Every finding on record at Creekside Village

Based on interview and record review, the facility failed to ensure a medication was administered as ordered by the physician for 1 of 3 residents reviewed for medication administration, (Resident B).Finding includes:Resident B's clinical record was reviewed on 7/13/26 at 10:04 A.M. Diagnoses included but were not limited to senile degeneration of brain, chronic respiratory failure with hypoxia, chronic kidney disease, cerebral cysts, and anxiety. Resident B was under the care of hospice services.Review of Resident B's physician orders included but were not limited to:Hydromorphone, take 1/2 of a 2 mg (1 mg) tablet by mouth two times daily between 7:00 A.M. and 11:00 A.M., and between 7:00 P.M. to 11:00 P.M., for Shortness of Breath or difficulty in breathing. The order start date was 6/13/26 at 7:09 P.M., and the order was discontinued on 6/15/26 at 9:21 A.M.Hydromorphone, to take 1/2 of a 2 mg tablet (1 mg) by mouth every 3 hours as needed every three hours, with a start date of 6/13/26 at 7:06 P.M. and discontinued on 6/15/26 at 9:21 A.M.Review of Resident B's Medication Administration Record (MAR), from 6/13/26 to 6/15/26 indicated the resident did not receive either the scheduled nor any as needed doses of Hydromorphone. Notations in the MAR indicated on 6/13/26 from 7:00 P.M. to 11:00 P.M, the medication was not administered because it was unavailable and on 6/14/26 from 7:00 A.M. to 11:00 A.M., the medication was not administered and was on hold.A Nursing Progress Note dated 6/13/26 at 7:10 P.M., indicated Resident B's hospice nurse and responsible party were with the resident and hospice had evaluated the resident and issued a new order for Hydromorphine [Hydromorphone] 2 mg half tablet two times daily and Hydromorphine [Hydromorphone] 2 mg [1/2 tablet] every three hours as needed for shortness of breath and difficulty breathing.A Hospice Visit Note Report dated 6/13/26 at 6:23 P.M., indicated, .Upon arrival.He is hallucination.POA [Responsible Party].we discussed options to add medication for comfort.he is experiencing some mild dyspnea evidenced by a slight noise and slight use of accessory muscles. Contacted [Director of Nursing and physician].requested a 'small dose of Dilaudid [hydromorphone] to start.' Orders from [physician] for 1 mg BID [ twice daily] and 1 mg Q3H PRN [every three hours as needed].[facility nurse] contacted their pharmacy that does not have the liquid formulation in stock. Educated to combine with drops of warm water to dissolve and administer sublingual, verbalizes understanding.During an interview with the Director of Nursing (DON) on 7/13/26 at 12:09 P.M., she indicated when hospice was with the resident, on the evening of 6/14/26, they had discussed the addition of comfort medications for Resident B. The DON indicated she had advised hospice that the resident had had morphine before and had experienced a rash that appeared to be caused by the morphine, so hospice had prescribed a low dose of hydromorphone in liquid form. The DON indicated they had advised hospice that their pharmacy did not have the liquid formulation in stock, so the hospice nurse had indicated the facility nursing staff should give one half of a 2 gm tablet dose and dilute it in warm water and administer the liquid under the resident's tongue. The DON indicated she was later notified that the facility stock of hydromorphone 2mg could not be cut in half so nursing staff could not administer the medication. The DON indicated the medication had arrived from the pharmacy on 6/15/26 by noon, but the resident had transferred to another facility by that time. The DON indicated the nurse should have notified hospice and the physician that the medication as ordered was not available but had failed to do so.On 7/13/26 at 11:59 A.M., the Corporate Consultant provided a policy titled, Medication Shortages/Unavailable Medications dated 1/1/13 and indicated it was the current facility policy. The policy indicated, .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy.a licensed Facility nurse should obtain the ordered medication from the Emergency Medication Supply. If the ordered medication is not available in the Emergency Medication Supply, the Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action.If an emergency deliver is unavailable, Facility nurse should contact the attending physician to obtain orders or directions.This Federal tag relates to Intake 3049189.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on interview and record review, the facility failed to ensure staff accurately administered physician ordered medications and treatments for 2 of 2 residents reviewed for standards of care. (Residents 1 and 18)Finding includes:1. During an observation on 3/25/2025 at 2:22 P.M. Resident 1's oxygen concentrator was dirty and dusty. The filter on the back of the concentrator had a clump of dust clinging to it. A record review for Resident 1 was completed on 3/27/2026 at 8:40 A.M. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and emphysema. Physician Orders, initiated on 3/12/2024 for Resident 1 included, but were not limited to, change oxygen tubing, change humidity, clean oxygen concentrator, and clean filter once a day on Sundays. A Medication Administration Record for Resident 1, dated March 2026, showed the oxygen tubing and humidity, and the oxygen concentrator and filter were documented as having been cleaned as indicated by staff initials on: -3/1/2026 initialed as completed by QMA 3. -3/8/2026 initialed as completed by QMA 3. -3/15/2026 initialed as completed by LPN 4. -3/22/2026 initialed as completed by QMA 3. -3/29/2026 initialed as completed by LPN 2. During an observation and interview with the Unit Manager on 3/31/2026 at 9:52 A.M., she confirmed the oxygen concentrator and filter were dusty and dirty. The Unit Manger indicated the concentrator should have been cleaned on Sunday, 3/29/2026, and should have been cleaned weekly on Sundays. During an interview on 3/31/2026 at 3:00 P.M., the DON indicated staff should not have initialed tasks until after they had been completed. She indicated staff were oriented to this expected standard during orientation. Review of the following staff member's personnel records, on 3/31/2026 at 2:00 P.M. indicated the following employees had completed the Medication Administration orientation checklist: -LPN 2 on 3/20/2026. -LPN 4 on 3/11/2026. -QMA 3 on 2/28/2026. 2. The clinical record of Resident 18 was reviewed on 3/30/2026 at 10:33 A.M. The resident's diagnoses included, but were no limited to: Parkinson's disease, cellulitis of right lower limb, urinary tract infection, lymphedema, neuromuscular dysfunction of bladder, muscle weakness, hypertension, pemphigus foliaceous, presence of pacemaker and personal history of other venous thrombosis and embolism. A Significant change Minimum Data Set (MDS) assessment, dated 1/11/26, indicated Resident 18 was moderately cognitively impaired. A Weekly Skin Assessment, dated 3/18/2026 at 11:56 P.M., indicated Resident 18 had had lotion applied to his feet and had redness to his right lower abdominal quadrant and the areas under his umbilicus and scrotal area. Physician Orders included, but were not limited to: Eucerin Original (lanolin-mineral oil), initiated on 3/25/2026, lotion; was to be applied twice daily to dry skin and Hydrocortisone Ointment: 2.5 % strength, initiated on 3/25/2026, was to be applied to face, legs and lower abdomen (not the folds) for redness twice a day. A March Medication Administration Record (MAR) 2026 indicated the Hydrocortisone Ointment 2.5% strength was ordered on 3/25/2026 and was documented as having been administered starting on the day shift of 3/25/2026. The March 2026 MAR indicated Resident 18's Eucerin lotion had been documented as having been administered as ordered, staring on 3/25/2026, as well. During an interview, on 3/26/2026 at 1:58 P.M., Resident 18 indicated he was supposed to have two different specific creams for his umbilical region but the facility had not had administered them yet. The resident indicated he had an autoimmune disorder that caused problems with his skin, called pemphigus foliaceous. During an interview, on 3/30/2026 at 1:30 P.M., Resident 18 indicated he had not received any medicated creams or Eucerin lotion from nursing staff. He indicated he had asked several times but had never received either treatment. Resident 18 indicated the nursing staff had been applying the facility brand lotion to his legs. Resident 18 indicated the nursing staff were supposed to be using Eucerin brand lotion because of the recommendation of his dermatologist. During an interview, on 3/30/2026 at 2:48 P.M., Employee 7 indicated the physician's order for the ointments and Eucerin lotion had been changed, on 3/25/2026, from an as needed basis to a scheduled medication/treatment. She indicated the tubes of ointment and bottle of Eucerin lotion were being used for the resident and if there were not any opened tubes or opened bottles, the facility must have already emptied them and thrown them away. During an observation, on 3/30/2026 at 2:50 P.M., with Employee 8, three unopened tubes of hydrocortisone ointment with Resident 18's name on them, all without any open dates were located in the 200 hall's treatment cart and none were located in the unit's medication cart. These hydrocortisone ointments had the following pharmacy dispense dates: 9/12/2025, 2/4/2026 and 3/25/2026. The Eucerin lotion for Resident 18 had an open date of 3/27/2026. During an interview, on 3/31/2026 at 1:23 P.M., Resident 18 indicated he had been receiving the Eucerin lotion since yesterday and was going to have his hydrocortisone cream applied after lunch. The resident indicated the abdominal area of skin had not been itching or burning him. Resident 18 indicated he has had some itching on his legs bilaterally because of his lymphedema. During an interview and observation, Resident 18's skin was completed with Employee 9 on 3/31/2026 at 2:13 P.M. Resident 18 had reddened and excoriated skin to the entire lower half of his abdomen. The resident denied pain, discomfort or itching to skin area. There were no other areas of skin redness or excoriation visible. On 3/31/2026 at 2:30 P.M., the Executive Director indicated the facility did not have a policy for following physician orders nor a policy for accurate records. 3.1 -35(g)(1)

Based on observation, interview and record review, the facility failed to ensure treatments to address a skin condition were administered for 1 of 1 reisdents reviewed for skin conditions. (Resident 18)Findings included:The clinical record of Resident 18 was reviewed on 3/30/2026 at 10:33 A.M. The resident's diagnoses included, but were no limited to: Parkinson's disease, cellulitis of right lower limb, urinary tract infection, lymphedema, neuromuscular dysfunction of bladder, muscle weakness, hypertension, pemphigus foliaceous, presence of pacemaker and personal history of other venous thrombosis and embolism. A Significant Change Minimum Data Set (MDS) assessment, dated 1/11/26, indicated Resident 18 was moderately cognitively impaired. Physician Orders included, but were not limited to: Eucerin Original (lanolin-mineral oil), dated 3/25/2026, lotion; was to be applied twice daily to dry skin and Hydrocortisone Ointment: 2.5 % strength, dated 3/25/2026, was to be applied to face, legs and lower abdomen (not the folds) for redness twice a day.A March Medication Administration Record (MAR) 2026 indicated the Hydrocortisone Ointment 2.5% strength was ordered on 3/25/2026 and administered starting on the day shift of 3/25/2026. The March 2026 MAR indicated Resident 18's Eucerin lotion started to be administered on 3/25/2026, as well.During an interview, on 3/26/2026 at 1:58 P.M., Resident 18 indicated he should have had two different creams for his umbilical region but has not had them administered. The resident indicated he had an autoimmune disorder that caused problems with his skin, called pemphigus foliaceous.During an interview, on 3/30/2026 at 1:30 P.M., Resident 18 indicated he had not received any medicated creams or Eucerin lotion from nursing staff. He indicated he had asked several times but had never received either treatment. Resident 18 indicated the nursing staff had been applying the facility brand lotion to his legs. Resident 18 indicated the nursing staff were supposed to be using Eucerin brand lotion because of the recommendation of his dermatologist.During an interview, on 3/30/2026 at 2:48 P.M., Employee 7 indicated the order for the Hydrocortisone cream and Eucerin lotion had changed on 3/25/2026, and both treatments were ordered as scheduled instead of as needed. She indicated the nursing staff were using the designated lotion and ointment. During an observation and interview, on 3/30/2026 at 2:50 P.M. with Employee 8, three unopened tubes of hydrocortisone ointment with Resident 18's name, all without any open dates were noted in the medication room. The hydrocortisone ointments had the following pharmacy dispense dates: 9/12/2025, 2/4/2026 and 3/25/2026. The Eucerin lotion bottle was opened for this resident had an opened date of 3/27/2026. Thus, although Employee 7 indicated the ordered treatments had been applied, there was no explanation as to why none of the ordered hydrocortisone tubes had been opened and the Eucerin lotion had an opened date of 3/27/2026 even though the lotion had been documented as having been applied prior to 3/27/2026.During an interview, on 3/31/2026 at 1:23 P.M., Resident 18 indicated he had been receiving the Eucerin lotion since yesterday and was going to have his hydrocortisone cream applied after lunch. During an interview and observation, on 3/31/2026 at 2:13 P.M., a skin observation of Resident 18's skin was completed with Employee 9. Resident 18 had reddened and excoriated skin to the entire lower half of his abdomen. Resident denied pain, discomfort or itching to skin area. There were no other areas of skin redness or excoriation visible.On 3/31/2026 at 2:30 P.M., the Executive Director indicated the facility did not have a policy for following physician orders nor a policy for accurate records.410 IAC 3.1 - 37

Based on observation, record review, and interview, the facility failed to provide oxygen according to the standards of practice regarding changing oxygen tubing and cleaning the oxygen concentrator and filter for 2 of 2 residents reviewed for respiratory care. (Residents 1 and 61)Findings include: 1. During an observation on [DATE] at 2:22 P.M. Resident 1's oxygen concentrator was found to be dirty and dusty. The filter on the back of the concentrator had a clump of dust clinging to it. A record review for Resident 1 was completed on [DATE] at 8:40 A.M. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and emphysema. Physician Orders, initiated on [DATE] for Resident 1 included, but were not limited to, oxygen at 2 liters per minute every shift, change oxygen tubing, humidity, clean oxygen concentrator, and clean filter once a day on Sundays. A Medication Administration Record for Resident 1, dated [DATE], indicated oxygen tubing was changed and the concentrator and filters were cleaned on [DATE], 15, 22, and 29, 2026. During an observation and interview with the Unit Manager on [DATE] at 9:52 A.M., she confirmed the oxygen concentrator and filter were dusty and dirty. The Unit Manger indicated the concentrator should have been most recently cleaned on Sunday, [DATE], and should have been cleaned weekly on Sundays. 2. During an observation, on [DATE] at 2:01 P.M., Resident 61 was noted with an undated oxygen tubing connected to her nasal cannula, connected to a portable oxygen tank behind her wheelchair. There was an empty, clear plastic bag, dated [DATE] hanging behind her wheelchair. The clinical record of Resident 61 was reviewed on [DATE] at 11:42 A.M. The resident's diagnoses included, but were not limited to: acute on chronic diastolic congestive heart failure, metabolic encephalopathy, cellulitis of left lower limb, sepsis, chronic obstructive pulmonary disease, morbid obesity, acute on chronic respiratory failure, paroxysmal atrial fibrillation, peripheral vascular disease, pulmonary hypertension, chronic kidney disease, obstructive sleep apnea, hypertension and glaucoma. Physician Orders, dated [DATE], included the following: change [the] oxygen tubing and humidity, clean concentrator and filter once a day on Sunday during the night shift. During an interview, on [DATE] at 10:50 A.M., the Regional Nurse Consultant (RNC) indicated she had checked for expired oxygen tubing in Resident 61's room on [DATE]. On [DATE] at 12:28 P.M., the Executive Director provided a policy titled, Oxygen Therapy and Devices, undated and indicated the policy was the one currently used by the facility. The policy indicated - .Concentrators and their filters should be maintained for optimal function.Oxygen devices.Nasal cannula.change out weekly and PRN. On [DATE] at 12:28 P.M., the Executive Director provided a policy titled, Oxygen Concentrator, undated, and indicated the policy was the one currently used by the facility. The policy indicated, .Clean the air inlet filter PRN and weekly. 3.1-47(a)(6)

