Every finding on record at Cypress Grove Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure medications were not left at bedside for a resident to self administer without completion of a self administration of medications assessment during a random observation. (Resident 2) Finding includes:During a random observation on 4/6/26 at 9:29 A.M., Resident 2 had a medication cup on her bedside table with a small white round pill with imprint 111. Resident 2 indicated she was unsure what pill it was. The medications in the medication cart for Resident 2 were reviewed at that time, the pill was determined to be exemestane 25 milligrams (mg) (steroidal drug). On 4/8/26 at 1:21 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, malignant neoplasm of upper-inner quadrant of left female breast. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/5/26, indicated Resident 2 was cognitively intact and was independent for eating. Physician orders included, but were not limited to: exemestane tablet 25 mg oral once a day; Start date 10/9/23 During an interview on 4/9/26 at 11:35 A.M., the Director of Nursing (DON) indicated Resident 2 did not have a self-administration of medications assessment. On 4/9/26 at 12:48 P.M., the Administrator provided a policy titled Self Administration of Medications, revised 1/2008, that indicated The nurse at the Community must also evaluate each resident who self-administers his or her medication by completing the Self-Administration of Medication Assessment form. The nurse will approve each resident that self-administers medication to ensure safe and effective procedures are followed. 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed accurately for 1 of 5 residents reviewed for medication usage (Resident 10) and 1 of 5 residents reviewed for falls (Resident 39). Findings include:1. On 4/7/26 at 8:57 A.M., Resident 10's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease and major depressive disorder.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/30/26, indicated Resident 10 had severe cognitive impairment and received an antidepressant during the 7-day lookback period.The clinical record lacked an active physician order for an antidepressant medication between 3/23/26 and 3/30/26. The March 2026 electronic Medication Administration Record (eMAR) lacked documentation that an antidepressant medication was administered to Resident 10 between 3/23/26 and 3/30/26.2. On 4/7/26 at 10:57 A.M., Resident 39's clinical record was reviewed. Diagnoses included, but were not limited to, dementia.The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/30/26, indicated Resident 39 had severe cognitive impairment and had one fall with no injury since the prior assessment on 12/29/25.The clinical record lacked documentation to indicate Resident 39 fell between 12/30/25 and 3/30/26.During an interview on 4/9/26 at 10:50 A.M., the Administrator indicated Resident 39 did not fall between 12/30/25 and 3/30/26.During an interview on 4/9/26 at 11:22 A.M., the Regional Clinical Nurse indicated that the MDS Assessments dated 3/30/26 for Resident 10 and Resident 39 were both wrong. The MDS Coordinator looked at the wrong dates for the fall and antidepressant.During an interview on 4/9/26 at 12:48 P.M., the Administrator indicated that the facility followed Resident Assessment Instrument (RAI) guidelines to code MDS Assessments.

Based on interview and record review, the facility failed to ensure residents were provided bathing on their scheduled days for 2 of 4 residents reviewed for bathing. (Resident 25 and Resident 18) Findings include: 1. On 4/9/26 at 10:24 A.M., Resident 25's clinical record was reviewed. Diagnoses included, but were not limited to, hypertension. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 1/13/26, indicated Resident 25 was cognitively intact and required partial assistance from staff (staff does half of the work) for bathing. A grievance form, dated 10/29/25, indicated Resident 25 was not getting her showers and was not getting her hair washed. The form indicated staff were educated on preference of shower not a complete bed bath. A shower schedule, updated 4/1/26, indicated Resident 25's shower dates were Tuesday and Friday. Shower documentation reviewed in the electronic medical record and paper shower documents indicated Resident 25 had not received a shower on the following scheduled days from 3/9/26-4/9/26: 3/10/263/27/263/31/26 2. On 4/9/26 at 8:49 A.M., Resident 18's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most recent admission Minimum Data Set (MDS) Assessment, dated 3/18/26, indicated Resident 18 was cognitively intact and required supervision from staff during bathing. A shower schedule, updated 4/1/26, indicated Resident 18's shower dates were Wednesday and Saturday. Shower documentation reviewed in the electronic medical record and paper shower documents indicated Resident 18 had not received a shower on the following scheduled days from 3/11/26-4/9/26:3/14/263/18/263/25/26 Shower documentation indicated Resident 18 refused a shower on 4/8/26 due to the shower being offered outside of his preferred shower time. On 4/19/26 at 12:48 P.M., the Administrator provided a policy titled Residents Rights, revised 7/2023, that indicated All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well being, and proper delivery of care 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)

