room. Resident 55 had tried to hit LPN 22 and LPN 22 had to let go of the wheelchair and move around to keep from getting hit by Resident 55. After LPN 22 had removed Resident 55 from the other resident's room, Resident 55 tried to re-enter the room. LPN 22 went into the room and shut the door LPN 22 held the other resident's room door closed with her foot. She waited for a little while and exited through an adjoining room. When LPN 22 came back into the hallway, she noticed that Resident 55 was trying to go back into the other resident's room. LPN 22 went back into the other resident's room and shut the door again. Resident 55 was beating at the door trying to get into the room. LPN 22 stayed in the other resident's room for a couple of minutes and then exited through the adjoining room again. Resident 55 saw LPN 22 exit the adjoining room and focused on LPN 22 and came down the hallway after LPN 22 backing her into a different room. LPN 22 shut the door of the room and Resident 55 started beating at the door and yelling. LPN 22 went through an adjoining room and came back into the hallway. LPN 22 attempted to talk with Resident 55 to calm her but was unsuccessful and left the unit to find help. Other staff went to try to help Resident 55 but were not successful. LPN 22 explained that staff always get into it with Resident 55 about the linen carts. Resident 55 would charge at them when they redirected her from the carts. The staff would try to talk with Resident 55 when she was having behaviors and try to diffuse the situation by accommodating her needs. Resident 55 displayed the worst behaviors when trying to get linens. The staff took her day by day with Resident 55. During an interview on 8/4/22 at 11:37 a.m., CNA (Certified Nursing Assistant) 23 indicated she had been caring for Resident 55 on the night of 7/25/22. She had assisted Resident 55 with incontinent care and gotten her into her wheelchair while changing her bed. CNA 23 had put a clean sheet on the bed but did not have a pad available to use. CNA 23 explained to Resident 55 that she would bring one when the linen was delivered from laundry. Resident 55 had refused to get back into bed. LPN 22 had gone to a different unit to get a pad for the bed. CNA 23 had left the room and went to provide care for another resident. CNA 23 had not witness the incident between Resident 55 and LPN 22. She was told about it after it happened and went to try to assist Resident 55, but Resident 55 had gone back to her room and refused care. During an interview on 8/5/22 at 9:21 a.m., LPN 24 indicated Resident 55 had behaviors daily. She would refuse care and go in and out of other resident's rooms to find linen. The staff would try to provide her with linen, but she would not always take it from them. LPN 24 had never witness any staff member be abusive toward Resident 55 but had witnessed Resident 55 hitting staff. During an interview on 8/5/22 at 9:28 a.m., LPN 25 indicated Resident 55 would often have behaviors, she would throw things at the staff and start screaming and that she had seen the staff display a lot of patience while caring for Resident 55. During an interview on 8/5/22 at 9:44 a.m., the SSD (Social Services Director) indicated Resident 55's behaviors were reviewed in IDT's (Interdisciplinary Team) morning stand up meeting almost daily. She reviewed the behaviors on a daily basis. Most of Resident 55's behaviors involved refusing care and there were behaviors about linens. Every 2 weeks the psychiatric team would meet and go over the residents who needed to be seen. Resident 55's behaviors seemed to be affected by her communication deficit. Resident 55 had trouble communicating her needs to staff but seemed to be able to communicate her needs so that her daughter understood. The staff had tried using the communication book to communicate with her, but she was not able to effectively utilize it. The IDT team reviewed her behaviors and what interventions had worked and were trying to develop a new plan. The only new intervention that had been somewhat effective was to call her daughter when she was having a behavior. She had been seen by the psychiatric physician. 2. The clinical record for Resident 30 was reviewed on 8/5/22 at 9:16 a.m. Resident 30's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30's quarterly MDS (minimum data set) dated 6/1/22 indicated, Resident 30 was cognitively intact, had no [CONDITION(S)] or behaviors. Resident 30's care plan dated 5/17/22 indicated, she displayed the following behaviors: hitting at others, yelling out, and inappropriate remarks relate to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, but not limited to, to receive psychiatric services as needed, social services to intervene when needed, and redirection when behavior begins. A behavior sheet dated 5/11/22 indicated, staff walking by patient in [sic] hall. patient[sic] put her hand up as to hit staff,[sic] staff moved out of the way. Therapy staff stated[sic] did you think she was going to hit you.[sic] Staff stated [sic] she hit me the other day. [sic]Patient stated[sic] 'Yes I know I hit you'. The intensity score on the behavior sheet indicated 3. Interventions used and their outcomes were: - Approached in calm manner; outcome was behavior unchanged - Identified self; outcome was behavior unchanged - Established eye contact; outcome was behavior unchanged The solution was Staff to avoid contact with patient Resident 30's May MAR (medication administration record) and TAR (treatment administration record) were reviewed 8/5/22 at 9:16 a.m. Neither the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 30's May 2022 behavior tracker under tasks in the electronic charting system was received on 8/5/22 at 1:10 p.m. from ED (Executive Director) indicated, on 5/16/22 at 9:55 a.m., Resident 30 displayed no behavior symptoms. Resident 30's behavior tracker for the past 30 days did not contain any documentation. An interview with CNA (certified nursing assistant) 3 was conducted on 8/05/22 at 10:54 a.m. CNA 3 indicated, Resident 30 still displays some behaviors such as cursing at staff and motioning as though she was going to hit you. CNA 3 stated, when she displayed those behaviors, he would just tell the nurse when they happen. An interview with LPN (licensed practical nurse) 4 was conducted on 8/05/22 at 10:57 a.m. LPN 4 indicated, when a behavior symptom occurs, the behavior should be documented in the behavior binder or in the electronic charting system as a behavior note. An interview with DON (Director of Nursing) was conducted on 8/05/22 at 11:06 a.m. DON indicated, the behavior binders on the units contain the behavior care plans, interventions, and a list of known behaviors, but to her knowledge it did not contain behavior notes. She further indicated, if the resident has a behavior, it should be placed in the electronic charting system under the behavior sheet assessment. 3. The clinical record for Resident 37 was reviewed on 8/3/22 at 10:28 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment, dated 6/13/22, indicated Resident 37 was cognitively impaired. A care plan last review date of 6/14/22, indicated I [Resident 37] have behavioral symptoms such as making inappropriate sexual remarks to staff during care related to a cognitive deficit. A nursing note dated 5/16/22 indicated Pt [patient] (Resident 37) noted to have inappropriate sexual advances towards staff on multiple occasions. Expressed per staff and also per spouse . A nursing note dated 6/7/22 indicated .Pt. has expressed sexually inappropriate gestures toward staff. Pt. is mostly redirectable. No aggressive behavior noted. A behavior sheet dated 6/7/22 indicated Resident 37 had sexually inappropriate behavior. The sheet noted, .RN [Registered Nurse] not able to determine what contributed to behavior. Behaviors happens in pt. room during care. Remarks are made towards CNA [Certified Nursing Assistant]. A nursing note dated 8/3/22 indicated .Resident's was more confused and aggressive today during cares, wife tries to instruct resident during cares while CNA's attempt to do cares on resident, resident seems to get more angry and confused trying to listen to his wife and the cna's during cares, cares was completed today. A nursing note dated 8/4/22 indicated .Cna states resident was being inappropriate during cares, he felt on her buttocks. The resident's clinical record did not include behavior sheets on 5/16/22, 8/3/22, or 8/4/22, nor continuing monitoring every shift conducted after each behavior incident. An interview was conducted with License Practical Nurse (LPN) 22 on 8/5/22 at 10:57 a.m. She indicated she had heard about Resident 37's sexual inappropriate behaviors, but had not observed any incidents herself. An interview was conducted with the Social Services Director on 8/5/22 at 2:58 p.m. She indicated she was currently working on improvement of the behavior management program. An interview was conducted with the Director of Nursing (DON) and the Nurse Consultant on 8/5/22 at 3:30 p.m. The DON indicated the staff would complete a behavior sheet after an incident, and then the behavior would be added in the task tab. The behavior would then be monitored and documented in the task tab every shift. She was unable to find any behavior sheets for the 5/16/22, 8/3/22 and 8/4/22 incidents nor monitoring of Resident 37's behaviors conducted every shift. A Behavior Management Policy was provided by the Executive Director on 8/5/22 at 8:57 a.m. It indicated .Policy: To ensure the resident receives effective treatment and interventions for behavior and mood symptoms. To ensure the resident is receiving the necessary medication at the lowest effective dose to treat their symptoms. Procedure: 1. The CNA will document behaviors in the Electronic Medical Record when behaviors occur. The CNA will notify the nurse of the behavior. 2. The nurse or social service will complete the behavior sheet upon being notified of or witnessing a behavior .5. Social Services will complete follow-up documentation of behaviors under progress notes. 6. Residents that are on Behavior Management Programs will have documentation of behavior symptoms completed every shift by the nursing staff on Point of Care. This will allow for accurate documentation and assessment of the resident's behaviors, and therefore appropriate follow-up by the Interdisciplinary team. 7. Residents that have a new behavior will have documentation on behaviors on the Point of Care for two weeks to determine if the behavior is ongoing. This will allow for appropriate assessment of the behavior 10. Criteria for the Behavior Management Program would include: a) Behaviors that present a risk of danger or harm to the resident, b) Behaviors that present a risk of danger or harm to others, c) Behaviors that fringe upon the rights of others, or is so disruptive that is interferes with the rights and dignity of others. d) Behaviors that significantly reduce staff ability to provide care . 3.1-37(a)

Based on interview and record review, the facility failed to timely address a resident's continued pain resulting in a delayed hospitalization with rib fracture and [CONDITION(S)] related to a [CONDITION(S)] (urinary tract infection) and to monitor the effectiveness of pain medication timely for 2 of 3 residents reviewed for falls and hospitalization . (Residents B and D) Findings include: 1. The clinical record for Resident B was reviewed on 5/9/22 at 10:50 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [CONDITION(S)] care plan indicated he was at risk for urinary tract infections. The goal was for him to be free from signs and symptoms of a [CONDITION(S)] with an intervention for him to report and for the facility to observe for signs and symptoms of a [CONDITION(S)] such as burning and pain on urination. The at risk for falls care plan indicated the goal was to minimize his risk for falls resulting in serious injury. The 4/12/22 nurse practitioner note referenced and unwitnessed fall with a skin tear while transferring from the wheel chair to the toilet seat. There was no pain. His vitals were stable, and his neurological checks were within normal limits. The 4/14/22, 9:11 p.m. NP (Nurse Practitioner) note, written by NP 3, indicated he was seen for an acute visit for dysuria (discomfort, pain, or burning when urinating.) He self catheterized and had frequent UTIs. He denied hematuria (blood in urine,) fever, chills, or flank pain. His recent labs showed elevated WBC (white blood cells) from baseline at 10.1. There were no other concerns today. It read, He reports difficulty urinating and increased urinary frequency but reports no hematuria. The assessment and plan section of the note read, Dysuria - UA/CS [urinalysis, culture and sensitivity] .Painful micturition [action of urinating.] The family history section of the note indicated he was married and had a daughter. The 4/15/22, 12:50 p.m. nurse's note read, Resident called wife and c/o [complained of] lower back pain. Wife called to speak to writer about maybe going to ER [emergency room .] Writer went in to assess resident. Resident stated that if writer could give him Tylenol and obtain urine for a UA he would wait for the results before going to the ER. Urine obtained and Tylenol administered. The April, 2022 MAR (medication administration record) did not indicate any Tylenol was given to Resident B on 4/15/22. The 4/15/22 Urinalysis results indicated the specimen was collected on 4/15/22 at 10:00 a.m. and reported on 4/16/22 at 1:19 p.m. There