Based on record review and interview, the facility failed to follow a monitor medications for 1 of 5 residents whose medications were reviewed. (Resident 3)Finding includes:Resident 3's record review was completed on 3/27/2026 at 9:15 A.M. Diagnoses included but were not limited to: dementia, major depressive disorder, morbid obesity, congestive heart failure, hypothyroidism and type 2 diabetes mellitus.Review of the physician's orders for medications for Resident 3 indicated the resident was to receive the following diabetic medications: Freestyle [NAME] insulin 5 units three times a day, Jardiance 10 mg tablet once daily and Insulin Glargine 20 units sq once a day. In addition, the resident was receiving the following medication to address thyroid issues: Levothyroxine 100 mcg once daily. A Physician's order, dated 3/20/2026, indicated Resident 3 had a blood laboratory order to have his hemoglobin A1C (measures average blood sugar levels) and thyroid-stimulating hormone (measures thyroid levels) tested.Resident 3's record lacked the documentation to indicate his laboratory orders had been completed.During an interview on 3/31/2026 at 12:30 P.M., the Director of Nursing (DON) indicated Resident 3 had not had his laboratory orders completed. The DON indicated the facility processes laboratory orders daily and Resident 3 had not had his laboratory order completed timely.On 3/31/2026 at 1:00 P.M., the Executive Director (ED) provided a policy dated 4/2024 and titled, Guidelines for Lab and Radiology Tracking. The ED indicated it was the policy currently used by the facility. The policy indicated, .Confirm that each lab and/or radiology test due has been obtained.410 IAC 3.1-48(a)(1)

Based on interview and record review, the facility failed to ensure an order for oral surgery was transcribed timely and followed timely for 1 of 19 residents who were reviewed. (Resident 3)Finding includes:During an interview on 3/25/2026 at 11:19 A.M., Resident 3 indicated he was scheduled for oral extractions for that day, but the procedure had been cancelled because the facility had not held his medication. Resident 3's record review was completed on 3/27/2026 at 9:15 A.M. Diagnoses included but were not limited to: dementia, major depressive disorder, morbid obesity, congestive heart failure and type 2 diabetes mellitus.Pre-Surgical Procedure/Surgery Instructions from a local oral surgery center dated, 3/10/2026, indicated Resident 3 was scheduled for oral surgery on 3/25/2026. The instructions indicated the facility was to hold the resident's scheduled doses of Jardiance four days prior to his surgery.A current Physician's order dated, 10/17/2024, indicated Resident 3 had been receiving 10 mg tablet of Jardiance once a day.A review of Resident 3's March 2026 Medication Administration Record indicated Resident 3 had been administered the Jardiance medication on March 21, 22, 23 and 24, 2026.A Nursing Note dated 3/24/2026 at 2:13 P.M. indicated Resident 3's oral extractions scheduled for 3/25/2026 were cancelled due to the Jardiance medication not being held prior to the procedure.During an interview on 3/27/2026 at 9:30 A.M., Unit Manager (UM) 6 indicated the facility had received a fax from the oral surgery center with orders to hold Resident 3's Jardiance four days prior to the procedure, but the orders on the fax had not been transcribed into the resident's Electronic Medical Record.A policy for following the Physician's orders was requested on 3/27/2026 at 10:00 A.M., but the Regional Nurse Consultant indicated the facility did not have a policy for following the Physician's orders. 410 IAC-3.1-24-(a)(1)

Based on observation, interview and record review the facility failed to ensure a controlled narcotic medication was either secured in a locked environment or under direct observation of the staff member administering the medication for 1 of 1 residents observed for medication administration and safety. (Resident D) Finding includes: During an observation and interview on 3/21/2025 at 10:11 A.M., Resident D had a breakfast tray and a disposable scouffle cup of medications on his bedside table by the foot of the bed. He indicated they always left his pills on his table and there was a pain pill in the cup for him. During an interview on 3/21/2025 at 10:56 A.M., LPN 2 indicated Resident D had refused his medication and he plamned to go back later to see if Resident D had taken them. He identified the medications in the cup as the following: Eliquis 2.5 mg(milligrams) (blood thinner), tamsulosin 0.4 mg (prostate), lexapro 5 mg and 10 mg (antidepressant), daily-vite (vitamin) hydrocodone-acetaminophen 5-325 mg (narcotic pain medication) and mucinex 600 mg (expectorant). He indicated he should not have left the medications at the bedside. On 3/21/2025 at 11:45 A.M., the DON provided a medication pass procedure titled, Medication Administration, revised 7/2023, and indicated the procedure was the one currently used by the facility. The procedure indicated .11. Observed (sic) taking medications-not left at bedside .

Based on observation, interview and record review, the facility failed to ensure individual and group activities were provided per individual preferences for 1 of 1 resident reviewed for activities (Resident 11). Finding includes: During an observation, on 1/07/2025 at 11:00 A.M. Resident 11 was observed gazing off into the distance while seated in her reclining gerichair. Resident 11's chair had been placed was in the living room area of nursing pod in front of a television. The television was on, but Resident 11 was not watching the television. There was no other activity being provided that included Resident 11. During an observation on 1/08/2025 at 9:34 A.M., Resident 11 was seated in her reclining gerichair in front of the television in the living room area of the nursing pod. Resident 11 was not looking at the television during the observation nor was she involved in any type of activity program. During an observation on 1/09/2025 at 10:20 A.M., Resident 11 was observed seated in her reclining gerichair in the living room area of the nursing pod. She was noted to intermittently talk to no one in particular and was not watching the playing television. During an observation, on 1/10/2025 at 10:01 A.M. Resident 11 was observed lying in bed in her room, looking at the television. During an observation, on 1/10/2025 at 2:01 P.M. Resident 11 was seated in her reclining gerichair in the living room area of the nursing pod, looking out of a window. The record review for Resident 11 was completed on 1/10/2025 at 9:50 A.M. Diagnoses included, but were not limited to: dementia, hypertension, diabetes mellitus, hypothyroidism, depression, anxiety, cognitive communication disorder, brief psychotic disorder and chronic obstructive pulmonary disease. A Quarterly Minimum Data Set (MDS) assessment, dated 11/20/2024, indicated Resident 11 was severely cognitively impaired. An Annual MDS assessment, dated 9/3/2024, indicated Resident 11's activity preferences indicated it was very important for her to listen to music she liked, somewhat important for Resident 11 to read, be around pets, keep up with the news and participate in religious practices. Resident 11 indicated it was not very important to do things with groups, do past favorite activities or go outside. A current Care Plan, revised on 12/3/2024, indicated Resident 11 was identified with a potential for psychosocial well-being issues. Interventions included, but were not limited to: encourage activities of interest such as people-watching, musical activities, watching western movies and TV game shows. A Preferences for Routines and Activities form, dated 9/9/2024, indicated the resident was non-responsive to questions on the form. An Activity Assessment, dated 9/9/2024, indicated the resident was non-responsive to questions on the form. During an interview, on 1/10/2025 at 1:33 P.M., the Activities Director indicated Resident 11 was scheduled for one-to-one activities on Mondays, Wednesdays and Fridays with an activity aide. These activities consisted of playing games on an electronic tablet or touching a sensory blanket. The Activity Director indicated there were no activity participation documented for Resident 11 for the months of November 2024, December 2024, and up to and including January 10th, 2025. The Activities Director indicated the 1:1 activities should have been documented by the activity's aide for Resident 11. On 1/13/2025, at 9:00 A.M., the Administrator indicated the facility did not have an activity program policy. 3.1-33(a)

Based on observation, interview and record review, the facility failed to assess a resident's skin or notify the Physician of the need for a treatment timely for 1 of 3 residents who were reviewed for a skin condition (Resident 30). Finding includes: During observations on the following dates, Resident 30 had multiple scratches across the top of his head in various stages of healing. Six of the scratches had thick scabs covering part of the scratches: 1/7/2024 at 11:07 A.M., 1/8/2024 at 2:06 P.M. and 1/9/2024 at 9:35 A.M. During an interview with CNA 7, completed on 1/9/2025 at 9:43 A.M., she indicated Resident 30's scratches on the top of his head were from the resident scratching himself. CNA 7 indicated Resident 30 refused nail care often and it was the family's preference that the family provided Resident 30's nail care. Resident 30's record review was completed on 1/9/2025 at 10:50 A.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure, cerebral palsy, schizophrenia, dysphagia, oropharyngeal phase and major depressive disorder. Resident 30's record lacked documentation that a weekly skin assessment had been completed by a nurse. A current Physician's order dated, 12/2/2024, indicated the resident received Hospice services. A Visit Note Report from the Hospice nurse, dated 1/7/2024 at 4:16 P.M., indicated the resident had been assessed by the Hospice nurse, but the scratches were not included in the documentation. During an interview on 1/9/2024 at 2:06 P.M., the Assistant Director of Nursing (ADON) indicated Resident 30's scratches had not been reported to her prior to 1/9/2024 and she did not know how long the scratches had been there present. The ADON indicated she was responsible for wounds follow up in the building and she had completed an assessment upon finding out about Resident 30's scratches. The ADON indicated the resident was itchy but could not say if he had an order for anything to relieve the itching or if Hospice had been notified about his excessive scratching. Resident 30's record lacked the documentation to indicate he had a treatment ordered for itching or that Hospice had been notified of the Resident's itching. He also did not have a Care Plan indicating he had a problem with excessive itching or scratching. On 1/10/2025 at 1:53 P.M. the Regional Clinical Nurse (RNC) provided a policy dated, 5/2022, and titled, Skin Management Program. The RNC indicated the policy was the one currently used by the facility. The policy indicated, . Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters and rashes. The licensed nurse is responsible for assessing all skin alterations by the direct caregivers on the shift reported . All newly identified areas after admission will be document on the New Skin Event A plan of care will be initiated to include resident specific risk factors and contributing factors with appropriate interventions implemented 3.1-37(b)

Based on interview and record review, the facility failed to obtain an admission weight and weekly weights of a newly admitted resident that resulted in an undetermined weight loss for 1 of 3 residents reviewed for a weight loss (Resident 62). Finding includes: During an interview on 1/8/2025 at 1:15 P.M., the family of Resident 62 indicated they were worried about the resident's weight because it appeared to the family the resident was losing weight. Resident 62's record review was completed on 1/9/2025 at 3:00 P.M. She was admitted on [DATE] and her diagnoses included, but were not limited to: fracture of left femur, Alzheimer's disease, dementia, anxiety, hypertension and abnormal weight loss. An Admission Minimum Data Set assessment (MDS) dated , 11/27/2024, indicated Resident 62 did not have a swallowing problem, required supervision for meals and weighed 125 pounds. Resident 62's record lacked documentation that she had been weighed upon admission. A Nutrition Observation form was completed by the Registered Dietician on 11/29/2024. The observation form indicated the resident had not been weighed by the facility and the weight used for recommendations was the weight provided from the hospital on 11/15/2024. The resident weighed 125.4 pounds on the hospital discharge paperwork and the dietician recommendations were to weigh the resident weekly. Resident 62's weight was not assessed until 12/2/2024 and she weighed 117 pounds. On 12/15/2024 she weighed 116.4 pounds. These weights indicated a 6.7 percent weight loss in less than 30 days (11/21/2024 through 12/2/2024).wq A current Care Plan dated, 11/29/2024, indicated Resident 62 was at risk for weight loss related to behaviors and poor intakes. The goal was for the resident to maintain her weight. Interventions to the Care Plan dated, 11/29/2024, indicated the resident's weight should be monitored and the Physician and family should be notified of significant weight changes. The record lacked documentation the Physician or family had been notified before the resident's weight loss. During an interview on 1/13/2024 at 9:50 A.M., the Director of Nursing (DON) indicated Resident 62 had not been weighed upon admission and the weight recorded in the MDS assessment was from the hospital discharge paperwork the facility received upon the resident's admission. The DON indicated the facility was not able say if the resident had a significant weight loss because the facility was unsure if the weight on the hospital discharge papers was accurate at the time the resident was admitted to the facility. It was the policy of the facility to weigh all new admissions at the time they were admitted and then once a week for four weeks and to follow the Dietician's recommendations. On 1/10/2024 at 1:53 P.M. the Regional Clinical Nurse (RCN) provided a policy dated, 9/2024, and titled, Resident Weight Monitoring. The RCN indicated it was the policy currently used by the facility. The policy indicated, . Procedure 1. Upon admission, the resident's weight and height will be measured and recorded in the clinical record. 2. The interdisciplinary team will place the following residents on weekly weights: New admission or readmission for a minimum of 4 weeks . 6. The physician/health care practitioner and resident representative will be notified of unplanned significant weight loss . 8. Any significant unexplained weight loss is considered a change in condition and must be addressed by the Interdisciplinary Team to determine if a new MDS/Comprehensive Assessment is needed. 3.1-46(1)