were 3 abnormal results of slightly cloudy clarity, 1+ protein, and 1+ bacteria. There was no information in the clinical record to indicate the lower back pain or 4/15/22 urinalysis results were reported to the physician/nurse practitioner. An interview was conducted with the DON (Director of Nursing) on 5/10/22 at 11:59 a.m. She indicated there was no verification the physician/NP was notified of Resident B's lower back pain indicated in the 4/15/22 nurse's note. An interview was conducted with NP 3 on 5/10/22 at 1:44 p.m. She indicated she was not notified of the 4/15/22 UA results until 4/18/22. She was not notified of Resident B's lower back pain either. The facility could have forwarded her the information or used the on call number to notify. She would have wanted to know about the back pain, because it was a symptom of a [CONDITION(S)], a kidney stone, a lot of different things. Knowing about the back pain would have possibly changed her treatment. It would require an assessment of him. Ideally, she would have assessed him in person. If she couldn't do it physically, she could have given another order for maybe labs to see if there was WBC elevation to order an antibiotic or something. An interview was conducted with CNA (Certified Nursing Assistant) 6 on 5/10/22 at 2:22 p.m. She indicated she worked on 4/15/22 and 4/16/22. Resident B was complaining about hurting. She informed the nurse, but was unsure what was done from there. She stopped by his room to answer his call light. He wanted the nurse to come in, because something was hurting, his leg or back or something. The next nurse's note after the 4/15/22, 12:50 p.m. note was on 4/17/22 at 11:28 a.m. It read, Resident has left LOA [leave of absence] with daughter. Family stated that resident will return at approximately 5:00 p.m. The 4/17/22, 12:59 p.m. nurse's note read, Daughter placed a call to facility to inform staff that she placed a call to 911 while resident was LOA with family d/t [due to] SOB [shortness of breath,] fatigue and c/o pain from recent fall. Resident has been transported to [name of hospital.] An interview was conducted with Resident B's wife, Family Member 4, on 5/9/22 at 1:52 p.m. She indicated Resident B recently fell at the facility just before Easter. He went to use the commode and fell nearby it. That's the fall where he broke his rib. The next day or so he kept telling her he was really sore and needed to go to the hospital. Their daughter, Family Member 5, picked up Resident B from the facility for Easter, on 4/17/22. He was so weak, she had to pick him up and put him in the car. He came home and was looking forward to Easter Dinner. She asked him if he wanted to sit in his lounge chair. She then asked him if he could transfer himself into the chair. Resident B informed her he couldn't and needed to go the hospital. He was complaining of pain the entire time, saying not to touch him on his side. It took 4 fireman to pick him up and place him on the stretcher. At the hospital, they told him not to favor that side or hunch down or he'd get pneumonia and now he had pneumonia. He was also diagnosed with a [CONDITION(S)] at the hospital. He was in the hospital for a week, and was currently in another facility. The 4/17/22 emergency room note read, .presenting today with weakness and altered mental status. Per family as well as patient, he was brought from the ECF [extended care facility] that he lives at [name of facility] rehab [rehabilitation] and help [sic] home for Easter dinner with family. Daughter [name of Daughter] stated that the patient was feeling very weak and was unable to get out of his chair and walk around like he normally does. She did also mention that he seemed a bit disoriented. Patient told family that he had an episode of falling down 2 days ago and the ECF did not report that to the family. Patient has been complaining of difficulty breathing as well as right chest wall pain. Patient denied [CONDITION(S)] or loss of consciousness with the fall. Apparently he lost his balance and fell forward. On evaluation, patient was alert and oriented x [times] 1. He did mention pain with deep breaths. He also had a cough that he said he developed a couple weeks ago. In addition, patient states that he has had pain with urination with a burning sensation that has been ongoing for a couple days. Patient does have a history of urinary retention and it [sic] has a history of self-catheterization.Initial work-up is significant for WBC of 17.8, AST [[MEDICATION(S)] aminotransferase] 59, ALT [[MEDICATION(S)] transaminase] 16, alk phos [alkaline phosphatase] 221, T bili [bilirubin] elevated at 2.5 .CTA [computed tomography [MEDICATION(S)]] of the chest and abdomen showing a posterior right rib fracture as well as a L5 [fifth lumbar] compression fracture Assessment and Plan [A/P]: Problem 1: [CONDITION(S)] A/P 1. Patient meets SIRS [systemic [CONDITION(S)] response syndrome] criteria with an elevated WBC count of 17.8, tachypnea with respiratory rate of 32. Source of infection likely urinary with a UA showing moderate leukocytes, more than 100 WBCs, moderate leukocytes, marked bacteria. Chest x-ray is normal and lungs are clear to auscultation, unlikely respiratory infection .Continue [MEDICATION(S)] .Problem 3: [CONDITION(S)] A/P 3: Patient has clinical signs of urinary tract infection with burning sensation with urination. Patient has a chronic history of urinary retention .Continue antibiotics with [MEDICATION(S)] Problem 7: Rib Fracture A/P 7: Patient had an episode at his ECF a couple days ago where he lost his balance and fell forward. CT of the chest shows a posterior right 11th rib fracture as well as an L5 compressive fracture that is likely chronic We will treat for pain. 2. The clinical record for Resident D was reviewed on 5/9/22 at 2:41 p.m. Resident D's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated 4/9/22 at 3:35 p.m. indicated, Resident D had fallen. She was found laying on her back in her bathroom. A physician's progress note dated 4/11/2022 at 3:59 p.m. indicated, Patient seen in her room seated comfortably in her bed. Per discussion with staff as well as chart review, patient did sustain a recent fall. She was found on the bathroom floor by nursing staff. Patient was found lying on her back in the bathroom .Patient denies hitting her head or losing consciousness during her fall. She did have some right foot pain with swelling noted after her fall. A set of right foot plain radiographs was[sic, were] taken and these were reviewed today. Those plain radiographs were without evidence of acute fracture or dislocation. Patient is endorsing some aching type pain at the right foot today. Her pain is aggravated by touch. Her pain is alleviated with rest as well as oral medications . Resident D was discharged from the facility to home with her son on 4/11/22. Resident D was readmitted to the facility following a hospitalization for altered mental status and failure to thrive at home on 4/21/22. A nursing note dated 4/21/22 at 3:06 p.m. indicated, Resident D had bruising noted to her right outer foot and the treatment included painting it with [MEDICATION(S)] and wrap with kerlix daily and as needed. Also noted was, the presence of a blister to the top of right foot. Resident D rated her pain to the right foot as a 9 out of 10. A rating of 10 being the worst pain. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident D's April MAR (Medication Administration Record) was received on 5/10/22 at 1:36 p.m. from DON (Director of Nursing) The MAR indicated the following: - On 4/21/22, Resident D received the [MEDICATION(S)] at 2:25 p.m. for a pain rating of 4 out of 10. The effectiveness of the medication was not documented until 8:21 p.m. on 4/21/22 which was almost 6 hours after the administration of the medication. - On 4/22/22 at 9 a.m. Resident D received her hydromophone for a pain rating of 3. The effectiveness of the [MEDICATION(S)] was documented at 10:21 a.m. which was 1 hour and 21 minutes after the administration of the [MEDICATION(S)]. - On 4/24/22, Resident D was given a [MEDICATION(S)] tablet at 11:06 a.m. The effectiveness of the [MEDICATION(S)] was documented at 11:11 a.m. which was 5 minutes after the administration. - On 4/25/22, it indicated, Resident D was administered a [MEDICATION(S)] tablet at 9:09 a.m. The effectiveness of the [MEDICATION(S)]. was documented at 11:49 a.m. which is 2 hours and 40 minutes after the administration. - On 4/26/22, Resident D was given [MEDICATION(S)] at 10:50 a.m. for a pain level of 9. The effectiveness of the [MEDICATION(S)] was documented at 10:51 a.m. and was marked as 0, which was one minute after the administration. It was assessed again at 12:56 p.m. as 5, 1 hour and 2 minutes after medication administration. - On 4/ 27/22, Resident D was administered [MEDICATION(S)] at 7:45 a.m. The effectiveness of the medication was documented at 1:40 p.m., which was 5 hours and 55 minutes later. - On 4/28/22, Resident D was administered [MEDICATION(S)] at 9:14 a.m. The effectiveness of the medication was documented at 11:04 a.m., 1 hour and 50 minutes later. Resident D was administered [MEDICATION(S)] at 12:27 p.m. for a pain level of 10. The facility also documented a pain level of 5 at 12:27 p.m. The effectiveness of the medication was documented at 5:28 p.m., which was 5 hours and 1 minute after administration. A copy of Resident D's controlled medication count sheet for [MEDICATION(S)] was provided on 5/10/22 at 1:36 p.m. from DON. The controlled medication count sheet indicated, the following doses of [MEDICATION(S)] were administered, but not recorded on the April MAR and lacked documentation of the effectiveness of the medication: - On 4/22/22, 3 p.m. and 8 p.m. - On 4/23/22, 10:30 a.m. - On 4/24/22, 3 p.m. - On 4/26/22, 7:45 p.m. An interview with DON was conducted on 5/10/22 at 2:55 p.m. indicated, monitoring for the effectiveness of a pain medication should be done 30 minutes to an hour after its administration depending on the route in which the medication was given. She further indicated, monitoring for the effectiveness could identify the need to increase a pain medications frequency or increase in the amount of the medication may be needed. An interview with Resident D was conducted on 5/10/22 at 3:24 p.m. Resident D indicated, she enjoyed going to the activities, however she was not able to go when she was in pain. A Pain Evaluation policy was received on 5/10/22 at 3:05 p.m. from Executive Director 1. It indicated, Purpose: .To provide optimal comfort through a pain control plan, which is established with the members of the health care team 1. Residents will have a pain evaluation completed upon admission, quarterly, and when the resident experiences new pain in a different location 3. Residents will have pain assessed routinely with each dose of pain medication given therefore a new pain evaluation will not be required after changes in medication. This will include both routine and as needed pain medication .6. Nursing will document any complaints or signs/symptoms of pain in the progress notes as indicated. 7. The pain scale will be used to determine the effectiveness of pain interventions. This Federal Tag relates to complaint IN 018. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident did not fall from her bed during resident care that resulted in a fracture with hospitalization and surgical repair for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: The clinical record for Resident C was reviewed on 6/16/21 at 12:00 p.m. The diagnoses included, but were not limited to, [CONDITION(S)] and [CONDITION(S)] (paralysis of one side of the body) following cerebral infarction (ischemic stroke), muscle weakness, reduced mobility, need for assistance with personal care, and [CONDITION(S)]. A Physical Therapy (PT) discharge summary, dated 3/21/21, indicated total dependence with bed mobility, specifically with rolling to the left for Resident C. The interventions included instruction towards staff for optimal technique for bed mobility with cues needed for sequence and Resident C's hand placement. A Quarterly Minimum Data Set (MDS) assessment, dated 5/5/21, indicated Resident C was cognitively intact and marked for the need of extensive assistance with 2 staff persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. A care plan for activities of daily living (ADLs), revised 12/3/20, indicated the following, .I need assistance with my ADLS transfers, toileting, eating, bed mobility, bathing, dressing and grooming related to left side [CONDITION(S)]/[CONDITION(S)] .Interventions .I need physical assist of staff for toileting .I need physical assist of staff with bed mobility .I need physical assistance of staff to cleanse after toileting A care plan for falls, revised 6/3/21, indicated the following, .I am at risk for falls related to impaired balance .Interventions .2 staff members when doing care [bed mobility, toileting and peri (perineal) care] Make sure staff is on both sides of the bed [added on 6/3/21] .Mechanical lift and assist of 2 staff with transfers A progress note, dated 6/2/21 at 11:22 p.m., indicated the following, .while receiving patient care resident was turned onto left side and rolled onto the floor .Stat [urgent] x-ray ordered A document reported to the Indiana State Department of Health Survey Report System, dated 6/3/21, indicated the following, .Staff was providing care and assisted resident to roll on her side. Resident's weaker leg fell forward, causing her to roll off bed on to floor. X-ray of left hip was obtained .Type of Injury .Acute moderately displaced fracture left subcapital femoral neck .Follow-up added -- 6/8/2021 Resident remains at hospital and expect to discharge to another facility. CNA is [Name of CNA 4] .Is completing check-off's and re-education on repositioning residents while in bed A fall interdisciplinary team (IDT) note, dated 6/3/21 at 10:00 a.m., indicated the following, .while receiving patient care resident was turned onto left side and rolled onto the floor out of bed .X-ray of Left hip ordered. Results Acute fracture of left hip. Patient to be sent to hospital for evaluation .Root cause of fall: Patient rolled out of bed during care .Intervention .Two person assist during care for bed mobility and pericare [perineal care] A hospital note, dated 6/3/21, indicated the following, .patient [Resident C] was being cleaned and while she was being turned in the presence of her caregivers at the nursing home, fell out of bed onto her left side .x-ray of the left hip was done this morning on 6/3 which showed left femoral neck fracture A hospital note, dated 6/7/21, indicated the following, .Plan .Admit to Hospitalist. Once the patient is appropriately cleared from the standpoint of other treating physicians, major surgery is planned .Planned Procedure .L [left] hip hemiarthroplasty [surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact] An interview conducted with Qualified Medication Aide (QMA) 8, on 6/16/21 at 10:50 a.m., indicated she would always have a second staff person come to assist with the care of Resident C. She required total assistance with ADLs. An interview conducted with Nurse Consultant 5, on 6/16/21 at 2:05 p.m., indicated Resident C should have been a two-person assist. Her leg was heavier, and the weight would have made it more of a risk in the bed with bed mobility. That's why we made her a two-person assist after the incident. An interview conducted with Certified Nursing Assistant (CNA) 6, on 6/16/21 at 2:53 p.m., indicated she went into the bathroom to prepare washcloths for perineal care of Resident C. She went back towards Resident C's bed and proceeded to turn her on her left side and her right leg went over the side of the bed, towards the window, and Resident C fell on to the floor from the bed. She attempted to hold onto Resident C to prevent her from falling off of the bed but was unsuccessful. She was working evening shift and there were only 2 CNAs scheduled instead of the usual 3 on the 400-hallway. There were usually 2 staff members to assist with the care of Resident C and each staff member would be on either side of Resident C's bed. CNA 6 indicated there was a possibility that Resident C was too far over and not center on the bed enough that could have played a role with the incident. A policy titled Fall Investigation and Risk Evaluation, revised 2/2020, was provided by the Assistant Director of Nursing on 6/16/21 at 3:50 p.m. The policy indicated the following, .It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents .Avoidable Accident means that an accident occurred because the facility failed to: Identify environmental hazards and /or assess individual resident risk of an accident, including the need for supervision and/or assistive devices .Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident This Federal tag relates to Complaint IN 300. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to monitor a resident's toe as ordered and obtain a venous Doppler ultrasound timely that resulted in a hospitalization with the need for surgical intervention for a necrotic toe for 1 of 2 residents reviewed for hospitalization , provide a wound dressing as ordered for 1 of 2 residents reviewed for wounds, and ensure a resident received care in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident L, Resident N and Resident T) Findings include: 1. The clinical record for Resident L was reviewed on 5/18/21 at 11:30 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident L was admitted to the facility on [DATE] and discharged to hospital on 5/8/21. An Admission Minimum Data Set (MDS) dated [DATE], indicated Resident L was moderately cognitively impaired. The resident needed extensive assistance of 2 persons for bed mobility, transfers and total assistance with bathing, dressing and toileting of 1 person. A skin care plan for Resident L dated 5/3/21 indicated I have skin failure (bruise) related to recent fall to my R foot, 1st digit [toe] .Goal I will state my pain is managed with my care plan interventions .Monitor area and notify MD [medical doctor] with any changes noted. During a confidential interview on 5/14/21 at 3:25 p.m., she indicated the nursing staff did not closely monitor or address Resident L's toe timely. They diagnosed her toe as bruised from a fall. Then the resident was days later sent to the hospital and now have toes that are necrotic and gangrene. A Physical Therapy Evaluation dated 4/26/21 indicated on pain assessment .patient states she is having pain that has been going on for a while. Patient did demonstrate pain behaviors when palpating R [right] calf .Patient winces/[NAME] with any movement of RLE [right lower extremity] .behaviors exhibited: moaning, grunting, facial grimacing and tense with any passive movement to RLE . A nursing note dated 4/27/21 indicated Resident L had an unwitnessed fall on this day. Resident L was found on floor of room.Can move upper and lower extremities within normal limits. Alert and oriented x2 [times 2] with slight confusion. Pain in right lower extremity on a scale 3 out of 10 but states pain was present before the fall . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Today, she is endorsing right leg pain, it is in the posterior calf, localized, sharp, hypersensitive to minimal touch, it is fairly constant throughout the day. She denies any significant relief for it. She has no pain medication at this point. She denies any other relief Her pain does get worse with walking pain .[MEDICATION(S)] 50 mg (milligrams) 2x [twice] a day .2. Deconditioning/Gait Instability - Patient is high risk for functional impairment without therapy and adequate pain control. Patient has high risk for developing contractures, pressure ulcers poor healing or fall if not receiving adequate therapy and pain control .7. Right lower calf pain hypersensitive. Recommend a Doppler to rule out blood clot . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication in the health record that this was completed. A nursing note dated 4/30/21 indicated Resident L had an unwitnessed fall on this day. Resident L was found on the floor of room. Staff assessed and no injury noted. An initial skin report dated 5/2/21 indicated Resident L had a bruise on her right great toe. The skin appearance was purple. The resident denied pain. A nursing progress note dated 5/3/21 indicated Resident L had a purple bruise on her right foot big toe. Resident L had no complaints of pain, and it appeared to be from a fall. A physician note dated 5/3/21 indicated Resident L was being seen for pain in her right big toe.Musculoskeletal: Extremities no lower leg [CONDITION(S)]. Right big toe cold, [CONDITION(S)] [redness], tender to touch, weak pulse .6. Great toe pain, right. Suspect ischemia [reduction in blood flow] will have vascular see her today per her follow up . A nursing progress note written by License Practical Nurse (LPN) 3 dated 5/3/21 indicated .MD [medical doctor] saw right big toe this am [a.m.] No new orders. Resident to go see vascular today. Will see if they recommend anything new for resident. Will continue to monitor resident closely. An After Visit Summary from heart and vascular clinic dated 5/3/21 at 10:30 a.m., did not include documentation the toe had been assessed by the clinic. There was no documentation in Resident L's clinical record the nursing staff clarified with the clinic Resident L's toe was assessed on the 5/3/21 follow up appointment. An interview was conducted with Nurse Practitioner (NP) 7 at the cardiac/vascular clinic on 5/17/21 at 10:25 a.m. She indicated Resident L was seen by her on 5/3/21 for a follow up visit due to the resident's hospitalization after a cardiac event a few weeks ago. NP 7 was unaware Resident L's great toe needed to be looked at due to possibly ischemic. The resident was in a wheelchair during her appointment. She had assessed her pulses but had not removed her socks. Resident L's feet were not observed at the appointment, and she had no complaints of pain during the visit. NP 7 indicated she would have absolutely wanted to be informed about the ischemic toe. She would have referred her to be looked at by the vascular team. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .every shift for impaired skin integrity. The May 2021 Treatment Administration Record (TAR) indicated the nursing staff was placing a check mark on the electronic TAR indicating Resident L's bruised toe was monitored for changes every shift on the following days and shifts: 5/3/21 - night shift 5/4/21 - day, evening and night shifts, 5/5/21 - day, evening, and night shifts, 5/6/21 - day, evening, and night shifts, 5/7/21 - day, evening, and night shifts, 5/8/21 - day shift. An interview was conducted with LPN 3 on 5/17/21 at 4:15 p.m. She indicated on the morning of 5/3/21, Physician 35 had come in to see Resident L, and he recommended to notify the vascular clinic to look at Resident L's toe at her appointment that day due to possibly ischemic. She was unsure if the clinic was notified. She had not notified the clinic. LPN 3 had seen Resident L's toe on 5/2/21, when it was a small bruise, but had never seen her toe after that day. She had signed off on Resident L's TAR she had monitored Resident L's bruised toe on Thursday, 5/6/21, day and evening shift, and Friday, 5/7/21, on day shift. An interview was conducted with LPN 2 on 5/18/21 at 9:50 a.m. She indicated she did have Resident L on the week of 5/2/21. The resident had gone to [CONDITION(S)] that morning, so she had not looked at her toe. The resident went to [CONDITION(S)] on Mondays, Wednesdays, and Fridays. She had never seen the resident's toe until she helped assist the evening nurse on Saturday, 5/8/21 to send the resident out to the hospital due to toe pain. LPN 2 had signed off on the TAR she had monitored Resident L's bruised toe on Wednesday, 5/5/21 day and evening shift and Saturday, 5/8/21 day shift. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . This pain remains localized, sharp, hypersensitive to minimal touch and is consistent throughout the day. She states that she does not believe she has been receiving any pain medication and denies any significant relief for the pain in the right calf .She believes that she has been working well with therapy and has been participating well despite her pain .Did discuss patient's case with the nursing staff and they informed me a previous Doppler ultrasound of the right calf was ordered but could not find it per chart review today .Right lower calf pain, hypersensitive. Per chart review and discussion with nursing, there was not yet an order in for a Doppler to rule out blood clot .I personally ordered a Doppler ultrasound of the right calf and communicated directly to nursing verbally and via written script . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Venous Doppler ultrasound of right lower extremity dated 5/6/21 indicated Resident L did not have DVT (deep vein thrombosis). An interview was conducted with Physical Therapist 4 on 5/17/21 at 2:31 p.m. She indicated the resident did have complaints of pain from knee down her lower extremity by just touching it. Nursing staff was aware. An interview was conducted with Physician 36 on 5/17/21 at 11:03 a.m. He indicated he ordered the venous Doppler on 4/29/21, and it had not been done. He reordered it on 5/4/21 to be done immediately. A change of condition for Resident L dated 5/8/21 indicated .Skin Status Evaluation: Discoloration Wound . Pain Status Evaluation: Does the resident/patient have pain? Yes .Nursing observations, evaluation, and recommendations are: Palpated pedal weak or absent pulse skin sloughing present possible necrotic tissue swelling to right great toe. Advancing to second toe with hematoma [bruise] on lateral side of the same leg. Cold to touch painful with movement .Primary Care Provider responded with the following feedback: A. Recommendations: Send out urgent due to rapid change in condition The hospital records for Resident L dated 5/8/21 indicated admitted with .Chief complaint. toe pain. RT [right] great toe x 2 weeks, weak pedal pulse great toe dark in color .necrotic great toe with proximal purple discoloration and swelling which extends into two and a small area on 4. Not able to palpate dp [foot pulses] .on r [right] foot. Mild swelling to foot, colder to touch. Full range of motion .Assessment/Plan .Principal Problem: 4. Ischemic ulcer of toe of right foot Patient states the pain in her toe has been there for a while. Facility reports about 1-2 weeks. Toe is painful, black, with open wound .Has a right common femoral stenosis [narrowing in blood vessel] which is severe and an occluded right popliteal artery [blocked artery lower leg] .She has dry gangrene of her first and second toe .She will likely need a right femoral endarterectomy [removal of blockage] and femoral-tibia bypass [blood redirected through a healthy vessel] She is extremely high risk from an operative standpoint . Podiatry Consult Note .1. Ulceration of the right hallux [toe] with signs of dry gangrene, stable. no clinical infection. 