Based on observation, interview and record review, the facility failed to follow physician's orders related to enternal feedings and water flushes for 1 of 1 resident reviewed for a gastronomy tube (G-tube) (Resident 27). Finding includes: During an observation on 1/7/2025 at 1:40 P.M., a bottle of Jevity 1.5 (enteral therapy) was disconnected from Resident 27 and hanging on an intravenous line (IV) pole. The bottle of Jevity 1.5 was dated 1/6/2024 and had 200 milliliters (mLs) left in the bottle. During an observation on 1/8/2025 at 10:40 A.M., a bottle of Jevity 1.5 was disconnected from Resident 27 and hanging on an IV pole. The bottle of Jevity 1.5 was dated 1/7/2024 and had 75 mLs remaining in the bottle. During an observation on 1/10/25 at 8:40 A.M., a bottle of Jevity 1.5 was disconnected from Resident 27 and was hanging on an IV pole with 225 mLs still remaining in the bottle. The date on the bottle was 1/9/2024. During an interview on 1/10/2025 at 8:41 A.M., LPN 5 indicated there was 225 mLs remaining in the bottle of Jevity 1.5 and it was normal for Resident 27 to have 200-300 mLs remaining in the bottle in the mornings. The entral feed was shut off at 7 A.M. and the remaining Jevity 1.5 was thrown away. LPN 5 had not charted the amount of Jevity 1.5 given, but instead marked the task complete in the Electronic Medical Record (EMAR). LPN 5 indicated she was not sure if the resident received the correct amount of feeding and calories recommended by the dietician if 200 to 300 mLs of Jevity 1.5 were routinely not administered. In addition, the physician had not been notified when Resident 27 did not receive the full amount of ordered enteral feedings. Resident 27's record review was completed on 1/10/2024 at 9:10 A.M. Diagnoses included, but were not limited to: moderate protein-calorie malnutrition, cerebral infarction, neuroleptic induced parkinsonism, schizoaffective disorder, hemiplegia, epileptic, major depressive disorder, dysphagia, and Parkinson's disease. A Quarterly Minimum Data Set (MDS) assessment dated , 11/27/2024, indicated Resident 27 received 51% or more of calories through tube feedings. A current Physician's order dated, 9/4/2024, indicated Resident 27 was to receive an enteral feeding of Jevity 1.5 daily. The enteral feeding was to run at 85 mLs per hour for 12 hours for a total of 1000 mLs. A current Physician's order dated, 12/11/2024, indicated Resident 27 was to receive 225 mLs of water every six hours. A current Care Plan dated, 1/28/2024, indicated Resident 27 was at risk for complications related to tube feeding. The goal of the Care Plan was to be free from complications related to enteral feeding. Resident 27 had a Care Plan intervention to give tube feedings and water flushes as ordered. Resident 27's Treatment Administration Record (TAR) for December 2024 and January 2025 indicated the resident did not received 225 mLs water flushes on the following dates and times: - December 18, 2024 at 12:00 A.M. - December 19, 2024 at 12:00 A.M. - December 21, 2024 at 12:00 P.M. - December 23, 2024 at 12:00 P.M. - December 27, 2024 at 12:00 A.M., 6:00 A.M., 12:00 P.M. and 6:00 P.M. - December 30, 2024 at 12:00 A.M. - December 31, 2024 at 12:00 A.M. - January 1, 2024 at 12:00 A.M. - January 2, 2024 at 12:00 A.M. and 12:00 P.M. - January 3, 2024 at 12:00 A.M. and 6:00 P.M. - January 5, 2024 at 12:00 A.M. - January 6, 2024 at 12:00 P.M. - January 9, 2024 at 6:00 P.M. Resident 27's record lacked the documentation a Physician had been notified when Resident 27 had not received her full enteral feeding or water flushes. During an interview with the Regional Clinical Nurse (RCN) on 1/13/2024 at 10:00 A.M., the RCN indicated Resident 27 had not received her water flushes as ordered by the Physician. On 1/10/2025 at 1:53 A.M. the Regional Clinical Nurse (RNC) provided a policy dated, 1/2016, and titled, Enteral Therapy. The RNC indicated the policy was the one currently used by the facility. The policy indicated, .It is the policy of this facility that the licensed nurse, in cooperation with other healthcare team members, must carefully monitor the resident's response to the enteral feedings and feeding techniques to ensure the attainment of therapeutic goals .A licensed nurse will take, note, and implement physician orders for enteral therapy 3.1-44 (a)(2)

Based on observation, interview, and record review the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) machine and tubing was stored properly, the water provided for the machine was sealed while being stored and there was a completed order regarding settings for the machine for 1 of 2 reviewed for respiratory care. (Resident 140) Finding includes: During an observation and interview on 1/7/2025 at 10:27 A.M., Resident 140's CPAP storage bag was on the floor and the mask for the CPAP was under her bed covers. In addition, the sterile water for the machine was from a concentrator bubbler, dated 1/5/25 ,unsealed with about half the water left in the container. The resident indicated the concentrator bubbler container was what the facility used to fill her CPAP machine at night. During an observation and interview on 1/8/2025 at 9:16 A.M., Resident 140's CPAP face mask was on the bed, not stored in the bag. The sterile water container was on the nightstand empty and the resident indicated the water from the container was used last night to fill her CPAP machine. She indicated at home, she used distilled water. During an observation on 1/9/2025 at 9:04 A.M., Resident 140's CPAP machine and mask was lying on the bed, not stored in a bag. During an observation on 1/10/2025 at 9:05 A.M., Resident 140's CPAP mask was lying on the bed not stored in a bag. A record review was completed on 1/9/2025 at 9:51 A.M. Diagnosis included but not limited to: obstructive sleep apnea, anxiety disorder and major depressive disorder. A Physicians Order, dated 1/5/2025, indicated ____BIPAP_____CPAP/setting, on at bedtime and off upon rising. The portion of the order to note the pressure settings was left blank. During an interview on 1/13/2025 at 10:42 A.M., RN 2 indicated the CPAP tubing and mask should have been stored in a bag when not in use. In addition, she indicated the facility used the sterile water from the concentrator bubbler but were to discard any remaining water after the container had been opened because it could not be sealed. RN 2 indicated the order for the CPAP settings was not complete because the settings should have been documented on the order. On 1/13/2025 at 11:43 A.M., the Regional Director of Clinical Services provided a policy titled, CPAP Therapy, undated, and indicated the policy was the one currently used by the facility. The policy indicated .10) Verify physician orders, 17) Fill humidifier with distilled or sterile water . The policy did not indicate how the equipment was to be stored and/or maintained. 3.1-47(a)(6)

Based on observation, interview, and record review the facility failed to ensure a newly admitted resident received the influenza vaccine after signing the consent form for 1 out of 5 records reviewed. (Resident 141) Finding includes: During a record review on 1/10/2025 at 2:00 P.M. for Resident 141, the admission influenza vaccination consent form, dated 1/6/2025, indicated she wished to receive the influenza vaccine. The Medication Administration Record (MAR) indicated the influenza vaccine had not been administered to Resident 141. During an interview on 1/13/2025 at 10:00 A.M., the Admissions Director indicated she completed the admission paperwork, including the consents, then uploaded them into the electronic medical record. She indicated the nursing department then took care of providing the vaccinations. During an interview on 1/13/2025 at 11:19 A.M., the DON indicated the facility's process regarding vaccines was as follows: the Infection Preventionist (IP) would ask the resident if they wanted any vaccines, then she would look on CHIRP (Children & [NAME] Immunization Registry Program) to see what vaccines had previously been documented for the resident. If a new admission declined vaccines when asked verbally then signed a consent for the vaccination upon completing the admission paperwork, the resident should have received the vaccine. There was no documentation or explanation given as to why Resident 141 had not received the Influenza vaccination after she had signed a consent requesting the vaccine on 1/6/2025. On 1/7/2025 at 2:00 P.M., the Administrator provided a policy titled, Influenza (Flu) Vaccination (Resident), revised 8/2021, and indicated the policy was the one currently used by the facility. The policy indicated .Current and newly admitted residents will be offered the influenza vaccine, unless the immunization is contraindicated, or the resident has already been immunized during this time period . 3.1-13(a)

Based on record review and interview, the facility failed to complete and submit a timely 5-day follow-up report regarding a fall investigation that had been reported to IDOH (Indiana State Department of Health) for 1 of 3 residents reviewed for falls. (Resident D) Findings include: A record review was completed, on 7/1/2024 at 11:24 A.M. The resident's diagnoses included, but were not limited to: atrial fibrillation, metabolic encephalopathy, dementia, hypertension, weakness and fracture of right pubis. A Significant Change MDS (Minimum Data Set) Assessment, dated 6/13/2024, indicated Resident D was severely cognitive impaired, required the assistance of 1 staff member for transfers and utilized a front wheeled walker for mobility. A current care plan, dated 2/15/2023, indicated the resident was at risk for falls related to: History of recent fall with fracture to right pelvic region, age, medication use, incontinence, impaired mobility. Resident's lack of understanding of her own limitations, abnormalities of gait and mobility, unsteadiness on feet and lack of coordination. A Nursing Progress Note, dated 6/12/2024 at 11:45 P.M., indicated Resident D was found on her bathroom floor, on her right side with her head facing the toilet. The resident had complaints of pain to her right hip, right shoulder, head and neck. She had a 5cm (centimeters) in length laceration to her left lower extremity. The Director of Nursing, Executive Director, Medical Director and resident's family member were notified and 911 was notified. A report was given to the local receiving hospital and Resident D was transferred by paramedics to the hospital. A Progress Note, dated 6/13/2024 at 8:40 A.M., indicated Resident D had returned to facility via the local ambulance transport service. An IDT (Interdisciplinary Team) note regarding Resident D;s fall, dated 6/13/2024 at 3:49 P.M., included a description of the incident indicated Resident D's wheelchair was noted to be backed into the shower stall. The foot pedals of the wheelchair were on with the foot rests in the lowest position. Resident D was dressed in a shirt, pants, shoes and was continent of her bowels and bladder at the time of the fall. The call light was not activated in the room or the bathroom. The resident stated she was taking herself to the bathroom and tripped. Resident D had skin tears noted to both shins and a fracture to her right superior pubic ramus and pubic symphysis bones. The Medical Director and the resident's family member were notified of the change in condition. Review of the Facility Reported Incident revealed Resident D's incident was submitted to the State agency on 6/13/2024 but there with no 5-day follow-up investigation reported. During an interview on 7/2/2024 at 8:55 A.M., the Executive Director indicated she did not complete a 5 day follow up of the incident or report the follow up to ISDH (Indiana State Department of Health). She indicated the follow up was completed on 6/24/2024 and should have been completed within five days of the initial report. She indicated she had been re-educated regarding the facility's policy to investigate and submit any reportable issue timely, within the 5 day time frame to the State agency by the Regional Executive team. In addition, a monitoring system was implemented to ensure the reportable investigations were submitted timely in the future. On 7/2/2024 at 3:19 P.M., the Executive Director provided a policy titled, Long-Term Care Abuse and Incident Reporting Policy dated 4/1/2024, and indicated it was the current facility reporting policy. The policy indicated, .2. Follow-up report should include: a. Results of the investigation. b. Interventions implemented or corrective action taken. c. Method in which facility will continue to monitor efficacy of plan/interventions. d. Other persons or agencies to which the incident was reported This deficient practice began on 6/18/2024 when the facility failed to complete and submit a timely follow up investigation to the fall for Resident D, which occurred on 6/13/2024. The deficiency was corrected on 6/24/2024 when the facility Administator was re-educted, a follow up investigation report was submitted to the Department of Health and an auditing system was implemented to ensure compliance was acheived. Therefore , the deficient practice was deemed Past Noncompliance This citation relates to complaint IN00434201 3.1-28(e)

Based on observation, interview, and record review, the facility failed to create a Baseline Care Plan related to a resident whose native language was not English, and a resident with methicillin-susceptible staphylococcus aureus (MSSA), for 2 of 19 residents who were reviewed for Baseline Care Plans. (Residents 55 & 244) Findings include: 1. During an observation, on 2/5/2024 at 11:16 A.M., Resident 55 was on a video call speaking Gujarati on a personal cell phone. No picture board or language line was present in his room. During an interview, on 2/5/2024 at 11:16 A.M., Resident 55's daughter indicated her father does not speak English, and did not always understand what staff was saying, unless a family member was present to translate. A record review was completed, on 2/8/2024 at 3:31 P.M. Resident 55's diagnoses included, but were not limited to: hemiplegia and hemiparesis of dominant side, cognitive communication deficit, dysphagia, and aphasia. An Admission MDS (Minimum Data Set) assessment, dated 1/15/2024 indicated Resident 55 had severe cognitive impairment. Resident 55's preferred language was Hindi. Resident 55's record lacked any documentation that a Baseline Care Plan for communication was created. During an interview, on 02/09/24 at 9:59 A.M., the Executive Director indicated Resident 55 did not have a Baseline Care Plan for communication, but should have. On 2/9/2024 at 8:25 A.M., the Executive Director provided a policy dated, 5/2019, and titled, Communication Barriers/Interpreter Services Policy. The Executive Director indicated the policy was the one currently used by the facility. The policy indicated, .2. For resident's whose native language is not English, the IDT will determine alternate methods for communication and comprehension. These methods will be added to the plan of care 48054 2. A record review, on 2/07/2024 at 9:23 A.M., indicated Resident 244 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: MSSA (Methicillin-resistant Staphylococcus Aureus) of the left knee replacement with bacteremia (contagious bacterial infection), COVID, Respiratory failure, Atrial Fibrillation, left big toe and 2nd left toe tip gangrene. A Care Plan, dated 1/31/2024, indicated Resident 244 had impaired skin integrity related to surgical incisions to left medial and lateral knee, and required assistance with mobility, transfers, and toileting, but did not indicate the resident required contact precautions due to MSSA of the left knee. A Physician's Order, dated 2/3/2024, indicated the resident was to be in contact isolation, due to having an active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission, related to MSSA in wound. During an interview, on 2/9/2024 at 1:11 P.M., the Director of Nursing indicated the resident should have had a care plan in place for contact isolation due to MSSA in his wound and did not. A policy provided by the Administrator, on 2/8/2024 at 1:18 P.M., titled IDT Comprehensive Care Plan Policy, dated 8/2023 and indicated this is the current policy used by the facility. The policy indicated, .The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being .Improve relationships between resident, families and/or representative, and facility caregivers through understanding if resident's social history, culture and preferences to enhance the resident's life 3.1-35(a)