2nd digit early stages of gangrenous changes Plan: .patient right foot wrapped with a [MEDICATION(S)] wet to dry dressing. No sign of infection, no need for antibiotics .Ulcer can be followed by [name of wound care center] . The records indicated Resident L would be placed on palliative care. She was not a candidate for surgical interventions at that time. 2. The clinical record for Resident N was reviewed on 5/12/21 at 3:15 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was .cleanse with normal saline or wound cleanser. Pat dry. Lightly pack with collagen. Cover with dry dressing. every day shift for wound care. A Skin and Wound Evaluation dated 5/11/21 at 7:50 a.m., indicated an assessment was conducted of Resident N's surgical wound to his groin. The measurement of the wound was 0.1 centimeters in area, 0.3 centimeters in length, and 0.5 centimeters in width and 0.3 centimeters in depth. It had light serosanguinous drainage. The old dressing was removed, and the appearance was intact and saturated. An interview was conducted with Resident N on Tuesday, 5/11/21 at 3:24 p.m. He indicated the wound team had come in that morning around 7:30 a.m. and removed the dressing on his groin to assess and take pictures. The nurse was supposed to come in to place a new dressing on, but she had not been in yet. The wound dressing on his groin had been off all day. An interview was conducted with License Practical Nurse (LPN) 2 on 5/11/21 at 3:36 p.m. She indicated she was aware the resident did not have a dressing on his wound. She was waiting to place the dressing on after Resident N took his shower. LPN 2 stated she would place the dressing on now. An interview was conducted with Resident N on 5/11/21 at 3:40 p.m. He indicated today was not his shower day. A shower schedule was provided by the Director of Nursing on 5/13/21 at 4:00 p.m. It indicated Resident N's scheduled shower days was on Mondays and Thursdays. 3. The clinical record for Resident T was reviewed on 5/13/21 at 3:47 p.m. Resident T's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) dated [DATE] indicated, Resident T was cognitively intact and was able to make daily decisions regarding her care. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] >5 lbs in a week. Resident T's recorded weights were as follows: 5/3/21 -- Resident T weighed 444.8 lbs 5/6/21 -- Resident T weighed 463.2 lbs The clinical record did not have weights recorded for the following dates: 5/1, 5/2, 5/4, 5/5, 5/7-5/11, and 5/13/21. The clinical record did not indicate if Resident T's physician was notified of the 18.4 lbs weight gain between 5/3/21 and 5/6/21. The TAR (Treatment Administration Record) was reviewed on 5/13/21. The TAR nor the clinical record provided an explanation as to why Resident T's daily weights were not completed for 5/1, 5/2, 5/5, 5/9, and 5/13 An interview with LPN (Licensed Practical Nurse) 26 was conducted on 5/14/21 at 10:26 a.m. LPN 26 indicated, she had documented Resident T's refusals of being weighed on 5/7, 5/8, 5/10 and 5/13/21. She stated, she thinks she had informed Resident T's physician of the 18.4 lbs weight gain on 5/6/21 yet failed to ensure the clinical record reflected the information. An interview with ADON (Assistant Director of Nursing) was conducted on 5/14/21 at 10:42 a.m. ADON indicated the correct charting for daily weights not recorded would be to indicate why it was not done and not to simply put no or weight not obtained at this time. The notification to physicians regarding weight fluctuation should be in clinical record and in regard to the 5/6/21 weight gain, there is no progress note from physician to indicate he was aware of the weight gain on 5/6/21. This resident often refuses weights, and her weight can fluctuate widely. Resident T is noncompliant with diet, eats double portions, and is not concerned about losing weight or maintaining weight. A Following Medication-Physician Orders/Parameters policy was received on 5/14/21 at 11:25 a.m. from the ADON. The policy indicated, P. Notification of Physician/Prescriber: 1. Persistent refusals. 2. Held medications for pulse, blood pressure, low or high blood sugar, or other abnormal test results, vital signs, resulting in medications being held. 3. Suspected adverse drug reactions. This Federal Tag relates to complaints IN 254, IN 434, and IN 741. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to identify, perform weekly skin assessments, accurately document and implement treatments for pressure ulcers timely for 5 of 5 residents reviewed for pressure ulcers.(Resident B, E, F, G and H) The facility also failed to provide preventative care and follow up with an alteration in skin integrity that was later identified as unstageable pressure injury for 3 of 5 residents reviewed for pressure ulcers. (Resident E, F and G) Findings include: 1a. The clinical record for Resident F was reviewed on 2/26/18 at 1:50 p.m. The [DIAGNOSES REDACTED]. A Quarterly MDS (minimum data set) Assessment, dated 2/1/18, noted a BIMS (brief interview for mental status) score of 12, indicating Resident F is cognitively intact. An Admission Assessment, dated 1/9/18, indicated no pressure injuries/ulcers or any other skin conditions were noted upon admission to the facility. A progress note, dated 1/24/18, indicated the following, .Writer to room d/t (due to) nurse report of skin impairment on left heel. Upon assessment, open area noted to heel. 50% granulation 50% eschar at center (sic). Measures 2.2 x 2. Res (resident) heels floated at time of assessment. Res (resident) denies pain to the area. NP (nurse practitioner) made aware. New tx (treatment) order obtained. Res (resident) to be evaluated by wound MD (physician) on next visit A Weekly Skin Observation, dated 1/27/18, indicated the following, .Open Areas .(marked) YES .Description .buttock, and right heel There was no indication a weekly skin assessment was performed since the admission assessment, dated 1/9/18. A physician order, dated 1/24/18, indicated the following, .Left Heel .Cleanse with NS (normal saline) or wound cleanser. Pat dry. Apply skin prep to area and cover with foam dressing The order had no frequency noted and was discontinued on 2/2/18. The electronic treatment administration record (ETAR), for (MONTH) and February, (YEAR), did not show the treatment order listed above. The order did not have a frequency noted to be transcribed onto the ETAR for administration. A Wound MD progress note, dated 1/29/18, indicated the following, .Wound #1 status is Open. The wound is currently classified as a Unstageable/Unclassified wound with etiology of Pressure Ulcer and is located on the Left Calcaneous. The wound measures 1.7 cm (centimeters) length x 1.2 cm width x 0.1 cm depth Wound Progress .N/A - initial assessment .Plan .Cleanse left heel ulcer; pat dry. Apply skin prep and cover with foam. Change q (every) 3 days and PRN (as needed) displacement (sic) The plan for the use of skin prep and cover with foam was never implemented or noted on the physician orders [REDACTED]. A Wound MD progress note, dated 2/5/18, indicated the following, .Wound #1 status is Open. The wound is currently classified as a Unstageable/Unclassified wound with etiology of Pressure Ulcer and is located on the Left Calcaneous. The wound measures 1.5 cm length x 1.3 cm width x 0.2 cm depth .Wound Progress .Unchanged .Plan .Clean wound with wound cleanser - pat dry. Apply Santyl; cover with fluffed, hydrogel-moistened gauze. Cover with dry dressing and secure. Change daily A physician order, dated 2/8/18, indicated the following, .Left Heel: Cleanse with NS (normal saline) or wound cleanser. Pat dry. Apply Santyl to wound bed .Cover with fluffed, hydrogel-moistened gauze. Cover with dry dressing and secure The ETAR, for (MONTH) of (YEAR), indicated the Santyl was initially signed off, as administered, on 2/9/18. There was no indication in the clinical record as to why the Santyl was not implemented until 2/9/18 or if any treatment was in place until, 2/9/18, to Resident F's left heel. 1b. A Weekly Skin Observation, dated 1/27/18, indicated the following, .Open Areas .(marked) YES .Description .buttock, and right heel There was no indicated a weekly skin assessment was performed since the admission assessment, dated 1/9/18. There was no indication in the clinical record about any alterations in skin integrity related to Resident F's buttocks. An interview conducted with Resident F, on 2/27/18 at 8:55 a.m., indicated she has an area to the back of her butt. The area was identified a week ago. A skin observation was conducted, for Resident F, on 2/27/18 at 9:02 a.m., with the Assistant Director of Nursing (ADON) and the Wound Nurse 3. Resident F's right buttock noted with a dime sized open area that was red in the center with pink discoloration noted to the surrounding tissue. Resident F's left buttock was noted with 2 dime sized pink discolored areas, 1 quarter sized pink discolored area, and a half-dollar sized pink discolored area to her coccyx. These areas did not appear to be open at the time of observation. Wound Nurse 3 indicated, at that time, she was not aware of the area(s) to Resident F's buttocks and noted they were moisture related. An interview conducted with Corporate Nurse 5, on 2/27/18 at 4:50 p.m., indicated she observed Resident F's skin and agreed that it was a stage 2 pressure ulcer to her right buttocks. A Wound Assessment, dated 2/27/18, indicated the following, .Type: .Pressure .Stage 2 .Location .Right Buttock .Acquired .In-House .Notes: .Stage 2 pressure area noted to right buttock. No drainage/odor noted. Wound bed 100% granulation tissue. Peri wound moisture (sic), texture a WNL (within normal limits) (sic) .Has hx (history) of pressure area to buttock .Resident reports buttock tender @ (at) x's (times) 2. The clinical record for Resident E was reviewed on 2/23/18 at 1:30 p.m. The [DIAGNOSES REDACTED]. An Initial Pressure Ulcer Report, dated 2/5/18, indicated the following, .Site .Sacrum .Length .5.0 cm (centimeters) .Width .1.5 cm .Depth .0.5 cm .Wound Description .open area to sacrum, scant drainage skin around wound healthy (sic) .Treatment .no new orders at this time There was no indication an initial treatment was put into place on Resident E's sacrum. A Wound Assessment, dated 2/6/18, indicated the following, .Pressure .Unstageable .Location .Sacrum .Length .1.6 cm .Width .5.0 cm .Depth .0.3 cm A physician order, dated 2/6/18, indicated the following, .Dakins Solution .Apply to sacrum topically every day and night shift for wound A Weekly Skin Assessment, dated 2/7/18, indicated there was an open area to Resident E's coccyx. A Weekly Skin Assessment, dated 2/11/18, indicated no open areas were present for Resident E. A Wound MD progress note, dated 2/12/18, indicated the following, .Wound #1 status is open. The wound is currently classified as a Unstageable/Unclassified wound with etiology of Pressure Ulcer and is located on the sacrum. The wound measures 6 cm length x 2.5 cm width x 1 cm depth .Wound Progress .N/A - initial assessment .Wound #2 status is open. The wound is currently classified as a Category/Stage II wound with etiology of Pressure Ulcer and is located on the right gluteus. The wound measures 0.6 cm length x 1.3 cm width x 0.1 cm depth .Wound Progress .N/A - initial assessment Upon review of the progress notes, Resident E was sent to the hospital on [DATE] and returned to the facility on [DATE]. The hospital discharge orders, dated 2/16/18, indicated the following order, .Dakin's Solution .Apply to sacrum topically every day and night shift for sacral wound . The treatment was last administered on 2/16/18 at 5:00 a.m. An Admission/Readmission Evaluation, dated 2/16/18, indicated Resident E did not have any pressure injuries/ulcers or any other skin conditions noted. The ETAR for February, (YEAR), indicated, from 2/16/18 thru 2/19/18, no treatment was noted for Resident E's sacral pressure ulcer. A Wound MD progress note, dated 2/19/18, indicated the following, .Wound #1 status is open. The wound is classified as a Unstageable/Unclassified wound with etiology of Pressure Ulcer and is located on the Sacrum. The wound measures 2 cm length x 2 cm width x 0.8 cm depth .Wound Progress .Improving .Plan .Wound #1 Sacrum (sic) .Clean wound with wound cleanser - pat dry. Apply Santyl; follow with fluffed moist gauze to fill dead space. Cover with ABD (abdominal pad) and secure. Change daily 3. The clinical record for Resident G was reviewed on 2/27/18 at 11:24 a.m. The [DIAGNOSES REDACTED]. An Initial Non Pressure Skin Report, dated 1/5/18, indicated the following, abrasion .right iliac crest (rear) .2.5 cm x 2.5 cm in size pinkish gray in color No drainage noted (sic) .Treatment .