Based on record review and interview, the facility failed to ensure comprehensive care plans were updated related to self administration of eye drops, isolation, and NPO (nothing by mouth) status, for 3 of 22 residents whose care plans were reviewed. (Residents 20, 244, & 30) Findings include: 1. A record review was completed on 2/8/2024 at 11:32 A.M. Resident 20's diagnoses included, but were not limited to dry eye syndrome, diabetes, hypertension, and chronic pain. Resident 20's current Physician Orders included: Refresh plus eye drops 0.5% to both eyes BID (twice per day). A current Care Plan, with a revised date of 1/12/2024, indicated the resident had impaired vision and utilized glasses. An intervention, dated 5/4/2018, indicated the resident self-administered artificial tears for diagnosis of dry eyes, and kept the artificial tears at bedside. During an interview, on 2/9/2024 at 10:40 A.M., the Unit Manager indicated the resident did not self-administer eye drops. During an interview, on 2/9/2024 at 10:41 A.M., QMA 11 indicated the resident did not self-administer her eye drops, the nurse or the QMA administered the eye drops. During an interview, on 2/9/2024 at 10:42 A.M., the MDS Coordinator indicated the care plan should have been updated. 48054 2. A record review, on 2/07/2024 at 9:23 A.M., indicated Resident 244 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: MSSA (Methicillin-resistant Staphylococcus Aureus) of the left knee replacement with bacteremia (contagious bacterial infection), COVID, Respiratory failure, Atrial Fibrillation, left big toe and 2nd left toe tip gangrene. A Physician's Order, dated 1/31/2024, indicated the resident was to be in droplet/contact isolation due to having an active COVID infection. The order was discontinued on 2/2/2024. A Care Plan, dated 1/31/2024, indicated the resident remained in droplet/contact isolation related to COVID-19. During an interview, on 2/9/2024 at 1:11 P.M., the Director of Nursing indicated that the care plan should have been updated after the resident no longer had COVID and the COVID isolation had been discontinued. 47419 3. A record review for Resident 30 was completed on 2/07/2024 at 9:09 A.M. Diagnoses included, but were not limited to: encephalopathy, neuroleptic induced Parkinsonism, dysphagia, hemiplegia, and hemiparesis following cerebral infarction (stroke). An Admission Minimum Data Set (MDS) assessment, dated 12/26/2024, indicated Resident 30 had an intact cognition. The resident had a feeding tube and more than 50% of food intake was via the feeding tube. Physician Orders included the following: on 12/22/2023, Resident 30 was to have nothing by mouth. On 1/3/2023, the resident was to receive Jevity 1.5 at 65 milliliters (ml) per hour continuously via a gastrostomy tube. A Care Plan, dated 1/28/2024, indicated the resident had a risk for skin breakdown. Interventions included, but were not limited to, .encourage resident to eat at least 75% of meals During an interview, on 2/08/2024 at 10:56 A.M., the MDS Coordinator indicated that the intervention for consuming 75% of meals was preloaded on the wound care plan and should have been updated to reflect the resident's current condition and physician orders. A current policy, provided on 2/8/2024 at 1:18 P.M. by the Administrator, titled IDT Comprehensive Policy and dated 8/2023 indicated, .Create an organized, resident-centered review on a routine basis to improve communication with residents, resident families and/or representative regarding the resident goals, total health status, including functional status, nutritional status, rehabilitation and restorative potential, ability to participate in activities, cognitive status, psychosocial status, sensory and physical impairments, as well as care and services provided to maintain or restore health and well-being, improve functional level or relieve symptoms 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to follow the Pharmacist's Recommendation related to the use of a diuretic medication, for 1 of 5 residents review for unnecessary medications. (Resident 8) Finding includes: A record review for Resident 8 was completed on 2/07/2024 at 10:57 A.M. Diagnoses included, but were not limited to, acute on chronic congestive heart failure. A Quarterly Minimum Data Set (MDS) assessment, dated 11/12/2023, indicated Resident 8 received a diuretic medication daily. A Physician Order, dated 5/30/2023\, indicated furosemide (diuretic) 40 milligrams (mg) orally once a day. A Pharmacy Recommendation, dated 7/27/2023, indicated Resident 8 experienced 2 falls in July 2023 and had received a medication that may cause low blood pressure. The recommendation indicated to monitor orthostatic blood pressures periodically. The Medication Administration Record (MAR) for August, September, October, and November 2023, indicated Resident 8's blood pressure was checked every other day. The MAR did not indicate the blood pressures were orthostatic. The order was discontinued on 11/7/2023. The record lacked documentation of any blood pressures for the remainder of November 2023, December 2023, January 2024, and through February 7, 2024. During an interview, on 2/7/2024 at 2:13 P.M., the Director of Nursing (DON) indicated blood pressures should have been done and documented in the vital sign section of the clinical record, and would check to see if they were documented elsewhere. On 2/7/2023 at 2:20 P.M. the DON indicated she could not find blood pressures documented in the clinical record and that vital signs should be done monthly, but were not. On 2/8/2024 at 12:13 P.M., the Administrator indicated there were no specific policies for following pharmacy recommendations or obtaining routine vital signs. 3.1-25(i)

Based on record review and interview, the facility failed to ensure a resident's psychotropic medication was not increased and deemed a failed GDR (gradual dose reduction) without adequate indication/documentation and other non-pharmacological interventions consistently implemented by facility staff, for 1 of 5 residents reviewed for unnecessary medications. (Resident 33) Finding includes: A record review was completed on, 2/7/2024 at 11:45 A.M. Resident 33's diagnoses included, but were not limited to cerebral palsy, Schizophrenia, depression, and anxiety. Resident 33's medication orders included, Seroquel (anti-psychotic) 25 mg (milligrams) every night, ordered 1/13/2023 as a GDR. A current Care Plan, with a revised date of 1/5/2024, indicated Resident 33 displays delusions/hallucinations as evidence by seeing people/things in his room and making up stories about his past. Misperceptions of staff actions or responses. He has a diagnosis of Schizophrenia with an order for anti-psychotic medication. A current Care Plan, with a revised date of 1/5/2024, indicated the resident was at risk for s/s (signs and symptoms) of depression related to feeling bad about his decline in health and inability to perform ADLs (activity of daily living) for himself. He calls for staff if he feels lonely, has a diagnosis of depression, and receives as antidepressant medication. A current Care Plan, with a revised date of 1/5/2024, indicated the resident displays s/s of anxiety related to a diagnosis of anxiety, as evidenced by calling out, heavy breathing, SOB (short of breath), difficulty communicating his thoughts, feeling overwhelmed and crying. He utilizes anxiety medication. A Visit Note Report, dated 1/25/2023 and completed by the Hospice Social Worker (HSW), indicated for the behavioral assessment findings, the documentation was checked as None of the Above Behaviors Demonstrated. What symptoms area causing the most distress- pain and insomnia. A Visit Note Report, dated 1/31/2023 and completed by the HSW, indicated for the behavioral assessment findings, the documentation was checked as None of the Above Behaviors Demonstrated. A Narrative Note, indicated the nurse reported he had ongoing anxiety and yelling out, especially during the night shift. The HSW encouraged staff that the resident would likely benefit from a psychosocial intervention, i.e. spending time with him. A Social Service Note, recorded as a late entry on 2/4/2023 at 9:45 A.M., indicated: Description of behavior: Increase in restlessness and yelling out. Immediate interventions: Provide calm reassurance; offer fluids Assessment of potential correlation to root cause: Psychosocial factors [activity participation, change in visitors, stressors, trauma history], Environment [over/under stimulation, approach, positioning, other resident behavior], Medications [potential adverse side effects, recent changes], Psychiatric conditions [depression, anxiety, psychosis, etc]. Potential correlation(s) to root cause: Possible over stimulated related to visitors in room; recent GDR of Seroquel. Root cause of behavioral expression: Dx. [diagnoses]: Schizophrenia; possible failed GDR. Describe preventative intervention relating to above root cause: Continues to receive hospice care and monitored for behaviors; Seroquel increased due to failed GDR. Care plan updated and current interventions revised as applicable: Yes. A New/Worsening Behavior Communication Event, dated 2/4/202 at 6:00 P.M., indicated at 6:00 P.M., Resident 33, had a behavior of increased in restlessness and yelling out. Under the section of: Describe the specific type of behavior that occurred, the documentation indicated: yelling out increase in anxiety and restlessness. Resident was given candy and pop from sister during visit. Intervention put into place to prevent another behavior was documented as follow up with hospice weekly and PRN (as needed). A Nursing Progress Note, dated 2/4/2023 at 7:01 P.M., indicated the on call Hospice Nurse came out and assessed the resident's condition. Staff received and noted a new order for Seroquel 25 mg BID (twice a day) and at night. Resident 33 was already on Seroquel 25 mg every night. A Visit Note Report, dated 2/4/2024 and completed by the Hospice RN, indicated Resident 33 had no abnormal mood/effect identified. No abnormal psychiatric symptoms identified. No change in the resident's depression, and anxiety did not significantly affect the resident. In the narrative section, the following was documented: Per facility nurse resident had been yelling out all day about back pain, even with increased doses. Especially when family was around. Spoke with [name of doctor], he ordered Seroquel 25 mg BID (twice a day). On 2/5/2023 the Seroquel order was increased to 25 mg BID (twice a day). A Nurses' Progress Note, dated 2/5/2023 at 6:35 P.M., indicated, the resident's yelling out continued for a bit this morning, but shortly after all medications given as ordered resident seemed to be calmer. No family at bedside with any type of sugary snacks and/or drinks. Just an observation made by staff that resident often becomes very antsy and restlessness after either sister or nurse from Hospice visits and always gives some type of sugary snack or drinks. Resident soon becomes very restless and antsy and the yelling out usually begins. During an interview, on 2/9/2024 at 9:21 A.M., CNA 6 indicated the resident usually had a behavior maybe 2 times a month, usually after his sister was here. CNA 6 indicated she would give him pop or talk to him, which would help with those behaviors. During an interview, on 2/9/2024 at 10:46 A.M., the Social Service Director (SSD) indicated the Seroquel was increased due to a failed GDR (gradual dose reduction). The resident had increased agitation and yelling, but it was his normal behaviors. She indicated Pharmacy would send the facility the recommendations and staff review them in the monthly meeting. A Social Service Annual Assessment Note, dated 3/15/2023, indicated. Behavioral Expressions: sometimes yells out at staff in place of using call light. Psychosocial Assessment: diagnoses: Schizophrenia, anxiety, depressive disorder. Behavioral Health Concerns: n/a. A Behavior Health Monthly Review, dated 3/22/2023, indicated New/Worsening Behaviors Exhibited: 2/4/2023 increase in restlessness and yelling out. What is the targeted behavior for each medication: agitation and yelling. On 2/9/2024 at 10:47 A.M., when asked for other monthly Behavior Review Meeting Notes other than 3/2023 and 11/2023, the SSD indicated all she had were in the chart and there was no further information. No other Behavior Health Monthly Review forms were located. There was no behavior monitoring documentation of any ongoing, frequent behaviors by facility staff after the initial GDR on 1/13/24, or any consistent non-pharmacological interventions implemented prior to deeming a failed GDR and increasing the Seroquel on 2/5/24. On 2/9/2024 at 1:15 P.M., the Administrator provided the policy titled,Psychotropic Management, dated 7/2022, and indicated the policy was the one currently used by the facility. The policy indicated . These medications are managed in collaboration with professional services and facility staff to include non pharmacological interventions, assessment, and reeducation as applicable . 1. Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed . 4. For antipsychotropic medications, diagnoses alone do no necessarily warrant the use these of these medications. Antipsychotic medications may be indicated if: .c Non pharmalogical approaches have been attempted, but did not relieve the symptoms which are presenting a danger or significant distress . 6. Psychotropic medications may be considered regularly for potential GDR including during monthly pharmacy reviews, during behavioral health services visits, and when the IDT is evaluating behavioral expressions On 2/9/2024 at 1:15 P.M., the Administrator provided the policy titled, Behavior Management, dated 8/2022, and indicated the policy was the one currently use by the facility. The policy indicated .3. When a behavioral expression occurs, the staff communicate to the nurse what behavior occurred. The nurse records the behavior in Matrix (charting system). 4. If the behavioral expression is new, worsening, or high risk. the nurse will record the behavior using the New/Worsening Behavior Event. New or worsening behaviors are reviewed by the IDT for assessment an preventative actions. New/Worsening Behaviors include: a. Behaviors that are new for the resident. b. Behaviors that are directed at another resident. c. Behaviors that are increasing in either frequency or severity. d. Behaviors that have potential for risk to others including sexual advances, intrusive wandering, exit seeking and chronic combativeness with care. The IDT review is a discussion with the team as to the behavioral expression, and evaluation of interventions if applicable and an assessment of any underlying causes of the behavior (i.e. pain, environmental stressor, medical illness, etc) 6. Residents with documented behaviors will have a Behavioral Health Monthly Review. This review includes evaluation of behaviors which have occurred that month and that interventions for behavioral expressions are current and effective 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to ensure medication carts were free from loose pills and failed to date opened medications in 2 of 3 medication carts observed. (Halls 100 & 200) Findings include: 1. A medication storage observation was completed, on 2/6/2024 at 10:55 A.M. with LPN 5, on the 100 Hall medication cart. The following was observed: - 10 loose pills in various drawers. - An opened and undated bottled of latanoprost eye drops. - An opened and undated bottle of potassium chloride. - An opened and undated bottle of refresh tears. During an interview, on 2/6/2024 at 11:03 A.M., LPN 5 indicted the loose pills should not be in the cart and the medications should have been dated when opened. 2. A medication storage observation was completed, on 2/6/2024 at 1:52 P.M. with LPN 3, on the 200 Hall medication cart. The following was observed: 2 loose pills in the drawer. During an interview, on 2/6/2024 at 2:00 P.M., LPN 3 indicated the loose pills should not be in the drawers. On 2/9/2024 at 11:17 A.M., the Administrator provided the policy titled,Medication Administration, dated 7/2023, and indicated the policy was the one currently used by the facility. The policy indicated . 7. Medications with shortened expiration dates,(e.g., insulin, eye drops) have date opened on the medication label On 2/9/2024 at 11:17 A.M., the Administrator provided the policy titled, Storage and Expiration Dating of Medications and Biological's, dated 7/21/2022, and indicated the policy was the one currently used by the facility. The policy indicated . 5.Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened . 16 Facility should destroy or return all discontinued, outdated/expires or deteriorated medications or biological's in accordance with Pharmacy return/destruction guidelines and other Applicable law . 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis 3.1-25(j) .