(box left blank) .MD notification .1/5/18 There were no progress notes, dated 1/5/18, related to the alteration in skin integrity for Resident G. An Initial Pressure Ulcer Report, dated 1/8/18, indicated the following, pressure .right lateral back .unstageable .Length .1.3 .Width .1 .Depth ? (sic) .Wound bed with what appears to be slough tissue present. Surrounding tissue red. No odor or drainage noted .Dr.longave order to apply Sensicare to area and to have wound team follow up A physician order, dated 1/8/18, indicated the following, .Sensicare to open area to right lateral back every day. One time a day for open area The order was discontinued on 1/17/18. An Initial Pressure Ulcer Report, dated 1/15/18, indicated the following, .right flank .pressure .Length .2.2 .Width .5.1 .Depth .0.1 .unstageable .Treatment .Cleanse with NS (normal saline) or wound cleanser. Pat dry. Apply skin prep to peri wound. Santyl to wound bed and cover with foam dressing This form was completed by Wound Nurse 3. There were no other wound assessments completed by Wound Nurse 3 prior to 1/15/18. A physician order, dated 1/15/18, indicated the following, .Santyl .Apply to right flank topically every day shift for wound care The order was noted with a start date of 1/18/18. The ETAR for January, (YEAR), indicated the first administration of Santyl was signed off on 1/18/18. The order for Sensicare was still being implemented on 1/16/18. The order was not signed off, as being administered, on 1/17/18. 4. The clinical record for Resident B was reviewed on 2/23/18 at 10:30 a.m. The [DIAGNOSES REDACTED]. Resident B was readmitted to the facility on [DATE]. A Wound Assessment, dated 1/10/18, indicated a stage 4 pressure ulcer to the sacrum was noted upon readmission to the facility. No other skin concerns noted at that time. A progress note, dated 1/27/18 at 14:22 (2:22 p.m.), indicated the following, .Resident has new area to left and right buttock. Wound nurse notified for follow up This progress note was signed by Licensed Practical Nurse (LPN) 6. There was no initial assessment involving measurements or a description of the area(s) to Resident B's buttocks. A progress note, dated 1/28/18, indicated the following, .Resident protective cream applied to buttock . This progress note was signed by LPN 6. An interview conducted with LPN 6, on 2/23/18 at 12:05 p.m., indicated she noted 2 separate areas to Resident B's bilateral buttocks. The areas appeared open and believed to be from the adhesive or tubing from the wound vac Resident B had to her sacrum. LPN 6 indicated she wasn't aware of the facility policy in regards to new alterations in skin integrity. She sent a message to Wound Nurse 3 on 1/27/18 but never heard a response. LPN 6 further indicated they are supposed to complete a weekly skin assessment in the computer system but that hasn't been getting completed. A progress note, dated 2/3/18, indicated the following, .Dietary .Skin condition: stage 4 sacrum improving (sic) .3 other areas undiagnosed per skin/wound tab in (name of electronic medical records system) A Wound MD progress note, dated 2/5/18, indicated the following, .Wound #2 status is open. The wound is currently classified as a Unstageable/Unclassified wound with etiology of Pressure Ulcer and is located on the Left, Medial Gluteus. the wound measures 4.2 cm length x 2 cm width x 0.2 cm depth .Wound Improvement .N/A - initial assessment A weekly skin assessment, dated 2/8/18, indicated the following, .patient has sacral wound and cheek wound There were no weekly skin assessments being completed prior to 2/8/18. There were no treatment orders for Resident B's buttocks noted on the ETAR until 2/6/18. This occurred after she was seen by the Wound MD on 2/5/18. An interview conducted with Wound Nurse 3, on 2/23/18 at 12:31 p.m., indicated the wound to Resident B's buttocks was believed to be caused by the tubing from her wound vac. She was made aware of the skin concern on 2/5/18 when she was doing wound rounds with the Wound MD. She was not aware of any other skin concerns with Resident B, prior to 2/5/18. An interview conducted with Corporate Nurse 8, on 2/23/18 at 12:35 p.m., indicated the weekly skin assessments are to be completed weekly for all residents. 5. The clinical record for Resident H was reviewed on 2/27/18 at 12:00 p.m. The [DIAGNOSES REDACTED]. A Wound MD progress note, dated 1/29/18, indicated the following, .Wound #4 status is open. The wound is currently classified as a Category/Stage III wound with etiology of Pressure Ulcer and is located on the Right, Medial Toe Fifth. The wound measures 0.8 cm length x 0.6 cm width x 0.1 cm depth .Wound Progress .N/A - initial assessment .Plan .Cleanse right fifth toe ulcer; pat dry. Cover with foam; change q (every) 3 days A Wound Assessment, dated 2/1/18, indicated the following, .Pressure .Stage 3 .Location .Right Toes . There were no measurements or a description of the wounds noted. A physician order, dated 2/9/18, indicated the following, .Right 5th toe: place foam dressing every day shift There were no other treatment orders noted for Resident H's right 5th toe prior to 2/9/18. A weekly skin assessment, dated 2/9/18, didn't note any alterations in skin noted to Resident H's right toes. A weekly skin assessment, dated 2/16/18, didn't note any alterations in skin noted to Resident H's right toes. A Wound Assessment, dated 2/19/18, indicated a stage 3 pressure area to Resident B's right toes but no measurements or description of the wounds were noted. A Wound MD progress note, dated 2/26/18, indicated the following, .Wound #4 status is open. The wound is currently classified as a Category/Stage III wound with etiology of Pressure Ulcer and is located on the Right, Medial Toe Fifth. The wound measures 0.5 cm length x 0.4 cm width x 0.1 cm depth An interview conducted with Corporate Nurse 8, on 2/27/18 at 1:10 p.m., indicated there is an initial assessment to be completed and the wound nurse will follow-up within 24 to 72 hours, or the next time she's in the building. The facility will try to treat the wounds in-house but will refer to the Wound MD as needed. A treatment should be implemented when an area is found. When the wound nurse follows up she will make sure that treatment is appropriate. An interview conducted with the Director of Nursing, on 2/27/18 at 4:55 p.m., indicated a weekly skin assessment is performed on all residents. If there is a new alteration in skin integrity an initial pressure or non-pressure assessment is completed with physician notification and orders for a treatment. The next working day the wound nurse will follow-up to make sure that treatment is appropriate. The wound nurse then performs weekly assessments of the wounds that contain measurements and the description of the wound. She did notice a concern related to the weekly skin assessments not being completed. She expects the weekly skin assessments and weekly wound assessments to be accurate and complete. A policy titled Wound Documentation, revised 01/18, was provided by Corporate Nurse 8 on 2/23/18 at 1:04 p.m. The policy indicated the following, .1. On admission the admitting nurse will document any wounds or skin conditions on the initial pressure or non-pressure progress reports or using the skin and wound application. The facility will decide how the initial documentation is to be completed .2. The wound nurse/designee will complete an assessment within 24-72 hours from admission .The wound nurse/designee will be responsible for documentation of any areas on the skin using the skin and wound application within 24-72 hours of admission .The wound nurse/designee will address each area using the skin and wound application weekly (no later than 7 days) until resolved .3. When a wound is found after admission the nursing finding the wound will complete an initial pressure or non-pressure report or an assessment using the skin and wound application. The wound nurse/designee will follow up on the report within 24 hours of the observation on Monday - Thursday and within 72 hours when observed on Friday - Sunday .6. Weekly Skin Observations- This is to be completed weekly (no later than 7 days) by the staff nurses .The nurse is to document all areas of skin conditions that are present whether they are new or ongoing. A wound that has already been noted should be documented on this assessment .7. Initial Pressure Ulcer Report- To be completed by the nurse that found the pressure ulcer, if the facility elects to use this. Also to be completed on admission when the resident is admitted A policy titled Wound Documentation Guidelines, revised 01/18, was provided by Corporate Nurse 8 on 2/23/18 at 1:04 p.m. The policy indicated the following, .When charting a description of a pressure injury, the following components should be a part of your weekly charting .1. Location .2. Stage .3. Dimensions .4. Undermining/Tunneling .5. Wound Base Description .6. Drainage .7. Wound Edges .8. Odor .9. Pain .10. Progress This federal tag relates to Complaint IN 602. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a non-verbal resident did not experience pain during treatment, including wound dressing changes, as expressed by grimacing, groaning, moaning, facial expressions, and body posture. 1 resident of 3 (Resident #D) reviewed for pain in a sample of 4. Findings include: The record of Resident #D was reviewed on 6/10/14 at 1:00 P.M. [DIAGNOSES REDACTED]. A significant change Minimum Data Set assessment dated [DATE] indicated Resident #D was severely cognitively impaired (severe difficulting thinking or communicating), did not ambulate, required extensive to total assist with all activities of daily living, required extensive assist of 2 staff for bed mobility, and was incontinent of bowel and bladder. Progress notes for Resident #D indicated: 5/03/14 3:48 P.M. "...facial grimacing noted. Brow is wrinkled. Resident is moaning...Level of pain is difficult to assess." 5/04/14 4:01 P.M. "...difficult to rate pain as resident is not able to verbalize..." 5/05/14 2:39 P.M. "...complains of pain at site of wound. Facial grimacing noted. Resident is moaning. Resident does not verbalize pain with descriptions." 5/06/14 4:08 P.M. "...Resident unable to rate pain..." 5/09/14 4:03 P.M. "...Resident unable to rate pain..."5/12/14 3:59 p.m. "...Facial grimacing noted. Has been grunting." 5/13/14 3:33 P.M. "...Resident has been frowning. Resident is moaning. Has been grunting..." 5/14/14 2:18 P.M. "...Resident is moaning. Has been grunting. Has been resistive to care." 5/18/14 3:26 P.M. "...Resident in a fetal position most of shift...Resident unable to communicate pain. Wincing and moaning with movement..." 5/22/14 1:16 P.M. "...Resident has jaws clenched. Mouth is turned down. Resident is moaning. Has been grunting. States constantly in pain..." 5/26/14 3:50 P.M. "...Resident is moaning. Has been grunting. Resident is unable to rate pain." 5/29/14 3:52 P.M. "...Resident is moaning. Has been resistant to care." 5/31/14 12:50 P.M. " Resident unable to verbalize pain scale. Resident moans intermittently with treatment, resists with tense muscular movements. Facial grimacing noted. Resident is moaning. Has been grunting..." Resident #D's record did not contain any documentation of physician notification, requests for additional pain medication or alteration in medication scheduling, or communication with nursing management related to the above documented incidents of non-verbal expression of pain. Resident #D had a health care plan dated 5/08/14 which indicated: "Focus: (Resident #D) is at risk for pain related to wounds. Goal: Resident will not have uncontrolled pain through next review. Interventions: Administer pain medication as indicated. Observe for non-verbal signs of pain such as grimacing or other facial expressions. Reposition every 2 hours and PRN (as needed) to provide comfort." physician's orders [REDACTED].#D's "Order Recap Report" for the period of 03/01/2014 through 06/30/2014 indicated: 4/30/14 "[MEDICATION NAME]-[MEDICATION NAME] 5-325 MG (milligrams) Give 1 tablet by mouth three times a day for pain related to pressure ulcer." This medication order was discontinued 6/10/14 due to "change in pain medications." 5/30/14 "Medicate resident at least 30 minutes prior to wound care." This order contained no additional instructions. During an interview 6/10/14 at 1:30 P.M. L.P.N. #3, Resident #D's assigned nurse, indicated she believed this order was intended to indicate Resident #D was to receive pain medication 30 minutes prior to wound dressing changes. She stated "She has wounds which are painfulul when we change dressings." During an interview on 6/10/14 at 3:50 P.M. with the D.O.N. and Nurse Consultant, both indicated the above order was not a valid physician's orders [REDACTED]. They also indicated they had reviewed Resident #D's medication and treatment records for the period of 5/30/14 through 6/10/14 and could not determine if Resident #D had pain medication administered 30 minutes prior to wound treatment. 6/10/14 "[MEDICATION NAME] (Concentrate) Solution 20 MG/ML (milligrams per milliliter) Give 0.25 ml sublingually (under the tongue) every 6 hours related to pressure ulcer..." 6/10/14 "(Brand name of medication) Tablet 5-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet via [DEVICE] (gastrostomy tube) every 4 hours as needed for pain." Resident #D's medication orders did not contain any PRN (as needed) pain medication orders from admission on 4/29/14 through 6/10/14. A "Pain Monitoring Tool (PAINAD)" assessment, the facility's pain assessment tool for non-verbal residents, was completed 6/10/14 and indicated Resident #D had a pain rating of 6, indicating moderate pain. Resident #D's record contained no "Pain Monitoring Tool (PAINAD)" pain assessment prior to that date. During an interview with the D.O.N. on 6/12/14 at 10:30 a.m. she indicated no "Pain Monitoring Tool (PAINAD)" assessment had been completed for Resident #D prior to 6/10/14, as indicated by facility policy. A "Pain Evaluation" policy dated 3/2012 received from the D.O.N. on 6/11/14 at 9:25 A.M. indicated: "Purpose: 1. To establish guidelines to measure a resident's level of pain. 2. To provide optimal comfort through a pain control plan, which is established with the members of the health care team. Policy: 1. Residents will have a pain evaluation completed on admission, quarterly, and with significant change in pain status. 2. A resident with cognitive impairment that is unable to verbalize pain will have the PAINAD completed..." This federal tag relates to Complaint IN 445. 3.1-37(a)

Based on record review and interview the facility failed to ensure a resident who was without pressure sores did not develop pressure sores, as evidenced by a resident who developed who developed stage lll and stage lV pressure sores. 1 resident (Resident #C) of 3 reviewed for pressure sores in a population of 4. Findings include: The record of Resident #C was reviewed on 6/09/14 at 2:00 P.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (M.D.S.) assessment dated [DATE] indicated Resident #C was cognitively impaired (difficulty thinking or communicating), did not ambulate, was incontinent of bowel and bladder, and required extensive to total assistance with activities of daily living. "Weekly Skin Observation" assessment documentation records for Resident #C contained categories for documenting Skin Tears, Open Areas, Bruises, Surgical Wounds, Dry Cracked Lips, Rashes, Burns, and Dry Mucous Membranes. These assessments indicated the following: 4/29/14 All categories marked "No." 5/06/14 "Open Areas" marked "Yes" with the note "Ammonium [MEDICATION NAME] 12% lotion apply to bilateral lower extremities topically two times a day for dry skin." All other categories marked "No." 5/13/14 "Open Areas" marked "Yes" with the note "Resident has redden (sic) area to scrotum." All other categories marked "No." 5/23/14 All categories marked "No." 5/27/14 Categories "Skin Tear" and "Dry Mucous Membranes" marked "Yes" with no accompanying narrative notes. All other categories marked "No." 5/30/14 Categories for "Skin Tears" and Surgical Wounds" not marked as assessed. All other categories marked "No." An interview with C.N.A. #2 conducted by the D.O.N. on 6/10/14 related to L.P.N. #1's assessment of Resident #C's skin indicated: "Employee (C.N.A. #2) stated she gave resident (Resident #C) a shower on 5/30/14 and notified nurse to come do a skin assessment. She stated she lifted the resident, and the nurse felt over his bottom, and viewed all other areas of skin..." During an interview on 6/09/14 at 3:15 P.M. with the Administrator, Nurse Consultant, and Resident #C's assigned nurse present, the Director of Nursing (D.O.N.) reviewed Resident #C's clinical record in it's entirety and indicated that prior to the identification of Stage lll and Stage lV pressure sores on 5/31/14, Resident #C's record contained no documentation of any open areas. During an interview on 6/11/14 at 4:15 P.M. with the Administrator, Nurse Consultant, and Corporate Director of Nursing present, the Director of Nursing (D.O.N.) indicated that all recent skin assessments for Resident #C had been completed by the same nurse, L.P.N. #1. The D.O.N. indicated that L.P.N. #1 had been educated and trained in facility policies and procedures related to skin assessment and documentation. She indicated L.P.N. #1 had not followed facility guidelines in assessing and documenting Resident #C's skin condition as noted in the "Weely Skin Observation" above, and that these assessments did not accurately reflect Resident #C's skin condition. The D.O.N. also indicated that the assessment described in C.N.A. #2's statement above did not reflect an appropriate assessment based on facility policy and procedure. Progress Notes for Resident #C indicated: 2/17/14 4:00 P.M. "Writer assessed bilateral lower extremities and skin integrity noted clean/dry and intact." 2/18/14 3:48 P.M. "Writer assessed resident scrotum and bilateral buttocks, no open areas noted. Skin integrity noted clean, dry and intact..." 3/21/14 1:30 P.M. "Dietary note...No wounds or [MEDICAL CONDITION] noted per skin assessment dated [DATE]..." 4/09/14 2:25 P.M. "...no redness or open areas noted at this time..." 5/31/14 9:11 P.M. "...open areas to the right and left buttock folds with necrotic tissue. (Name of Medical Director) notified, order received for daily wound treatment with (brand name for an enzymatic debridding agent)..." An "Initial Pressure Ulcer Report" for Resident #C dated 5/31/14 at 11:19 P.M. indicated: "Date first Observed: 05/31/2014 Was pressure ulcer present on admission? No. Document location, type, size and stage of pressure ulcer... Site: Left ischium (the lower part of the hip bone); Type: Pressure; Length: 4.5; Width 5.0; Depth: 0.2; Stage: lll (measurements in centimeters.) Right ischium; Type: Pressure; Length: 5.0; Width 3.0; Depth: 1.5; Stage: lV (measurements in centimeters.)" A health care plan for Resident #C dated as initiated 3/07/14 indicated "Focus: Potential for Pressure Ulcers related to history of ulcer(s), immobility." During an interview with the D.O.N. on 6/10/14 at 3:50 P.M., she indicated after Resident #C's pressure sores were identified on 5/31/14, a Low Air Loss pressure relieving mattress was ordered for Resident #C. Prior to that Resident #C had been on the facility's standard foam "pressure relieving" mattress. The D.O.N. also indicated that prior to 5/31/14 Resident #C had not received any [MEDICATION NAME] (preventative) treatment to prevent skin breakdown, including but not limited to, the application of barrier cream to the perineal and or buttocks area. A facility document titled "Wound Prevention Protocol" dated 4/2012 received from the D.O.N. on 6/11/14 at 9:25 A.M. indicated: "Purpose: Identify residents that are high risk for developing pressure areas...Relieve or remove pressure. To prevent tissue trauma... Policy: All skin surfaces should be exposed for a thorough examination by a licensed nurse...skin inspection should be done as a component of routine care...Resident specific interventions will be care planned...Weekly skin observations will be recorded in the resident's medical record...Inspect the entire body for any areas with redness or open areas..." This federal tag relates to Complaint IN 431. 3.1-40(a)(1)

Based on observation, interview and record review the facility failed to measure and Stage a resident's pressure ulcers per facility policy, ensure a resident's Stage IV pressure ulcer was securely wrapped to prevent direct contact with and soilage through her sock, ensure appropriate infection control practice was maintained during dressing changes, provide necessary care to ensure proper wound healing and prevention, and follow a plan of care for multiple pressure ulcers resulting in Stage IV pressure ulcer development for 5 of 5 residents reviewed for pressure ulcers. (Residents #42, 37, 118, 100 and 111) Findings include: 1. Resident #100's clinical record was reviewed on 1/14/2014 at 11:20 am. [DIAGNOSES REDACTED]. An Admission/Readmission Data Collection Tool, dated 8/11/2013 at 16:22 (4:22 p.m.), indicated, "2. Skin observations: Using the diagram, indicate all marked areas on body- section were blank. Other open lesion specify: lower left leg-erupted blistering of skin, one area on front of leg, two on back of leg. 6. Foot observations: 8. Describe any open [MEDICAL CONDITION] on feet" the section was blank. An Admission/Readmission Data Collection Tool, dated 8/11/2013 at 18:00 (6:00 p.m.), indicated, "Section 2. Skin Observations: Using the diagram, indicate all marks on body (e.g. pressure ulcers...)" this section was blank. Admission Braden Scale for Predicting Pressure Sore Risk, dated 8/13/2013, indicated, "Score 20: no risk." A care plan, dated 7/31/2013, indicated, "Potential/Actual alteration in skin integrity r/t [MEDICAL CONDITION] of bilateral lower legs and heel. Interventions:...Observe/document location, size and treatment of [REDACTED]." A care plan, dated 10/8/2013, indicated, "Focus: Pressure ulcer present on left heel and right heel r/t history of ulcers. Goals: Pressure ulcer will show signs of healing and remain free from infection through review date. Interventions: Administer treatments as ordered and assess for effectiveness. Assess wounds weekly. Encourage use of bed rails, trapeze bar, etc. for resident to assist with turning. Follow facility policies/procedures for the prevention of/treatment of [REDACTED]. Observe nutritional status. Serve diet as ordered. Monitor and record meal intake. Pressure reducing mattress. Provide supplemental protein, amino acids, vitamins." A 10/21/2013 MDS assessment indicated, "Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? Yes. Stage 4 Pressure Ulcers: 2. Were pressure ulcers present on the prior assessment: No." A care plan meeting note, dated 9/4/2013, indicated, "Bilateral heels and legs are breaking down and receiving treatment..." An interview, with the DON, on 1/13/2014 at 11:14 am indicated, when a new wound is noted, the nurses chart in the electronic chart, initial pressure or an initial non-pressure ulcer skin report. Then they should continue to document daily and the wound nurse should document a weekly summary." The first mention of any wound to Resident #100''s heels was on 9/19/2013. On 9/19/2013 at 4:00 pm, the 'Daily wound documentation' indicated, "1. Wound location(s): left and right lower leg and heels. 9. MD notified? No." On 9/20/2013 at 5:31 pm, the 'Daily wound documentation' indicated, "1. Wound location(s): left and right lower leg and heels. 9. MD notified? No." On 9/21/2013 at 5:31 pm, the 'Daily wound documentation' indicated, "1. Wound location(s): (blank). 9. MD notified? No." On 9/23/2013 at 5:31 pm, the 'Daily wound documentation' indicated, "1. Wound location(s): both feet. 9. MD notified? No." On 9/24/2013 at 11:31 am, the 'Daily wound documentation' indicated, "1. Wound location(s): right and left heel. 9. MD notified? No." On 9/25/2013 at 4:00 pm, the 'Daily wound documentation' indicated, "1. Wound location(s): both feet and heels. 9. MD notified? No." On 9/26/2013 at 6:00 pm, the 'Daily wound documentation' indicated, "1. Wound location(s): both lower extremities and heels. 9. MD notified? No." A 'Non-pressure ulcer skin condition progress report', dated 9/27/2013 at 7:23 am, indicated, "Type of Skin Condition: other. Description: left heel-covered with eschar, 2 cm x 1.5 cm, no drainage or odor. Right heal covered with dry eschar, 4 cm (x) 2.5 cm, no drainage or odor. Treatment/Recommended Changes: Cleanse heels with wound cleanser. Cover with foam and wrap with kerlix. Change daily. MD notified? No. Comments: Eschars on both heels result of excessive fluid from [MEDICAL CONDITION] opening up skin and damage underneath skin surface." An interview with the RN consultant, on 1/14/2014 at 10:59 am, indicated, "I didn't know about the Stage IV's until I went in her room the day she was discharged and the smell was awful. This lady was very non-compliant in general. The nurse should have filled out an "initial pressure ulcer report" when the bilateral heel wounds were first identified. At that time the wound nurse also should have notified the MD, which he did not do. I'm not sure why he didn't notify the MD on 9/20/2013, when the wound first appeared. I'm not sure why the treatment recommendations from 9/27/2013 weren't followed. The resident went out to the hospital and then ended up at a different LTC facility. On 9/27/2013, where the wound nurse documented 'eschar' he should have filled out a pressure ulcer report, because eschar is present with pressure ulcers. The wound nurse also should have, at that point, notified the MD to get the recommendation to be written by MD order." An MD order, dated 10/8/2013 at 3:00 pm, indicated, "Cleanse left and right heels with wound cleanser. Apply santyl (a debridement agent to clean the wound) to wound bed and cover with [MEDICATION NAME], wrap with kerlix, change daily every evening shift for wound healing. D/C (discontinue) dated 10/15/2013 at 8:34 am." An MD order, dated 10/16/2013 at 7 am, indicated, "Santyl ointment 250 unit/gm. Apply to bilateral heels topically every day shift for wound healing. Cover with aqualcel ag and cover with foam dressing. Wrap with kerlix." A (hospital name) operative note, dated 10/24/2013 at 10:56 am, indicated, "Date of Operation: 10/23/2013. Indications for procedure: The patient has been admitted to (name of hospital) [MEDICAL CONDITION] and gangrene to her bilateral heels...She was found to have extensive gas gangrene to her left heel and osteo[DIAGNOSES REDACTED] (bone infection) to her right and left calcareous (heels)...I discussed the need for surgical incision and drainage of both of her heels to try to release the abscess bacteria within the feet, to try to help with [MEDICAL CONDITION]. I discussed the surgery in detail and also discussed that the patient will most likely need 1 (one) , if not both, legs amputated in the future." A (hospital name) discharge summary note, dated 11/6/2013, indicated, "Date of admission: 10/21/2013. Date of discharge: 11/6/2013. Hospital course: 1.