Based on observation, record review, and interview, the facility failed to ensure proper infection control practices were completed during 1 of 1 blood sugar checks observed. (LPN 2) Finding includes: On 2/7/2024 at 10:58 A.M., LPN 2 completed a blood sugar check of Resident 43. LPN 2 placed the accucheck device on the bedside table. He cleansed his hands with alcohol gel and applied gloves. LPN 2 then cleansed Resident 43's finger with an alcohol pad, and with an opened hand, fanned the area that was just cleansed. During an interview, on 2/7/2024 at 11:07 A.M., LPN 2 indicated he should not have fanned the area. On 2/9/2024 at 11:17 A.M., the Administrator provided the policy titled,Blood Glucose Meter Testing, dated 7/2011 and revised 1/2024, and indicated the policy was the one currently used by the facility. The policy indicated .8. Cleanse resident's fingertip with alcohol wipe and allow to air dry 3.1-18(a)

Based on record review, observation, and interview, the facility failed to identify a pressure ulcer on admission and provide a treatment for the pressure for 1 of 2 residents reviewed for pressure ulcers. (Resident 224) Finding includes: A clinical record review of Resident 224 was completed on 11/30/2022 at 8:34 A.M. Diagnoses included, but were not limited to: acute cystitis, dementia, diabetes mellitus type 2, and peripheral vascular disease. A Clinical Hospital Rehabilitation Record on 10/27/2022 at 1:44 P.M., indicated, an unstageable pressure ulcer to the sacrum. The measurements were 1.6 centimeters by 0.8 centimeters by 0.1 centimeters. The pressure ulcer was not staged due to necrotic tissue with 100 percent adherent yellow slough. There was a small amount of serosanguineous drainage. The surrounding pressure ulcer tissue had erythema. The Hospital initiated Medi-Honey treatment with surrounding Skin Prep with an Allevyn dressing. Resident 224 was admitted to the facility on [DATE]. A Care Plan on 11/1/2022, indicated, .Resident is at risk for skin breakdown due to: limited sensory perception, skin moisture, impaired mobility, potential friction/shear while in bed, peripheral vascular disease and a goal of resident will be free from skin breakdown An Admission MDS (Minimum Data Set) Assessment was completed on 11/7/2022. The assessment indicated Resident 224 was at risk for pressure ulcer development, and had a stage 2 pressure ulcer present on admission. Resident 224 was always incontinent of bladder and bowel. She was severely cognitively impaired. Resident 224 required extensive assistance with two or more staff members for bed mobility, transfers, and toileting. She required extensive assistance with one staff member for eating. A Nurse's Note on 11/01/2022 at 8:09 A.M., recorded as a late entry on 11/17/2022 08:09 A.M., indicated, .Admission Skin Assessment: Resident has some redness to buttock and coccyx. Redness remains blanchable. House barrier cream applied . A Braden Scale Evaluation on 11/1/2022, indicated a score of high risk for skin breakdown. On 11/2/2022, a Braden Scale indicated, a score of moderate risk for skin breakdown. A Weekly Skin Assessment on 11/6/2022, indicated . areas of skin integrity alteration: Discoloration/Rashes BUE [bilateral upper extremity]-some redness On 11/12/2022 at 5:29 A.M., a Nurse's Note indicated, .Resident noted with open skin to the coccyx. Perimeter is red and the central area is covered with some creamy slough. Area cleaned and secured with opt-foam On 11/13/2022, a Weekly Skin Assessment indicated, .areas of skin integrity alteration: Open Areas Coccyx A Physician's Order 11/13/2022, indicated, .Cleanse area to the Coccyx with wound cleanser and pat dry. Secure with the Optfoam dressing every day and as needed This order was discontinued on 11/14/2022. A Wound Management Note on 11/14/2022 and documented on 11/17/2022 08:14 A.M., indicated a stage 2 pressure ulcer measuring 3 cm (centimeters) by 5 centimeters with an unmeasurable depth. The pressure ulcer had a light bloody drainage with no odor. There was no undermining or tunneling. The pressure ulcer had 85 percent of granulation tissue, 10 percent slough tissue and 5 percent eschar tissue. The surrounding tissue had blanchable erythema. The wound is indicated as stable with no signs and symptoms of infection and has a history of an open area to the coccyx. N unstageable A Physician's Order on 11/14/2022, indicated, .Cleanse coccyx with wound cleanser and pat dry. Apply collagen and cover with dry dressing daily The order was discontinued on 11/17/2022. A Care Plan on 11/14/2022, indicated, .Problem: Resident has impaired skin integrity: Pressure area noted to the coccyx. Dx: acute cystitis without hematuria, mixed hyperlipidemia, dementia with psychotic disturbance, COPD, chronic diastolic heart failure, insomnia, osteoporosis, peripheral vascular disease, diabetes, depression, repeated falls, encephalopathy, chronic respiratory failure, obstructive sleep apnea, atrial fib [fibrillation], hypokalemia, hypertension, osteoarthritis, CKD 3 [Chronic Kidney Disease Stage 3]. Contributing factors: limited sensory perception, skin moisture, impaired mobility, potential friction/shear while in bed, peripheral vascular disease .Goal: Wound will heal without complications A Nurse's Note on 11/15/2022 5:22 A.M., indicated, Dressing to the coccyx changed, some scant amount of drainage noted from the wound perimeter. The central part noted with some creamy slough. Procedure well tolerated A Wound Management Note on 11/16/2022, and documented on 11/17/2022 at 8:20 A.M., indicated, .an unstageable pressure ulcer due to slough and eschar. The pressure ulcer measured 3.7 centimeters by 7.1 centimeters by 0.1 centimeters. The pressure ulcer had a bloody drainage and no odor. There was no undermining or tunneling. There was no undermining or tunneling. The pressure ulcer had 85 percent granulation tissue, 10 percent slough tissue, and 5 percent eschar tissue. The surrounding tissue had blanchable erythema. The surrounding tissue had blanchable erythema. The wound is indicated as stable with area of new eschar. The treatment was changed, and there was no signs or symptoms of infection A Physician's Order on 11/17/2022, indicated .Cleanse coccyx with wound cleanser and pat dry. Apply Medi-honey to eschar, cover Medi-honey with calcium alginate, apply collagen to right and left buttock and cover with dry dressing daily and as needed. This order was discontinued on 11/30/2022. An order for an air mattress was placed on 11/17/2022, and indicated, .[Mattress brand] settings per resident comfort Every Shift On 11/18/2022 03:06 P.M., A Nurse's Note indicated, .Wound culture obtained at this time. Dressing change completed as ordered and tolerated well. Edges remain intact, no odor, drainage or s/sx [signs/symptoms] of infection observed. Foley cath [catheter] placed using sterile technique. 16fr [French] cath with 15mL [milliliter] balloon intact. Yellow urine draining to gravity at this time. Tolerated procedure well. No c/o [complaints of] pain or discomfort noted during placement or after procedure. Resting comfortably on left side to offload pressure area with call light in reach. POA [Power of Attorney] notified via voicemail On 11/21/2022 at 5:53 A.M., a Nurse's Note indicated, .Changed dressing to the coccyx. Zero bleeding/odor noted. However, the central area is covered with some creamy slough. Treatment administered as ordered On 11/21/2022 at 3:23 P.M., a Nurse's Note indicated, .Lab report for wound culture in and shows MRSA [Methicillin Resistant Staphylococcus Aureus}, NP [Nurse Practitioner] notified. Have a Picc [peripheral inserted central catheter] line placed and start Vancomycin IV [intravenously] with Pharmacy to dose for wound infection, Moxifloxacin 400 mg po daily x [times] 10 days for wound infection. [Company Name] was called for Picc line placement and will call back the facility when in route. Dressing to coccyx intact and no drainage or foul odor noted. Several attempts were made to notify dtr [daughter] [Daughter's name] but could not answer the phone, left message to call facility A Physician's Order on 11/22/2022, indicated, vancomycin 1,000 mg [milligrams] intravenously, infuse 1g [gram] @ 167[milliliter]/hr [hour] once a day On 11/28/2022 at 11:23 P.M., a Nurse's Note indicated, .Post NP [Nurse Practitioner] New orders received and noted: Referral Consultation wound clinic - MD [Medical Doctor]: Dx [Diagnosis]- Wound Coccyx: D/C PRN Norco Start Norco 7.5-325 po q 8 hrs [hours] scheduled A Wound Management Note on 11/30/2022 at 9:37 A.M., indicated, .a stage 4 pressure ulcer. The pressure ulcer measures were 5.1 centimeters by 4 centimeters with a depth of 2.2 centimeters. The pressure ulcer had a moderate amount of seropurulent drainage with no odor present. The pressure ulcer had 50 percent granulation tissue and 50 percent slough tissue. The wound margins were irregular. The surrounding tissue had erythema that was blanchable. New interventions were placed. A Physician's Order on 11/30/2022, indicated, .Cleanse coccyx with wound cleanser and pat dry. Apply Medi-honey to slough, cover Medi-honey with calcium alginate, apply collagen to granulated wound margins and cover with dry dressing daily On 12/2/2022 at 9:56 A.M., an observation of the pressure ulcer was completed with LPN 12. LPN 12 indicated the pressure ulcer was found on admission and was covered with eschar and slough at that time. He indicated the treatment on the pressure ulcer was Medi-honey and calcium alginate. The pressure ulcer was noted to have a foul odor and serosanguinous drainage when the dressing was removed. On 12/2/2022 at 10:18 A.M., CNA 14 indicated Resident 224 received bed baths. She indicated the wound was present upon admission and a dressing was applied to the wound. She indicated that the staff position Resident 224 side-to-side, get her out bed, and keep the resident clean and dry. During an interview on 12/2/2022 at 1:23 P.M., the Director of Nursing (DON) indicated, she could not say exactly when the pressure ulcer occurred. She indicated she was notified on 11/12/2022, and treatments began at that time. The DON indicated when the daughter was updated on the pressure ulcer, the daughter indicated Resident 224 had a pressure ulcer prior to admitting to the facility. The DON indicated, We knew this was going to be an issue. A policy was provided on 12/2/2022 at 12:49 P.M. by the Administrator. The policy titled, Skin Management Program indicated, .Avoidable Pressure Ulcer/injury: means that the resident developed a pressure ulcer/injury abs that the facility did not do one or m ore of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice, monitor and evaluate the impact of the interventions, or revise the interventions as appropriate .Procedure For Wound Prevention 1. All residents will be assessed at admission using a skin risk (Braden) assessment to determine risk for pressure ulcer/injury with initiation of a plan of care. 2. The admission skin assessment will include but not limited to: Interview of resident or family about history of skin alterations, Head-to-toe skin assessment, bed mobility, continence, signs/symptoms of peripheral vascular disease, skin alterations present on admission, skin discoloration and any evidence of scarring on pressure points, recent surgical procedures, complications such as infection and pain, nutritional status 3.1-40(a)(2)

Based on record review and interview, the facility failed to accurately assess and monitor a resident prior to and following the insertion of a Foley catheter which resulted in the Resident pulling out the catheter resulting in a traumatic urethral injury and hospitalization . This deficiency affected 1 of 3 residents reviewed for Foley catheters. (Resident D) Finding includes: The record of Resident D was reviewed on 11/16/15 at 11:30 a.m. Resident D was admitted to the facility, on 04/02/14, with [DIAGNOSES REDACTED]. The nurses Progress Notes indicated: 07/06/15 1050 (10:50 a.m.) Dr. (Urologist) office called (urology) stating that (Resident's spouse) called their office stating that resident is having issues c (with) urinary incontinence & (and) is requesting a urine sample be tested . New order received per Dr. (Urologist) to obtain a U/A (Urinalysis) C&S (Culture & Sensitivity) if indicated 07/09/15 See SBAR (Situation Background Appearance Review & Notify) for discharge note. The SBAR indicated: 07/09/15 Catheter was placed approx (approximately) 12:30 a.m. to collect a U/A. Res (Resident) has been incontinat (sic) and unable to provide a clean catch. This writer observed there still was no output p (after) 1 hr (hour) and attempted to check cath (catheter) placement. Res call-light and bed control were wrapped around cath and knotted together. Unable to deflate baloon (sic). Cath cut and still no fluid output. Cath not moving when attempted to reposition. Nurse notified manager, res. (resident's) wife and Dr. (Primary Physician). When returning to res. (resident) room, res. state he pulled it out himself. Foley out & intact. Sm. (small) amount of bleeding from penis. Sent to (hospital name) ER for eval (evaluation) The Physician order [REDACTED].>07/06/15 1050 (10:50 a.m.) U/A C&S if indicated. Dx (Diagnosis): urinary incontinence. The next Physician order [REDACTED].>07/09/15 0230 (2:30 a.m.) Send to (hospital name) ER for eval/tx (evaluate/treat). Res pulled foley catheter out. There was no documentation in the record in regards to obtaining an order for [REDACTED]. Review of the Acute Care Facility (hospital) History & Physical indicated: 07/09/15 .CHIEF CONCERN: Traumatic urethral injury (urethral tear). HISTORY OF PRESENT ILLNESS: The patient is a very poor historian and cannot tell me any reliable history .Wife has been requesting a urine sample. However, the nursing home cannot get a clean catch. Foley catheter is then ordered. However, the patient tried to pull it out after insertion. The Foley catheter then got stuck. Nursing home staff has to cut the Foley catheter and finally managed to get it out. The patient then had hematuria from the traumatic Foley removal . IMPRESSION: 1. Urethral injury due to traumatic Foley removal . PLAN: 1. Anticipating less than 2 midnights of hospitalization and the patient will be admitted as an observation status The DNS (Director Nursing Services) was interviewed on 11/16/15 at 12:15 p.m. The DNS indicated at the time of the incident she was a staff nurse and was unaware there was no order to catheterize Resident D. The DNS indicated staff should have obtained an order and document the procedure and assessments. RN #5 was interviewed on 11/16/15 at 2:35 p.m. RN #5 indicated she called the Urologist's office on 07/06/15 for the order for the U/A C&S. RN #5 indicated there was no order, at the time, to catheterize Resident D. On 11/16/15 at 3:00 p.m. the DNS provided the current corporate Policy & Procedure, BLADDER PROGRAM: 11/2014, which indicated: Policy: It is the policy of American Senior Communities to promote independence and dignity with an appropriate bladder program based upon each resident's ability. .Residents with Foley Catheters .3. If it is determined an indwelling catheter IS medically necessary, obtain a physician's orders [REDACTED]. This Federal tag relates to Complaint IN 037. 3.1-41(a)(1)

Based on record review and interview, the facility failed to ensure the plan of care was followed during a transfer using a Hoyer lift that resulted in a fall with femur fracture for 1 of 3 residents reviewed for transfers. (Resident C) Finding includes: On 8-27-15 at 10:00 A.M., the clinical record for Resident C was reviewed. Resident C was admitted to the facility, on 5-22-14, with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, with an assessment reference date of 5-22-15, indicated the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. Resident C required 2 persons and extensive assistance with transfers. The MDS further indicated Resident C had lower extremity range of motion impairment to both sides of his extremities. A Fall Risk care plan, initiated on 5-22-15, indicated . Resident is at risk for fall due to pain and [DIAGNOSES REDACTED].Approach: Resident utilizes a hoyer lift (mechanical lift used for transfer) with assist of 2 for transfers A SBAR (Situation Background Appearance and Review) communication form, dated 6-28-15, indicated .Nurses Notes: Resident slid from hoyer sling. Resident lowered to floor with help from CNA (Certified Nursing Assistant) from approx. (approximately) 2 ft. (feet) in air. Resident landed on back et (and) hit head on floor. No new injuries. Resident c/o (complained of) increase joint pain which is chronic discomfort. Ibuprofen (a pain medication) et (and) Tramadol (a pain medication) given at 2100 (9:00 P.M.) as scheduled prior to fall A Radiology Report, dated 6-29-15, indicated .Conclusion: Findings suspicious for nondisplaced oblique femoral neck fracture On 8-28-15 at 8:00 A.M., an interview was conducted with Resident C. Resident C indicated a CNA was attempting to transfer him from his wheelchair to his bed. Resident C further indicated he did not think the CNA got all the hooks of the sling on the hoyer and she didn't get a second person to help her with the transfer. Resident C indicated . I fell and hit the floor, she did not catch me On 8-28-15 at 10:00 A.M., a Witness Investigation Statement, dated 6-28-15 at 9:30 P.M., indicated . I (name of CNA #2) trying to put (name of Resident C) on the bed by myself w/(with) the hoyer machine at 9:30 P.M .I attempt to lift the machine because I couldn't find the other aid around, but the strap just come to loose so I hold his back and slowly put him on the floor and called the two nurses to help me put him in the bed On 8-28-15 at 11:38 A.M., a (Corporate name) Mechanical Lift Skills Validation check off form, provided by the Assistant Director of Nurses, was reviewed. The Skills Validation form indicated . Note: Two (2) staff is required at all times when using a mechanical lift On 8-28-15 at 11:43 A.M., a (Brand Name) Skills Check Off/Return Demonstration (brand name for the mechanical lift) form, provided by the Assistant Director of Nurses, indicated .I have reviewed the information on operating the (brand name of the mechanical lift). I have successfully demonstrated the skills and understand that these lifts are to be used to comply with the policy .I also understand that when transferring a resident with a lift, 2 trained staff members must be present to ensure the resident remains safe .Employee: (Name of CNA #2) .Date: 4-23-14 On 8-28-15 at 11:47 A.M., during an interview, the DON (Director of Nurses) indicated, .there should be 2 persons with a hoyer lift transfer regardless of the situation This Federal tag relates to Complaint IN 753. 3.1-45(a)(1)

Based on observations, record reviews and interviews, the facility failed to assure catheter care was provided in a manner to prevent infection for a resident with a history of UTI (Urinary Tract Infection) for 1 of 3 residents in a sample of 3 with a urinary catheter. (Resident "B") Finding includes: The record of resident "B" was reviewed on 02/19/13 at 10:30 a.m. Resident "B" was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident "B" had an A/C (anchored catheter) for urine output upon admission. Resident "B" was alert and orientated. Resident "B" was able to move and adjust his catheter without assistance. Resident "B" was being treated for [REDACTED]. Review of the physician's orders [REDACTED]. "01/21/12 CATH CARE EVERY SHIFT" "FOLEY CATH FLUSH W (with)/60 CC (centimeters) NS (Normal Saline) EVERY SHIFT AND PRN (as needed)" On 02/20/13 at 1:00 p.m., RN #15, the unit's full time RN, was observed to provide catheter care and catheter irrigation for Resident "B". RN #15 indicated she was the usual nurse who did the cath care and irrigation. RN #15 washed her hands and opened the sterile bottle of Normal Saline and the irrigation syringe without incident. RN #15 was then observed to disconnect the catheter drainage tubing from the catheter and proceed to irrigate the bladder through the catheter with the syringe and Normal Saline, then reconnect the catheter to the catheter drainage tubing without cleansing the area of connection. RN #15 then gave a clear and accurate assessment of checking the urine for color, clarity, flow and checking the catheter, tubing, and drainage bag for positioning. RN #15 indicated the assessment as the process for providing for cath care for Resident "B." The ADNS (Assistant Director Nursing Services) was interviewed, on 02/20/13 at 2:00 p.m., in regards to the facility's Catheter Care and Catheter Irrigation Policy and Procedures. The ADNS provided, at the time, a "PROCEDURE: Indwelling Urinary Catheters: 07/2012". The procedure did not address catheter care or catheter irrigation. The ADNS, when queried, indicated the staff refer to the "Lippencott Manual of Nursing Practice located on the unit, for direction. Reference to the provided manual, Chapter 21: RENAL AND URINARY DISORDERS, indicated: "PROCEDURE: Nursing Action: Care of the indwelling catheter 1. Clean around the area where catheter enters urethral meatus...with soap and water during the daily bath to remove debris..." "PROCEDURE: Nursing Action: To irrigate the catheter... 1. Wash hands. Put on gloves. 2. Using aseptic technique, pour sterile irrigating solution into sterile container. 3. Clean around the catheter and drainage tubing connection with sterile gauze pads soaked in [MEDICATION NAME]-iodine solution. 4. Disconnect catheter from drainage tubing. Cover tubing with a sterile cap. 5. Place a sterile drainage basin under the catheter. 6. Connect a large-volume syringe to the catheter and irrigate catheter using prescribed amount of sterile irrigant. 7. Remove syringe and place end of catheter over drainage basin, allowing returning fluid to drain into basin. 8. Repeat irrigation procedure until fluid is clear or according to physician's directives. 9. Disinfect the distal end of the catheter and end of drainage tubing; reconnect the catheter and tubing. Remove gloves. Wash hands." RN #15 was interviewed on 02/20/13 at 2:30 p.m. RN #15 indicated she was the full time day nurse who normally cared for Resident "B" and provided the catheter care and catheter irrigation as previously observed. This Federal tag relates to Complaint IN 071. 4.1-4(a)(2)

Based on observations, record reviews and interviews, the facility failed to assure catheter care was provided in a manner to prevent infection for a resident with a history of UTI (Urinary Tract Infection) for 1 of 3 residents in a sample of 3 with a urinary catheter. (Resident "B") Finding includes: The record of resident "B" was reviewed on 02/19/13 at 10:30 a.m. Resident "B" was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident "B" had an A/C (anchored catheter) for urine output upon admission. Resident "B" was alert and orientated. Resident "B" was able to move and adjust his catheter without assistance. Resident "B" was being treated for [REDACTED]. Review of the physician's orders [REDACTED]. "01/21/12 CATH CARE EVERY SHIFT" "FOLEY CATH FLUSH W (with)/60 CC (centimeters) NS (Normal Saline) EVERY SHIFT AND PRN (as needed)" On 02/20/13 at 1:00 p.m., RN #15, the unit's full time RN, was observed to provide catheter care and catheter irrigation for Resident "B". RN #15 indicated she was the usual nurse who did the cath care and irrigation. RN #15 washed her hands and opened the sterile bottle of Normal Saline and the irrigation syringe without incident. RN #15 was then observed to disconnect the catheter drainage tubing from the catheter and proceed to irrigate the bladder through the catheter with the syringe and Normal Saline, then reconnect the catheter to the catheter drainage tubing without cleansing the area of connection. RN #15 then gave a clear and accurate assessment of checking the urine for color, clarity, flow and checking the catheter, tubing, and drainage bag for positioning. RN #15 indicated the assessment as the process for providing for cath care for Resident "B." The ADNS (Assistant Director Nursing Services) was interviewed, on 02/20/13 at 2:00 p.m., in regards to the facility's Catheter Care and Catheter Irrigation Policy and Procedures. The ADNS provided, at the time, a "PROCEDURE: Indwelling Urinary Catheters: 07/2012". The procedure did not address catheter care or catheter irrigation. The ADNS, when queried, indicated the staff refer to the "Lippencott Manual of Nursing Practice located on the unit, for direction. Reference to the provided manual, Chapter 21: RENAL AND URINARY DISORDERS, indicated: "PROCEDURE: Nursing Action: Care of the indwelling catheter 1. Clean around the area where catheter enters urethral meatus...with soap and water during the daily bath to remove debris..." "PROCEDURE: Nursing Action: To irrigate the catheter... 1. Wash hands. Put on gloves. 2. Using aseptic technique, pour sterile irrigating solution into sterile container. 3. Clean around the catheter and drainage tubing connection with sterile gauze pads soaked in [MEDICATION NAME]-iodine solution. 4. Disconnect catheter from drainage tubing. Cover tubing with a sterile cap. 5. Place a sterile drainage basin under the catheter. 6. Connect a large-volume syringe to the catheter and irrigate catheter using prescribed amount of sterile irrigant. 7. Remove syringe and place end of catheter over drainage basin, allowing returning fluid to drain into basin. 8. Repeat irrigation procedure until fluid is clear or according to physician's directives. 9. Disinfect the distal end of the catheter and end of drainage tubing; reconnect the catheter and tubing. Remove gloves. Wash hands." RN #15 was interviewed on 02/20/13 at 2:30 p.m. RN #15 indicated she was the full time day nurse who normally cared for Resident "B" and provided the catheter care and catheter irrigation as previously observed. This Federal tag relates to Complaint IN 071. 4.1-4(a)(2)

Based on observation, record review, and interview, the facility failed to ensure fall prevention interventions were in place for resident's identified as fall risks related to alarms not in place which resulted in injury requiring staples for 1 of the 3 who did not have ordered interventions in place for falls. (Residents #H, #B, and #D) Findings include: 1. During orientation tour on 5/29/12 at 8:35 a.m., Resident #H was not observed in her room. CNA#1 was standing in the room by the resident's bed. The bathroom door was almost completely closed. The CNA indicated the resident was in the bathroom. The resident was not in view of the CNA. At this time, Unit Manager #1 indicated Resident #H had frequent falls and recently was sent the hospital emergency room for a head injury sustained during a fall. The record for Resident #H was reviewed on 5/30/12 at 10:10 a.m. The resident was admitted to the facility on [DATE]. The resident was admitted from the hospital. The resident's [DIAGNOSES REDACTED]. Review of the resident's current care plans indicated a care plan was initiated on 5/12/12. The care plan indicated the resident was at risk for falls or injury related to being unsteady, a [DIAGNOSES REDACTED]. The resident also had exhaustion and weakness. Care plan interventions included for one person assist to be provided for increased supervision and the assist of one staff for ambulation and transfers. Care plan interventions included chair alarm, bed alarm, floor mat and to lock the bed wheels. The care plan indicated the resident had two falls on 5/10/12 and one fall on 5/19/12. An IDT (Interdisciplinary Team) progress note was made on 5/10/12. The note indicated the resident was an "extreme fall risk" and had bed and chair alarms in place. The 5/2012 Nursing Progress Notes were reviewed. An entry made on 5/11/12 Communication Progress note indicated the resident fell on [DATE] and was sent out the hospital emergency room and received 6 staples to a laceration on the back of her head. The 5/10/12 Resident Transfer Form, completed at 9:00 a.m., indicated the resident fell and sustained a laceration to the posterior scalp area and she complained of pain in her pelvis and had an abrasion to the left elbow. A Resident Incident form, dated 5/10/12, indicated the resident was found laying on the floor next to her dresser. The resident was confused and had attempted to ambulate independently. The resident had a laceration to the back of the head and a skin tear to the left elbow. The resident was sent to the hospital emergency room for treatment. The 5/10/12 emergency room Discharge Instructions indicated staples were used to repair the scalp wound. When interviewed on 5/30/12 at 12:55 p.m., the ADON indicated the resident was a fall risk and interventions included chair and bed alarms. The ADON indicated the resident had two falls on 5/10/12 and was placed on 15 minute checks. The ADON indicated the resident required increased supervision and should not have been left alone in the bathroom. The ADON also indicated upon review of the fall of 5/10/12 at 8:57 a.m. The facility identified that the resident's chair alarm was not in place at the time of the fall. She indicated the alarm was observed to be on the dresser in the resident's room. The ADON indicated staff were disciplined for not assuring the alarms were in place. 2. On 5/29/12 at 2:45 p.m., Resident #B was observed sitting in a wheel chair in his room. The resident did not have an alarm in place. There was no alarm device observed in the resident's room. On 5/30/12 at 8:00 a.m., the resident was observed sitting in wheel chair at a table in the lounge area on the unit. The resident did not have an alarm in place The record for Resident #B was reviewed on 5/29/12 at 1:30 p.m. The resident's [DIAGNOSES REDACTED]. A care plan initiated on 4/17/12 indicated the resident was at risk for falls or injury related to exhaustion,weakness, and receiving cardiovascular medications. The care plan was last updated on 5/12/12. An intervention for the resident to have a chair alarm was added to the care plan on 5/19/12. The 5/19/12 Nursing Progress Notes were reviewed. An entry made at 8:15 a.m., indicated the resident across the hall from Resident #B notified the nurse the resident was on the floor in front of the wheelchair. The resident denied complaints of pain and was able to move all his extremities. When interviewed on 5/30/12 at 11:15 a.m., the ADON indicated the intervention for a wheel chair alarm to be in place was added to the resident's plan of care on 5/19/12 and the resident should have a wheel chair alarm in place when he is up the wheel chair. 3. The closed record for Resident #D was reviewed on 5/29/12 at 2:30 p.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the 5/2012 Nursing Progress Notes indicated an entry was made on 5/7/12 at 6:45 p.m. This entry indicated the resident was calling down the hall for the nurse. The resident was found sitting on the floor by his bed and stated he slipped out of his chair. Neuro checks(assessment to determine if any changes were noted in the neurological status) were initiated. The entry also indicated the resident was to be non weight bearing to his right hip. A care plan initiated on 4/21/12 indicated the resident was at risk for falls or injury related to a right hip fracture, syncope, and a history of a ground level fall. Care plan interventions included for the resident to have the assistance of two staff for ambulation and transfers. No other interventions were checked on the care plan. When interviewed on 5/30/12 at 12:45 p.m., the ADON indicated she was not aware of the resident's fall on 5/7/12. The ADON indicated care plan interventions should have been put into place at that time. The ADON indicated she felt an alarm should have been initiated at this time due to the resident making attempts to transfer and still having orders for non weight bearing due to his recent hip fracture and non weight bearing status. This federal tag relates to Complaints IN 375 and IN 956. 3.1-45(a)(2)