[MEDICAL CONDITION] secondary to osteo[DIAGNOSES REDACTED]. The patient had a heel necrotic ulcer...The patient had initial debridement on 10/23/2013 by Podiatry, but recommended to have amputation of the left foot. The patient underwent for procedure on 10/28/2013 with left BKA ([MEDICAL CONDITION])...7. Acute kidney injury, with iron-deficiency [MEDICAL CONDITION] and [MEDICAL CONDITION] of chronic disease on top of that. Blood loss likely from the wound. Received transfusion 10/22/2013 and also received iron infusion for 3 doses..." An interview with the RN consultant, on 1/14/2014 at 3:45 pm, indicated the resident only had a total of 3 Braden score assessments completed, all in August. No other Braden score assessments could be found. An interview with LPN #21, on 1/14/2014 at 4:00 pm, indicated he is the night shift unit manager, he remembers the resident, but it was a long time ago. He doesn't remember being the one who found she had wounds on her heels. He doesn't remember what the wounds looked like. If he were to find a new area on a resident he would do two things. He would notify the MD and also the wound nurse. The wound nurse would then take over from there and get orders for the wound. 2. The clinical record for Resident #42 was reviewed on 1/13/14 at 11:00 a.m. She was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The 10/24/13 Pressure Ulcer Progress Report for Resident #42 indicated she had 5 pressure ulcers with the following measurements in centimeters and stages: Right buttock- 1.4 x 0.6 x 0.1, Stage III;Left Ankle (outer) -2 x 1.2 x 0.1, unstageable; Left inner instep - 8 x 3 x 0.2, Stage III; Left heel - 1.5 x 2 x 0.1, did not indicate a Stage (field was blank); Right toe(s) - 0.5 x 0.5 x 0.1, Stage III The 10/31/13 Pressure Ulcer Progress Report for Resident #42 indicated she had 2 pressure ulcers with the following measurements in centimeters and stages: Right buttock- 1.4 x 0.6 x 0.1, Stage III; Left Ankle (outer) -2 x 1.2 x 0.1, Stage III The 10/31/13 Pressure Ulcer Progress Report did not indicate the measurements and stages for the left inner step, left heel, and right toe(s) mentioned in the 10/24/13 Pressure Ulcer Progress Report. The October, 2010 Wound Documentation Guidelines provided by the Nurse Consultant on 1/14/14 at 12:19 p.m. indicated, "When charting a description of a pressure ulcer, the following components should be a part of your weekly charting. 1) Location 2) Stage... 3) Dimensions..." The 12/31/13 potential for pressure ulcer care plan for Resident #42 indicated an intervention was to, "Follow facility policies/procedures for the prevention/treatment of [REDACTED]. The 11/21/13 Pressure Ulcer Progress Report for Resident #42 indicated she had 3 pressure ulcers with the following measurements in centimeters and stages: Left foot instep - 6.5 x 2 x 0.1, Stage IV; Left ankle (inner) - 0.6 x 0.5 x 0.1, Stage III; Left foot lateral - 0.8 x 0.6 x 0.1, Stage III The 11/27/13 Pressure Ulcer Progress Report for Resident #42 indicated the above 3 pressure ulcers remained, but the left lateral instep was now indicated as a Stage III. During an interview with the DON (Director of Nursing) on 1/13/14 at 2:15 p.m., she indicated once a pressure ulcer has been staged, it cannot be reduced to a lower stage. The 12/10/13 Initial Pressure Ulcer Report indicated a pressure ulcer to Resident #42's right lower leg was first observed on 12/10/13 as a Stage 2II It indicated the dimensions in centimeters were 1 x 1 x 0.1. The description of the wound was, "Pink [MEDICATION NAME] tissue, scant serous drainage, no odor." The 12/17/13 Initial Pressure Ulcer Report indicated a pressure ulcer to Resident #42's coccyx was first observed on 12/17/13 as a Stage III. It indicated the dimensions in centimeters were 4 x 1 x 0.3. The description of the wound was, "Red granulating, moist wound bed, no drainage or odor. Periwound clean, dry, intact." The Comments Section of the report indicated, "Wound discovered during skin sweep on 12/17." During an interview with the DON (Director of Nursing) and Nurse Consultant on 1/13/14 at 2:15 p.m., the DON indicated "I'm really big on wounds, and what I'm seeing in the care plans, treatments and documentation just doesn't make a whole lot of sense to me. The old wound nurse was not doing the job, was not meeting even the basic requirements, such as documentation. His risk factors did not make sense. He needed to go back and address those factors after identification. Failure to perform was his reason for termination." She indicated she'd only been at the facility for 6 weeks and on week 3 she realized there was a problem with wound care. During an interview with the Wound Nurse on 1/13/14 at 11:07 a.m., she indicated she changed the dressings for each of Resident #42's five pressure ulcers earlier that morning and found 3 of the dressings not intact. She indicated when she changed the dressing to the pressure ulcer on Resident #42's ankle it was heavily soiled with drainage, the foam was not intact and the ends were peeling off. She indicated the pressure ulcer to her right lower leg had no dressing or bandage over it at all. She indicated the pressure ulcer to her right lateral foot was heavily soiled with drainage and the edges of the foam were peeling off. An observation of Resident #42's dressing changes to her pressure ulcers was made on 1/14/14 at 10:15 a.m. CNA #20 was observed to pick up a disposable pad off the floor and place it onto the clean wound supply work area. LPN #7 told her to not put it there, and to place it in the trash if it had been on the floor. She then threw it away. The Wound Nurse was in the restroom at this time. When the Wound Nurse returned from the restroom, no one informed her the disposable pad was placed from the floor onto the wound supply work area. She continued with the dressing change to Resident #42's left foot utilizing the supplies from the now contaminated wound supply area. The green sock on Resident #42's left foot was observed with a bloody, wet soilage area the size of a 50 cent piece at the 5th digit area of the sock. The Wound Nurse peeled down Resident #42's left sock. The Stage 4 pressure ulcer with tendon exposed was not covered by the dressing. The dressing was observed 1/2 inch above the wound. The Wound Nurse indicated, "She had a shower this morning. It slid. Now I know to secure it more." During an interview with the Wound Nurse on 1/14/14 at 12:31 p.m. regarding the above observation she indicated, "If I had known (the disposable pad was placed from the floor onto the wound supply work area), it would have been a contaminated field, and I would have gotten new supplies.." 3. The clinical record for Resident #111 was reviewed on 1/15/14 at 2:30 p.m. The [DIAGNOSES REDACTED]. During a review of a (name of wound care company) Progress Note, on 10/2/13, it indicated, "Pressure ulcer, unstageable-Waffle boot not on at present; should wear at all times to prevent re-injury via additional pressure." The (name of wound care company) Progress Note was signed by MD #5. On 1/16/14 at 11:16 a.m., an interview with MD #5 indicated a verbal order was given to the Wound Care Nurse at the bedside during the 10/2/13 visit, for a waffle boot to be worn at all times. A review of the current physician's orders [REDACTED]. The order was initiated on 10/2/13. A review of the 12/20/13 Quarterly Minimum Data Set (MDS) Assessment indicated Resident #111 had a BIMS (Brief Interview of Mental Status) of 15, which was indicative of no cognitive impairment at all. A review of the care plan for pressure ulcer on coccyx, dated 9/17/13, indicated the following interventions: assess wound(s) weekly and follow facility polices/procedures for prevention of/treatment of [REDACTED]. A full body skin assessment (Weekly Skin Observation) was not located in the clinical record between the dates 12/17/13-1/13/14. Wound Measurements for the coccyx, hip, and heel were not located in the clinical record between the dates 1/1/14-1/15/14. A review of a policy, titled PCC Wound Documentation Protocol, received by the Facility Consultant, on 1/14/14 at 12:15 p.m., indicated, "...6. Weekly Skin Observation-This is to be completed weekly by the staff nurses." A review of a policy, titled Wound Documentation Guidelines, dated 10/10, received by the Facility Consultant on 1/14/14 at 12:15 p.m., indicated, "When charting a description of a pressure ulcer, the following components should be part of your weekly charting. (sic) 1. Location: (sic) 2. Stage:...3. Dimensions:...4. Undermining/Tunneling:...5. Wound Base Description:..." During an interview with the Director of Nursing (DoN), on 1/16/14 at 12:25 p.m., she indicated she was unable to locate any full body skin assessments (Weekly Skin Observation) in the timeframe listed above. The DoN also indicated wound measurements were done between the dates listed above, but were not put in the computer yet. The measurements for the wounds, for the dates listed above, were requested at that time. No wound measurements for Resident #111's wounds, for the dates listed above, were not received by final exit on 1/16/14. 4. A record review for Resident #37 was performed on 1/15/14 at 2:48 p.m. Resident #37's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Care plans were observed for both a right posterior thigh wound and right buttock wound. The care plan included, but was not limited to, the following interventions: "...Administer treatments as ordered and assess for effectiveness." On 1/15/14 at 2:29 p.m., during an observation of Resident #37's right buttock and right posterior thigh wounds with the facility wound nurse, she indicated the wounds had a foam dressing in place and a piece of "[MEDICATION NAME]" (a dressing securement device) over the top of it. She indicated the [MEDICATION NAME] should not be in place as it was not listed on the current wound treatment order for Resident #37 and it could potentially make the wounds "worse." She indicated the dressing is not "done the way it should be." On 1/15/14 at 2:48 p.m., during an interview LPN # 6 indicated she changed the dressing to the right posterior thigh wound on 1/15/14 and added the [MEDICATION NAME] over the foam as the " foam wouldn't stay without something over the top of it." She indicated the [MEDICATION NAME] is not part of the current wound treatment order for Resident #37. On 1/16/14 at 11:29 a.m., during an interview, the wound nurse indicated it is not appropriate for nursing staff to place a wound securement device on a wound without a physician's orders [REDACTED]. On 1/16/14 at 11:52 a.m., the Nurse Consultant indicated Resident #37 has not had any weekly skin checks documented by nursing staff since 11/29/13 at the time of admission. 5. On 1/13/14 at 10:32 a.m., during an observation, Resident #118 was sitting in his room, in his wheelchair, watching television. No pressure relief boots were observed on resident's feet. On 1/13/14 at 11:13 a.m., during an observation Resident #118 was observed participating in Physical Therapy without a pressure relief boot on either foot. On 1/13/14 at 11:58 a.m., during an observation, Resident #118 was observed in a wheelchair in his room watching television. No pressure relief boots were observed on his feet at the time. LPN #8 indicated not being aware of any current orders for pressure relief boots. On 1/13/14 at 1:54 p.m., during an observation of Resident #118, he was lying in bed on his back and his heels were not elevated off of the bed at this time. An observation of Resident #118 on 1/13/14 at 2:45 p.m., the resident was lying in bed. His heels were not elevated off of the bed at the time and were lying in contact with the bed. On 1/13/14 at 3:32 p.m., during an observation, Resident #118 was lying in bed, heels were lying in contact with bed. Resident #118 observation 1/14/14 at 10:12 am, resident up in wheelchair in room watching television. Resident #118 observation 1/14/14 at 11:51 am, resident up in wheelchair in dining room. Resident #118 was observed up in wheelchair on 1/14/14 at the following times: 12:48 p.m., 1:29 p.m., 2:42 p.m., 3:07 p.m., and 3:53 p.m. A record review was conducted on 1/13/14 at 10:22 a.m. for Resident #118's clinical record. Resident #118's [DIAGNOSES REDACTED]. The clinical record indicated on 12/17/13 Resident #18 was identified as having a Stage III pressure ulcer to coccyx. Resident #118 discharged to the hospital on [DATE] and returned to facility on 12/23/13. A 12/17/13 Initial pressure ulcer report indicated Resident #118's coccyx wound measured 3.2cm in length, 1.4 cm width, and 0.3 cm depth and identified the wound as a "Stage III." A care plan with a focus of "Potential for Pressure ulcers related to decreased mobility secondary to recent stroke, [MEDICAL CONDITION], diabetes, steroid use, iron def.