Based on interview and record review, the facility failed to provide the necessary care to ensure diabetic residents (#C, #E) who experienced a hypoglycemic (low blood sugar) episode were monitored for response to nursing interventions which resulted in Resident #C becoming non-responsive and requiring hospitalization . This deficient practice affected 2 of 7 residents reviewed with diabetes in a sample of 7. Findings include: 1. Resident #C's clinical record was reviewed on 8/23/11 at 3:45 P.M., and indicated [DIAGNOSES REDACTED]. Resident #C's clinical record included a "History and Physical Final Report" from his hospitalization prior to his 6/03/11 admission to the facility. It was dated 4/22/11, printed on 5/26/11, and indicated, "...We will monitor his blood sugars, adjust his medications. These are uncontrolled at this point due to his use of steroids. This should improve as he weans off his steroids...." A hospital list of discharge medications indicated Resident #C did not continue the steroid medication upon admission to the long term care facility. A physician's orders [REDACTED]." Review of Resident #C's Medication Administration Record (MAR), dated 7/01/11 through 7/31/11, indicated low blood sugar readings as follows: blood sugar of 66 at 11 A.M. and 51 at 9:00 P.M. on 7/10/11; blood sugar reading of 51 at 9:00 P.M. on 7/13/11, and blood sugar reading of 60 at 9:00 P.M. on 7/18/11. Nurse's Note, dated 7/13/11 at 8:00 P.M., indicated, "Res (resident) was noted sweating. BS was 41. Gave 120 cc of orange juice, repeated BS after 20 min. (minutes). BS level was 54. Re-offered more OJ...faxed to Dr. (Name) will keep monitoring." A Dietician's Progress Note, dated 7/14/11 at 12:05 P.M., indicated, "Resident reported to have hypoglycemic (low blood sugar) episode. BS checked 9 P.M. 7/13/11 with result 51. Resident receives Glimepiride, [MEDICATION NAME], and [MEDICATION NAME] in the A.M. Residents (sic) receives Meftormin and [MEDICATION NAME] before supper...MD notified. Orange jc (juice) 120 cc given during hypoglycemic episode. Repeat BS with result 54, more orange jc offered. Repeat BS with result 78. Review of last 7 days HS snack shows variable intake...." Nurse's Notes, dated 7/28/11, indicated the following: 4:00 P.M.- "In W/C (wheel chair) has poverty of thoughts. BS (blood sugar) 65. Given OJ (orange juice) & went to PT (physical therapy); 6:15 P.M.-Called to dining room. Pt (patient) diaphoretic (sweaty) and non-responsive. BS 38. Given insta-glucose & 1 cc (cubic centimeter) [MEDICATION NAME]; 6:45 P.M.-BS 116 B/P (blood pressure) 68/31. Still not responsive. Able to follow command; 7:00 P.M.-Called Dr. (Name)-Sent to Hospital; 7:30 P.M.-(Ambulance Service) here for pickup remains unresponsive B/P 67/35 P (pulse)-52. Sitting upright. Can follow commands. Late entry Nurse's Notes for 7/28/11 indicated: "4:00 P.M.-[MEDICATION NAME] (insulin) held for BS 65. Unable to verbalize...Given OJ & went to PT with instruction he drink all juice; 6:15 P.M.-Called to dining room stating "Something's wrong he's non-responsive." Pt. found with head down in W/C very diaphoretic. Responds to command. Able to squeeze my hand. Unable to speek (sic) or swallow is drooling-taken to nsg (nursing) station & BS check was 38. Given Given [MEDICATION NAME] 1 cc IM (intramuscular) L Ant (left anterior) thigh; 6:30 P.M.-BS 65-Able to swallow. Insta-glucose. Still unable to speek (sic). Head down but sitting upright in w/c; 6:45 P.M.-BS 116 A little more alert but still not normal. B/P 68/31, P 48...Able to follow command 'lifts hand;' 7:00 P.M.-B/P 65/27, P 52. Dr. (Name) paged-Sent pt. to Hospital; 7:30 P.M.-(Ambulance Service) here for pt. pickup. Remains non-verbal. B/P 64/27, P 48...." Nurse's Notes lacked documentation to indicate the nurse followed-up and monitored resident #C's response to the orange juice administered at 4:00 P.M. and the affect physical activity had on his already low blood sugar. Resident #C's Medication Administration Record (MAR), dated 7/01/11 through 7/31/11, indicated, "If BS is less then 60 initiate protocol...(step one): if alert, responsive and able to swallow: give 120 cc (cubic centimeters) (4 oz) of orange juice or 1 tube in (sic) instaglucose gel orally. Continue to monitor & repeat blood sugar in 15 to 20 minutes. (step two): If BS rises, follow with a protein snack. If unable to raise BS repeat 120 cc of juice & recheck BS in another 15-20 minutes. If unable to raise BS notify MD (medical doctor). Document all findings & actions...." During telephone interview with Resident #C's spouse on 8/23/11 at 12:45 P.M., she indicated the above incident occurred on 7/29/11, not 7/28/11 as indicated in the Nurse's Note. She further indicated she began bringing in cookies and fruit for Resident #C and insisted he eat them in the evening because she was concerned he might experience episodes of low blood sugar. "I complained numerous times to the nursing staff. RN #3 took my concerns to the Director of Nursing, but nothing was done about it. The day before (Resident #C) went into the coma, my two sons met with the Administrator and the Director of Nursing and they reviewed my husband's blood sugar. The Administrator said, 'Well, yeah, it did go down to 51, but we did get it up.' They were giving him four doses of insulin a day, but he was no longer getting the steroid. The reason he was on insulin was because the steroid elevated his blood sugars. I went to therapy with him (7/29/11) and he was having a hard time putting one foot in front of the other. He wanted to go lie down. (Resident #C) was unresponsive when he arrived at the emergency room ." The MAR, dated 7/01/11 through 7/31/11, indicated resident #C received the following medications to control and lower his blood sugar: [MEDICATION NAME] (long acting insulin)12 u (units) SQ (subcutaneous) (beneath the skin) every morning before breakfast (8:00 A.M.), [MEDICATION NAME] (rapid acting insulin) 5 u SQ in the morning with breakfast (8:00 A.M.), Actos 45 mg. (milligram) orally at 8:00 A.M., Glimepiride 6 mg. orally at 8:00 A.M., [MEDICATION NAME] 100 mg. orally at 8:00 A.M., [MEDICATION NAME] 1,000 mg. orally with breakfast (8:00 A.M.) and dinner (5:00 P.M.), [MEDICATION NAME] (rapid acting insulin) 7 u SQ with supper (5:00 P.M.). A pharmacy "Potential Drug Interaction," dated 6/3/11, indicated, "...Drug Dispensed: Aspirin EC ([MEDICATION NAME] coated) 325 Mg. Tablet Interacts with: Glimepiride 2 Mg. Tablet (Resident #C was receiving 6 Mg.)...Patient Management: Hypoglycemic (a state of low blood sugar level) signs and blood glucose levels should be monitored. Adjust the antidiabetic dose as needed...." Resident #C's "Resident Transfer Form," dated 7/29/11, indicated, "Sent to: (Name of Hospital)...Reason for transfer: BS @ 6:15 (P.M.) was 38...BP 72/34...." Emergency Department Physician Notes, dated 7/30/11 at 12:09 A.M., indicated, "...History of present illness: the patient presents with [DIAGNOSES REDACTED] (low blood sugar)...EMS (Emergency Medical Staff) had to administer 1 amp (ampoule) d50 ([MEDICATION NAME]) during transport...Notes: [DIAGNOSES REDACTED]. Given multiple medications with prolonged 1/2 life and repeat hypoglycemic episodes, will need admit for further checks. Started IV (intra-venous) [MEDICATION NAME]." 2. Resident #E's clinical record was reviewed on 8/23/11 at 2:00 P.M., and indicated [DIAGNOSES REDACTED]. During initial tour of the facility on 8/23/11 at 9:15 A.M., while accompanied by RN #2, she indicated Resident #E was alert and oriented and interviewable. Resident #E's most recent quarterly MDS (Minimum Data Set) Assessment, dated 7/22/11, indicated her cognicity score as 15 (no cognitive impairment). Resident #E's Medication Administration Record (MAR), dated 4/01/11 through 4/30/11, indicated, "If blood sugar os (sic) less then 60 initiate protocol...(step one): if alert, responsive and able to swallow: give 120 cc (cubic centimeters) (4 oz) of orange juice or 1 tube in (sic) instaglucose gel orally. Continue to monitor and repeat blood sugar in 15 to 20 minutes. (step two): If blood sugar rises, follow with a protein snack. If unable to raise blood sugar repeat 120 cc of juice and recheck blood sugar in another 15-20 minutes. If unable to raise blood sugar notify MD (medical doctor). Document all findings and actions...." It further indicated her blood sugar levels were to be checked at 4:00 A.M., 7:00 A.M., 11:30 A.M., 5:00 P.M. and 9:00 P.M. Review of Resident #E's MAR's indicated the following: 4/02/11 at 11:30 A.M. BS (blood sugar)=48, 4/06/11 at 7:00 A.M. BS = 40, 4/20/11 at 11:30 A.M. BS = 60, 4/25/11 at 4:00 A.M. BS = 48, 6/07/11 at 4:00 A.M. BS = 60, 6/15/11 at 11:30 A.M. BS = 55, 6/23/11 at 11:30 A.M. BS = 54, and 7/18/11 at 7:00 A.M. BS = 54. Further review of the MAR and Resident #E's clinical record lacked documentation to indicate the interventions were implemented. RN #2 indicated in an interview on 8/23/11 at 3:10 P.M., the documentation of nursing intervention that was implemented would be initialed on the MAR under the blood sugar protocol. "The nurse should have documented it. She didn't follow the Physician's protocol." During interview with Resident #E on 8/23/11 at 3:15 P.M., she indicated her blood sugar levels have dropped too low several times. "I can tell when it is too low." She further indicated the nurse would give her a glass of orange juice to drink in an attempt to bring the blood sugar up. When queried if the nurse rechecks her blood sugar level again in 15-20 minutes, Resident #E indicated her blood sugar levels were not checked again until meal time. This Federal tag relates to complaint IN 821. 3.1-37(a)

Based on interview and record review, the facility failed to ensure the physician sought hospital treatment for [REDACTED]. The lack of physician intervention resulted in the resident [MEDICAL CONDITION] which required hospitalization and radical surgical debridement to remove infected flesh. This deficient practice affected 1 of 2 residents reviewed with pressure ulcers in a sample of 3. Resident: # B Findings include: Resident # B's clinical record was reviewed on 4/25/11 at 3:15 P.M. and indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A "(Hospital Name) Consultation Report," dated 4/06/11, indicated Resident # B's recent medical history which precipitated his placement at a long term care facility: "...The patient is an (age in years documented) gentleman who has had a difficult course over the last 6 weeks to 8 weeks. Essentially, he was found down after a fall around 2/02/11 and was admitted initially to (Name) Hospital with hypertension and a fall...He made progress, despite [DIAGNOSES REDACTED]. Unfortunately, he did not do well in that setting and ended up being admitted to (Name) Nursing Facility. There, he continued to have further issues...." Resident # B's "Nursing Comprehensive Admission Data Collection and Assessment," dated 3/18/11, indicated: he was incontinent of both bowel and bladder, had right lower extremity impairment, needed limited assistance of two for bed mobility and transfers, and was totally dependent on staff for ambulation. An "Admission Skin Assessment," dated 3/18/11 indicated Resident # B was admitted to the facility with a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) pressure ulcer to the coccyx area (lower part of the spine located in the center of the buttocks) and a callus to left heel. A Skin Grid, dated 3/20/11, indicated resident # B's pressure ulcer was a stage III and measured 7.5 cm. (centimeters) in length, 4.0 cm. in width, and 0.1 cm. in depth. It further indicated the wound had a moderate amount of yellow drainage with odor and slough (dead tissue that is shed). A "Pressure Ulcer Healing Chart," dated 3/20/11, indicated the same data as the Skin Grid. Nurse's Progress Notes indicated: 3/20/11 at 7:35 A.M., "Open area on the coccyx on top of an old healed pressure area found at 5:50 A.M. Area cleaned with N/S (normal saline) and covered. Physician notified and tx (treatment) order requested...2:20 P.M. Did not eat very much lunch, was medicated for heel pain earlier with relieve (sic). Dr. (Name) aware of bil. (bilateral) heel areas and coccyx, no new orders received..." "Physician Notification" records, dated 3/20/11, indicated, 1:50 A.M.-"...Spoke with Dr. (Name), promised to see res. this morning during rounds...still waiting for TX (treatment) order to other skin areas...7:35 A.M.-"Old healed pressure area on the coccyx opened. L (length)-1.0 cm., W (width)-1.0 cm., tunneling 6 o'clock, depth 1. cm. x 0.5 cm. at the center of the area. Drainage red in color...Can we have order for calcium alginate (treatment) and apply [MEDICATION NAME] (wound cover) to area...Date/Time of Onset of Symptoms: 3/20/11, 6:50 A.M. ...." Nurse's Progress Notes indicated: 3/21/11 at 12:35 A.M.-"Dr. (Name) informed about low BP (blood pressure) 89/50, said he will see res (resident) in the A.M. ...1:50 A.M.-MD (Medical Doctor) notified about expanded skin area around the coccyx and bil. buttocks. Said he will see res in A.M. ...4:35 A.M.-c/o (complained of) bil. lower extremities pain. Rated pain at 9/10 (pain scale of 0-10 with 10 being severe), requested and was given pain med (medication)...9:00 A.M.-...has poor appetite...Evaluate (sic) by Dr. (Name) waiting for new orders...1:15 P.M.-New orders received and noted. Coccyx wound now measures 7.5 cm. x 4.0 cm. x < 0.1 cm., as superficial, no odor, mod (moderate) to sm (small) amt (amount) sero sang (serosanguineous) (thin and red) drainage...." A Physician's Telephone Order, dated 3/21/11 at 8:00 A.M., indicated the following laboratory order: "BMP (basic metabolic panel), CBC (complete blood count), [MEDICATION NAME], B12 level, Air Loss Mattress (specialized mattress used to reduce pressure on body points). A second Physician Order, dated 3/21/11 at 8:00 A.M., indicated, "Prevalon Boots (protective covering) to feet, Allevyn heel (medicated heel treatment) to Lt (left) heel and change q (every) 72 hours...Santyl (a chemical debridement)...to coccyx. Cover with dry drsg (dressing) and change daily or prn (as needed) for soilage...." A Physician's Progress Note, dated 3/21/11, indicated, "...Subjective: This patient is being seen...Review of Systems: ...Skin: Evidence of a stage II wound to the coccyx in a butterfly distribution to both buttocks. He also has heels with scaling. He also has a dry eschar (a black scab or dry crust that results from trauma) on the right heel. Physician's Telephone Orders, dated 3/27/11 at 1:00 A.M. indicated, "Diagnosis: [REDACTED]. (milligram) q 4 h (hours) prn (as needed) temp (temperature) > 100...6:00 P.M.[MEDICATION NAME](antibiotic) 250 mg. P.O. BID (twice daily) x 7 days for UTI (urinary tract infection)...." Nurse's Progress Notes indicated: "3/27/11-Late entry: @ 7:30 A.M.-Medicated with Tylenol ii (2) P.O. (by mouth) per c/o T (temperature) 102.5...9:30 A.M.-Medicated per c/o bilateral leg pain...3:00 P.M.-...Moderate amount of yellow/bloody drainage with odor...7:00 P.M.-Resident had fever of 102. Medicated with tylenol...." A Nurse's Progress Note, dated 3/28/11 at 10:00 A.M., indicated, "T-100.7...coccyx dsg (dressing) dry and intact, wound still has foul odor. Abt (antibiotic) continues for UTI...Still has some burning with urination...." A "Physician Notification," dated 3/29/11 at 5:30 P.M., indicated, "...1. Need parameters for [MEDICATION NAME] (blood pressure medication) 30 mg. QID (four times/day)-B/P running low. Need orders for when to hold. 2. Family upset* res. was on [MEDICATION NAME] (pain medication) patch 12 mcg. (microgram)...at home for chronic back pain...and it was D/C'd (discontinued) when he was admitted -THEY WANT HIM HACK ON IT-WILL NEED SCRIPT...Physician Response: Hold for SBP (systolic blood pressure) < (less than) 100. [MEDICATION NAME] 12 mcg. q 72 hours." "Physician's Telephone Orders," indicated: "3/30/11 at 11:40 A.M.- Tylenol Suppository 650 mg rectally q 4 hours PRN for temp > (greater than) 100 degrees for fever...4:00 P.M. ...Hold for SBP < 100. [MEDICATION NAME] 12 mcg. change q 72 hours...." A Nurse's Progress Note, dated 3/30/11 at 12:45 A.M. indicated resident # B had a fever with a temperature of 100.4 and was given Tylenol. Nurse's Progress Notes indicated the following: 3/31/11 (no time given but documented after 5:00 P.M. note of 3/30/11 and prior to 10:20 P.M. note of 3/31/11), "...Coccyx dressing changed. Lg. (large) amnt (amount) tan foul smelling drainage from wound bed. Dk (dark) brown on coccyx, pink on buttocks. C/O Pain when touched...10:20 P.M.-c/o back/leg pain, repositioned with no imp (improvement), medicated for pain...4/01/11 at 12:00 A.M.-reassessed for pain and pain was reduced to 3/10 from 8/10 (pain scale)...1:40 A.M.-Res c/o of pain again, said he wants to go (to) the hospital, sister (Name) was called to talk to res. to be satisfied give medication time. (Dr. Name) was contacted, he ordered [MEDICATION NAME] (moderate pain medication) to be given. Res. already has this med. Med given per order...4:30 P.M.-Res. has increased pain over past few days. [MEDICATION NAME] in place-prn pain meds as indicated...new TX order for coccyx to start tomorrow-to receive one unit PRBC (packed red blood cells) tomorrow...Drsg (dressing) to coccyx with brown drainage and odor... new order for [MEDICATION NAME] and charcoal. Change q day...." A Physician's Telephone Order, dated 4/1/11 at 1:00 P.M., indicated, "1. DC (discontinue) Santyl to coccyx. 2. Start-Cleanse area to coccyx with NS (normal saline), pat dry. Apply [MEDICATION NAME] (topical creme) and cover with charcoal drsg. Change daily and PRN...." Review of a facility laboratory report, dated 3/21/11, indicated Resident # B's RBC (red blood cell)(a count of mature red blood cells in a specimen of whole blood) was 3.69 (low) with the normal being 3.90-5.90; HGB (hemoglobin)(transports oxygen to the cells) was 10.09 (low) with the normal being 13.0-17.3; and HCT (hematocrit)(a measure of the packed cell volume of red cells) was 34.6 (low) with the normal being 39.0-53.0. A follow-up lab was drawn a week later, 3/30/11, indicated his RBC remained low at 3.01; HGB remained low at 8.9; and HCT remained low at 27.2. His white blood cell count changed significantly from 9.13 (3/21/11) to a high 18.78 on 3/30/11 (normal 4.00-11.00) which is often indicative of infection. A Physician's Telephone Order, dated 4/1/11 at 3:30 P.M., indicated, "1 unit packed cells...Type: Crossmatch...DX (diagnosis)-[MEDICAL CONDITION]." Nurse's Progress Notes, dated 4/2/11, indicated, "...10:00 A.M.-Resident taken to (Hospital Name) per ambulance for blood transfusion...6:00 P.M.-...Returned from (Hospital Name)...Res. refuse meal-fluids offered and encouraged. Accepted poorly...." Nurse's Progress Notes, dated 4/3/11, indicated, "12:40 A.M. ...Asked to be given sandwich. Could not eat the sandwich when offered to res. Took some H2O (water)...5:00 A.M.-C/O lower leg pain, rated pain at 7-8/10 (7 or 8 out of 10). Gave pain med per order...5:30 A.M. ...voiced relief from pain...8:00 A.M. ...Wound continues to have lots of sersang drainage. Wd (wound) bed has some yellow slough (necrotic or avascular in the process of separating from viable tissue. Usually soft, moist, and light in color; may be stringy). Areas blackened...9:00 P.M. ...TX in progress to coccyx and heel in progress. Drsgs. intact at this x (time). Foul odor remains-request to Dr. (Name) for wound vac D/T (due to) increased drainage...." A "Physician Notification" form, dated 4/3/11 at 3:30 P.M., indicated, "Can we please have order for Wound Vac Drsg. to coccyx open area. Change q M-W-F (Monday-Wednesday-Friday) and PRN...Physician Response: Not at this time." Nurse's Progress Notes, dated 4/4/11, indicated, "1:45 A.M. Drsg. to the wound on the coccyx changed due to copious brownish drainage that soiled bed sheets discharging from the tunnel at the center of wound. Res in excruciating pain and crying out Lord have mercy. Dr. (Name) notified of copious drainage, order for wound vac requested as a F/U (follow up) to 2nd shift...1:50 A.M. Medicated for pain rated 10/10 (10 out of 10) to lower back and leg...2:30 A.M. Resting with eyes closed no S/S (signs or symptoms) of pain at present. 2:00 P.M. TX done as ordered-Lg. (large) amt. (amount) brown drainage. Pt. (patient) eating poorly-only bites of breakfast and lunch, < 5% both [MEDICATION NAME] 5/500 (milligram) i (1) given at 10:40 (P.M.). C/O leg/back pain. Relief noted...." Nurse's Progress Notes, dated 4/5/11, indicated, "4:50 A.M. During PRN drsg. change, soft area noted above open area. Fluctuates when palpated. Lge (large) copious (sic) amount tan foul smelling purulent (containing pus) drainage poured from wound. Drainage soaked 4 4x4's (4 x 4 inch gauze pads) and completely soaked a new ABD (abdominal) (a large thick) pad. Area cleaned with saline wnd (wound) cleaner and Santyl ointment applied. Covered with 4x4's and ABD. Pt. medicated for pain...2:00 P.M. Coccyx wound continues to drain copious amt. tan, foul serosang./purulent drainage. Order received for wound vac to area...Pt. continues to eat and drink poorly...did not eat any of meals...BP (blood pressure) meds held D/T BP 90/50 this A.M. Dr. (Name) notified...9:00 P.M. ...The wound on his coccyx is draining a large amount of brown fluid. Doctor notified it appears worse and should evaluate in A.M. ...11:30 P.M. Pt. calling out. States he's in pain. Attempted to give him [MEDICATION NAME] crushed in applesauce but would not follow directions. Not following speekers (sic) eyes. Not appropriate in response to verbal stimuli. Unable to get BP with Durenap (electric blood pressure machine). BP 74/34 manual...Pt. spit applesauce with [MEDICATION NAME] out. Continues calling out and moaning. Dr. (Name) notified. Ambulance called-(Ambulance Service Name) unable to send paramedics. 911 called. Pt. transported to (Hospital Name) ER (emergency room ). Family notified." A Physician Telephone Order, dated 4/5/11 at 5:00 P.M., indicated, Not eating well-Dietary consult...." The "Physician Notification" Form, dated 4/5/11 at 11:30 (P.M.), indicated, "BP low. Pt change in LOC (level of consciousness). Will not answer questions, follow directions, calling out in pain but spit meds (crushed in applesauce) out when give. Not following directions to swallow. B/P very difficult to obtain. Hands cool to touch...Physician Response: Send to hospital." Review of the "Skin Grid" indicated the coccyx wound remained a stage III from 3/20/11 through 4/4/11. The length changed considerably from 7.5 cm (3/20/11) to 8.3 cm (4/1/11) to 8.0 cm (4/4/11). The width changed from 4.0 cm (3/20/11) to 6.4 cm (3/23/11) to 7.3 cm (4/4/11) and the depth changed from 0.1 cm (3/20/11) to 3.0 cm (4/4/11). The color of drainage changed from Serosanguineous (3/23/11) to purulent (3/26/11) and remained so through 4/4/11. The odor changed from mild (3/23/11) to foul (3/26/11) and remained foul through 4/4/11. A "Pressure Ulcer Healing Chart" indicated the exudate (fluid that has been forced out of tissues or capillaries because of inflammation or injury) amount changed from a moderate amount (3/20/11) to heavy amount (3/29/11) and remained so through 4/4/11. Resident B's "Braden Risk Assessment Scale," dated 3/18/11, indicated he was at high risk for the development of a pressure ulcer. RN # 3 indicated in an interview on 4/24/11 at 3:00 P.M. that all wound documentation is on the wound sheets (Skin Grid) themselves. She further indicated she does not do narrative charting on the wounds. Resident # B's clinical record lacked any documentation by his physician except for the progress note dated 3/21/11 and a statement on 4/5/11 which indicated, "Pt seen. Note dictated." On 4/25/11 at 3:10 P.M., the Director of Nursing (D.O.N.), when queried regarding the lack of physician progress notes [REDACTED]. (Name) just last week and he reported to her that he dictated his notes and a copy would be sent to the facility. She indicated she would contact his office and have them fax the notes over to the facility. She also indicated that the doctor made weekly rounds in the facility. RN #4 indicated in an interview on 4/25/11 at 4:30 P.M. that she looked at Resident # B's wound on or about 4/1/11 and recommended a change in treatment from the Santyl to [MEDICATION NAME] and a charcoal dressing. "The wound wasn't draining when I saw it. The nurse removed the dressing and the wound looked clean, but you could see this membrane in the center of the wound (indicated the size of a small tangerine with her fingers). It was mushy under that membrane and the fear was that it could be affecting the bone. You could tell there was something more going on then you could actually see." RN # 3 indicated on 4/25/11 at 5:00 P.M., that she had asked Physical Therapist #5 to look at the wound after the first treatment had begun. She indicated he had said the wound was not appropriate for debridement. She further indicated nursing had notified the doctor of changes with the wound. The D.O.N. presented a copy of a hand-written physician progress notes [REDACTED].M. It was in response to the previous day's request and was dated 4/26/11. The Progress Note indicated, "Pt. was evaluated on 4/4 for wound care. I reviewed all records and we changed dressing on 4/1/11 to topical [MEDICATION NAME]. Pt TX daily and no purulent drainage noted at that time. Pt was given charcoal dressing for odor. Pt became septic on (blank) and sent to (Hospital Name) ER...Wound was present prior to admission. We ordered air mattress, turn sched. (schedule), dietary consult. On protein. Pt was non-compliant with interventions." Resident # B's hospital History and Physical, dated 4/06/11, authored by the facility (nursing home) physician indicated, "...History of Present Illness: The patient is being seen on rounds today here. He came into the emergency room early this morning. He was previously at (Nursing Home Name). He comes in with [MEDICAL CONDITION] (low blood pressure). I do not know anything about this gentleman, but he came in cachectic (poor health and [MEDICAL CONDITION]) with severe sacral ulcer, acute [MEDICAL CONDITION] with dehydration, hypokalemia (low potassium)...We are seeing him this morning with mental status changes not responding to me. I do not know him at all. He was recently apparently placed in the ECF (extended care facility)...He had a purulent draining material from his wound...Physical Examination: ...Abdomen: Soft. He has a foul smelling order (sic) to the sacrum with an actively draining brown fluid. He has a sacral stage IV (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling) coccyx ulcer, which was present prior to this admission...Diagnoses: [REDACTED]. 2. Bacteremia. 3. Electrolyte abnormalities...5. Volume depletion. 6. [MEDICAL CONDITION]. 7. Stage IV wound...Plan: ...3. Rehydration with fluids of normal saline 125 an hour. 4. Two units of packed cells today. 5. Wound care regarding this wound...." A Emergency Department Report, dated 4/06/11, indicated, "...The patient at extended care facility was noted to have [MEDICAL CONDITION] with systolic blood pressure in the 80s, was sent to the Emergency Department. They also state today the sacral ulcer started draining putrid material. They deny any fevers or chills...Skin: There is a very large area to the lower back in the midline consistent with a sacral ulcer that is actively draining very foul odorous brown fluid...My attention to patient's sacral ulcer, I have expelled myself 30 ml (milliliters) of purulence; however, nurse states that prior to my evaluation, they had also expressed quite amount of material as well...Next, my attention to his pain, the patient was moaning severely...I have made them (family) aware of patient's grave status that he is fairly critical...." A "Consultation" Report, dated 4/07/11, indicated, "...Dr. (Name) assumed care and consulted me by phone yesterday to see this patient because he had a very foul-smelling large necrotic decubitus ulcer on his coccyx and sacrum...the patient was stabilized and taken to surgery earlier today where the wound was debrided and significant tissue was lost due to necrosis. The operative note describes the size of the wound, which is dramatic...I am now seeing the patient to suggest appropriate antibiotic therapy...Impression: Dehydration and [MEDICAL CONDITION] syndrome related to the severely necrotic infected coccyx and sacral decubitus wound...there was bone palpable in the base; as one might expect suggesting there would be underlying osteo[DIAGNOSES REDACTED] (infection of the bone)...." The "Operative Report," dated 4/07/11, indicated, "...We made an elliptical incision around the area of the sacral decubitus ulcer which had necrotic tissue and a significant amount of purulent material underlying the surface of this wound. As we debrided we noted that this wound continued to track significantly to the left lateral side and continued to uncover further and further areas of rather putrid smelling necrotic tissue and purulent material. In the end, once we debrided this tissue...we found that this wound tracked almost 15 cm x 8 cm towards the lateral side and extending almost all the way to his left hip...I spent around 25 minutes visiting with the family discussing with them the severity of this wound and the slim likelihood of him ever healing this process...." This federal tag relates to Complaints IN 055. 3.1-40(a)(2)