(deficiency) [MEDICAL CONDITION], and hx of ulcer" was identified in clinical record and the record was initiated 11/25/13. Interventions for this care plan focus area included, but were not limited to: "...Observe/document report to MD PRN changes in skin status: appearance, color, wound healing, size (length X width X depth), stage..." A care plan for Resident #118's coccyx pressure ulcer, dated 12/17/13, indicated the following, but not limited to, interventions, "...limit time up in chair..." A care plan for Resident #118's right heel ulcer, 12/17/13, indicated the following, but not limited to, interventions: "...EZ boot on right heel to off load..." and "...heels up while in bed..." Right (R) buttock abrasion wound order 11/25/13 for "sensi-care barrier to right buttock abrasion each shift, daily. No MD order was observed for pressure relief boots to be applied to resident. MDS admission assessment indicated no pressure ulcers or venous or arterial pressure areas present upon admission. Initial admission assessment, dated 11/22/13, indicated no pressure ulcers for Resident #118 and only a "skin tear" to right buttock area. Coccyx wound indicated as Stage III in 1/7/14 pressure ulcer assessment. A right heel ulcer was also identified in the assessment as "unstageable." A Wound Nurse assessment dated [DATE], indicated the right heel ulcer was "unstageable." During an interview with the DON and Nurse consultant on 1/13/14 at 11:17am, the DON indicated Resident #118 had no pressure ulcers upon admission to the facility. During an interview on 1/14/14 with LPN #13 at 10:12 a.m., she indicated she works "usually 5 days a week with him (Resident 118). She indicated the only wound Res 118 had was an unstageable wound to his R heel. She indicated a coccyx wound, which she indicated he arrived to facility with, is healed over. She indicated interventions for pressure relief for Resident 118 were a compression sleeve to R arm and turning and repositioning efforts done by staff. She indicated turning and repositioning is monitored by nursing who physically observes the resident at least every two hours. During an interview on 1/14/14 with PT Aide #10 and Physical Therapis #4, they indicated 1/14/14 as the first day they have seen Resident #118 with a pressure relief boot on either foot. PT aide #10 indicated he worked with Resident 118 on 1/3/13,1/7/13, 1/8/13, 1/9/13, and 1/13/13. Physical Therapist #4 indicated he worked with Resident 118 on 1/2/13 and 1/10/13 and did not observe Resident 118 with a pressure relief boot on either foot on any occasion. On 1/14/14 at 11:02 a.m., during an interview, the DON indicated that licensed nurses should be assessing residents at risk for pressure ulcer development at least weekly for skin breakdown issues. She also indicated the care plan intervention stating "Observe/document/report to MD PRN changes in skin status: appearance, color, wound healing, size (length X width X depth), stage." implies that a licensed nurse would assess all residents at risk of developing a pressure ulcer at least weekly using a weekly skin observations form. Surveyor requested a facility policy, from Nurse Consultant, on monitoring for skin breakdown at 11:20 a.m. on 1/14/14. The clinical record indicated completed PUSH tool documentation on 12/17/13 and 12/24/13 for Resident #118's pressure ulcers. No PUSH tool documentation was observed in the clinical record between 12/24/13 and 1/14/14. The clinical record indicated one weekly skin assessment was completed (1/6/14) for Resident #118 between 12/17/13 and 1/13/14. The clinical record did not reveal daily wound documentation for Resident #118 on the following dates between 12/17/13 and 1/6/14: 12/24/13, 12/25/13, 12/27/13, 12/28/13, 12/29/13, 1/4/14, and 1/5/14. On 1/14/14 at 1:18 p.m., the DON indicated the "limit time up in chair." intervention is "not as specific as it should be." On 1/14/14 at 1:27 p.m., the Nurse consultant indicated the nursing staff doesn't have a specific measurement instrument to use to determine what "limit time up in chair" means, and she also indicated the care plan intervention needed to be more specific and measurable. She indicated the staff has not been documenting "routinely" on whether the resident has been up in the chair or not in the chair. On 1/14/14 at 12:19 p.m., the Nurse Consultant provided the facility policy for Nursing to utilize to monitor, assess, and document skin condition of all facility residents. The policy indicated Nursing staff should conduct weekly skin assessments of all residents and daily wound documentation on all identified wounds, and weekly progress notes on all identified pressure and non-pressure wounds. She indicated that the weekly "PUSH tool should have been done weekly also" and she indicated "He (previously employed wound nurse) chose not to do that one." She indicated the PUSH tool is another assessment instrument used by nurses for residents with identified pressure ulcers. A facility policy titled "Wound Prevention Protocol" indicated the following: "...5. Daily Wound Documentation - To be completed by the staff nurse or wound nurse daily for any pressure ulcers, diabetic ulcers, vascular or arterial ulcers, and other wounds that require a daily assessment or a dressing. This is not an optional tool..." and, "...6. Weekly Skin Observations - This is to be completed weekly by the staff nurses. This is similar to a shower sheet and should be completed by the nurse working the unit. This cannot take the place of the Non-pressure ulcer or Pressure ulcer progress reports..." and "...It is not optional to use the weekly skin observation in place of the pressure or non-pressure ulcer progress reports..." 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to assess and provide necessary care to a resident with a [MEDICAL CONDITION] and complaints of breathing difficulty and having a rapid heart rate, resulting in the resident becoming unresponsive, having to have CPR (cardiopulmonary resuscitation) preformed and EMS (emergency medical service) called for transport to a hospital. This impacted 1 of 3 residents reviewed for care and treatment in a sample of 3. (Resident C) Finding include: The clinical record of Resident C was reviewed on [DATE] at 1:30 P.M. [DIAGNOSES REDACTED]. A hospital discharge order, dated [DATE], indicated "[MEDICAL CONDITION]- HR (heart rate) 120s -130s on admission down to 109 today - note patient has a history of sinus [MEDICAL CONDITION]- on previous admissions, likely secondary to dehydration in addition to breathing treatments. Patient given fluids initially and some improvement seen. Note patient is afebrial (no fever), elevated but resolving..., was given a beta agonist (regulates heart rate), does not appear in pain - other than some localized discomfort at the teach site noted on admission, he is in sinus rhythm, thus the [MEDICAL CONDITION]- could be secondary to anxiety from the difficulty breathing." Discharge vital signs: blood pressure - ,[DATE], heart rate 109 - 119, respirations 22, O2 saturation 100% on 4 liters of oxygen per tracheotomy. A hospital discharge note, dated [DATE], indicated "...Hospital course: 1. the patient had suctioning performed and was given [MEDICATION NAME] and humidified air, and the pt. (patient) felt better with his breathing. The pt. was also given [MEDICATION NAME] (a mucolytic) via nebs which helped loosen secretions. The patient was to continue receiving [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) and [MEDICATION NAME] via nebs, and humidified air and suctioning at regular intervals. There may be a component of anxiety as well in which the pt. feels even more dyspneic (short of breath), and so he was given [MEDICATION NAME] (an anti-anxiety medication) prn....If this recurrs, pt. needs aggressive suctioning of trach, and can try [MEDICATION NAME] (breathing treatment) and [MEDICATION NAME] via neb." Hospital discharge orders, dated [DATE], included, but were not limited to, Albut 2.5 mg (milligram)/Ipra 0.5 mg neb solution ([MEDICATION NAME][MEDICATION NAME]), one 3 ml (milliliter) vial via nebulization BID (twice a day) PRN (as needed) and [MEDICATION NAME] HFA inhaler, inhale 2 puffs PO (by mouth) every 4 hours prn, shortness of breath. Review of the resident's care plans indicated a plan of care for [MEDICAL CONDITION] and [MEDICAL CONDITION] care had not been developed. A Nursing note, dated [DATE] at 18:12 (6:12 P.M.), indicated "while writer went to check on her residents, found resident face down on floor beside his bed resident had complain to me earlier when I came through the door he could not breathe this writer told him to please inform nurse until I clock in. report nurse stated that resident was having some anxiety during the day shift before I came in she gave him an anxiety pill to calm him. After finding resident unresponsive to me I call (sic) CNA (certified nursing assistant) to watch over resident while I got materials to check resident further and another nurse we could not get a pulse at this time resident was given CPR initiated and 911 was called also resident sister (name of sister) was notified resident was transported to (name of hospital) unit manager aware also (name of doctor) made aware of resident status." An investigative report received from the Administrator on [DATE] at 11:00 A.M., not dated, indicated the incident occurred on [DATE] at 4:00 P.M. Brief description of incident: "Resident complained of not being able to breath and requested suctioning. His CNA requested twice per the resident that his (sic) wanted to be suctioned. (name of nurse) told the CNA she had just suctioned the resident five minutes prior and wasn't doing it again. After the change of shift occurred, the evening nurse was going to check (name of resident) and found him face down on the floor beside his bed." A review of the Nursing notes indicated the last time the resident received [MEDICAL CONDITION] care was on [DATE] at 10:29 (10:29 A.M.): vital signs: ,[DATE], 145, 20, 98.2, O2 99%. Respiratory assessment: breath sounds clear and unlabored. Condition of site: site clean dry and intact.[MEDICAL CONDITION]: half and half (half water and half hydrogen peroxide). Sputum: greenish, yellow in color. Patient tolerated: tolerates well. Oxygen use: 4 lpms (4 liters per minute). A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M.) from LPN #7. This was 12 hours prior to the Resident complaining of difficulty breathing at change of shift at 3:00 P.M. The Resident did not receive the Albut 2.5 mg/Ipra 0.5 mg neb solution, one 3 ml vial via nebulization BID PRN or [MEDICATION NAME] HFA inhaler, inhale 2 puffs PO every 4 hours prn, for shortness of breath. A Nursing [MEDICAL CONDITION] care note, dated [DATE] at 05:08 (5:08 A.M.) indicated a blood pressure of ,[DATE], pulse 121, respirations 18 and O2 Sat 99%. A Nursing Enteral note, dated [DATE] at 02:56 (2:56 A.M.), indicated a blood pressure of ,[DATE], pulse 145, respirations 20, O2 saturation 99%. The physician was not notified of the increased pulse rate. A Nursing [MEDICAL CONDITION] care note, dated [DATE] at 10:29 (10:29 A.M.), indicated a blood pressure of ,[DATE], pulse 145, respirations 20 and O2 saturation 99%. The physician was not notified of the increased pulse rate. During an interview with the Director of Nursing, on [DATE] at 10:00 A.M., she indicated the physician was not notified of the increased pulse rate. During an interview with the Corporate Nurse Consultant, on [DATE] at 11:45 A.M., she indicate the increased pulse rate should have been reported to the physician. A review of the physician's orders [REDACTED]. [MEDICAL CONDITION]; dyspnea, stridor, tachypnea." LPN #7 was recorded as having given [MEDICAL CONDITION] care on [DATE] at 1:00 P.M. and documented at 1:24 P.M. This was an hour prior to Resident C complaining of difficulty breathing at 2:00 P.M. During an interview with LPN #2, on [DATE] at 3:00 P.M., she indicated she saw Resident C talking on the phone in the dining room when she came into the building. Resident C told LPN #2 he wanted to be suctioned. I told him to ask his nurse. He said he didn't know where his nurse was. He didn't look like he was having breathing difficulty while talking on the phone. I put my things in my locker and went to get report and told LPN #7 Resident C said he was having trouble breathing. LPN #7 indicated he was like that earlier and was upset because his sister left, he had been [MEDICAL CONDITION], suctioned and PRN [MEDICATION NAME]; she indicated he was alright. After report Resident C was sitting in a chair in the hallway, I asked if he was OK, and he wanted to go outside. I told him no and asked him to lay down. His sister had called and wanted him to lay down. He agreed and I told him I would be back shortly. I was going to give him another [MEDICATION NAME]. It was 10 - 15 minutes at most when I went back, he was face down on the floor unresponsive. CNA #1 was coming out of a room and I called him into the room. We turned the resident over and I got another nurse and he started CPR while I called 911. Resident C could transfer himself, he was independent and didn't use a wheelchair. Vital signs were not taken when he was complaining of breathing difficulty. During an interview with CNA #1, on [DATE] at 3:20 P.M., he indicated Resident C had told him around 2:00 P.M. he was having a problem breathing. CNA #1 told LPN #7 Resident C wanted to be suctioned he had said he was having a problem breathing. LPN #7 told him Resident C had been suctioned five minutes ago and wasn't doing it again. He seemed short of breath, LPN #7 said Resident C was working himself up. The oncoming nurse, LPN #2, found him face down on the floor. Another nurse and I got him on the flat board and started CPR while LPN #2 got the crash cart. EMTs arrived shortly after and asked for proof of full code before they provided care. A hospital death summary, dated [DATE], indicated Disposition: Patient is deceased . Discharge Diagnoses: [REDACTED]. Hospital course: The patient was initially on the critical care service through [DATE]. After rewarming and off sedation, he remained GCS (Glasgow coma scale) of 3 with pupils fixed and dilated and no gag reflex. The family at that time understood that he had a very poor prognosis, and that it would be highly unlikely for him to regain any meaningful brain function. They withdrew care, and he was transferred to my service for palliative intent. I assumed care the evening of [DATE], and the patient expired a few hours later at 9:30 P.M. on [DATE]. A Facility Policy for "[MEDICAL CONDITION] Suctioning", dated ,[DATE], received from LPN #5, on [DATE] at 2:30 P.M., indicated the following: "23. Assess the need for suctioning every (2) hours and/or as needed." This federal tag relates to complaint IN 962 3XXX,[DATE](a)