Based on observation, record review, and interview, the facility failed to ensure documentation of skin assessments and medication administrations were completed accurately and timely for 1 of 3 residents reviewed for activities of daily living (ADL) and 1 of 5 residents for medication administration. (Resident C, Resident G)Findings include:1. During an observation of incontinence care on 4/8/26 at 10:37 A.M., Resident C was observed to have a large purple discoloration on a large area of both right and left buttocks. Barrier cream was applied to the area. On 4/7/26 at 2:00 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus, hemiplegia, and left below the knee amputation. The current Quarterly Minimum Data Set (MDS) Assessment, dated 4/1/26, indicated that Resident C was cognitively intact. Resident C needed setup assistance for eating, substantial to maximum assistance for hygiene, and was dependent on staff for dressing and transferring. A skin assessment was completed but there was no indication of skin discoloration. Physician orders included, but were not limited to the following:House barrier cream to bilateral buttocks each shift, dated 12/22/26.Weekly skin and vital sign assessments on Thursdays, dated 12/22/26. The current skin integrity care plan, dated 12/22/25, included, but were not limited to, the following interventions:Assess and document skin condition weekly and as needed. Notify MD (Medical Doctor) of abnormal findings, dated 12/22/25.House barrier cream at bedside - use as needed, dated 12/22/25. An after-visit hospital assessment, dated 12/15/25, indicated the resident had a non-blanchable purple discoloration on her buttocks. An admission nursing observation, dated 12/19/25 at 11:40 A.M., indicated the resident had no skin discolorations. A weekly nursing skin observation, dated 12/25/25 at 10:41 A.M., indicated the resident had a surgical wound but lacked documentation of any skin discolorations. The most recent skin observation, dated 4/2/26 at 8:51 A.M., indicated there were no skin discolorations noted. During an interview on 4/8/26 at 10:40 A.M., Registered Nurse (RN) 3 indicated the resident had a purple discoloration on her buttocks since admission. During an interview on 4/8/26 at 11:10 A.M., the Wound Nurse indicated the resident had purple discoloration on her buttocks since admission, but staff did not document the presence of it. 2. On 4/7/26 at 10:43 A.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent admission Minimum Data Set (MDS) Assessment, dated 1/15/26, indicate Resident G was moderately cognitively impaired and required setup assistance from staff for eating. Physician orders included, but were not limited to: calcitonin-salmon spray (a medication used to treat postmenopausal osteoporosis), non-aerosol; 200 unit/actuation; 1 spray by nasal, left nostril every other day; Start date 3/26/26 calcitonin-salmon spray, non-aerosol; 200 unit/actuation; 1 spray by nasal, right nostril every other day; Start date 3/27/26 A pharmacy consult report, dated 3/23/26, indicated the pharmacist noted staff were not giving calcitonin spray as ordered, and suggested staff be educated on how to properly administer the medication. The electronic Medication Administration Record (eMAR) indicated that from 3/26/26 to 4/9/26 staff gave Resident G calcitonin in the left nostril two out of seven administrations when the order was for the right nostril, and gave calcitonin in the right nostril three out of eight administrations when the order was for the left nostril. During an interview on 4/9/26 at 9:58 A.M., the Director of Nursing (DON) indicated staff were administering calcitonin spray to Resident G as ordered, but were not documenting it correctly. On 4/9/26 at 1:09 P.M., the Administrator provided a current Documentation policy, revised 8/2025. The policy indicated for staff to accurately document in an organized manner all information related to the resident in the medical record . Weekly Skin and vital sign assessment observation (All new skin areas must be reported to the wound nurse with new skin event completed) . Wound management entries for all ulcers and for non-ulcer areas that are not healing or showing signs of improvement. This citation relates to Intake 2803351. 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(1) 410 IAC 16.2-3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure a resident had orders from the attending practitioner for oxygen therapy use and maintenance of equipment. A resident documented as using oxygen therapy had no physician orders for use. (Resident B) Finding includes: On 1/7/26 at 9:14 a.m., Resident B's clinical record was reviewed. Diagnoses included, but was not limited to, nontraumatic acute subdural hemorrhage, chronic obstructive pulmonary disease, morbid (severe) obesity due to excess calories, and obstructive sleep apnea. An admission Minimum Data Set (MDS) dated [DATE] was not coded for oxygen therapy. Resident B had been discharged to the hospital on 1/4/26. Care plans were reviewed and included, but were not limited to:The resident has potential for impaired gas exchange related to: Head elevated while in bed to alleviate shortness of breath while lying flat, related to diagnosis of COPD (chronic obstructive pulmonary disease), and sleep apnea. Approaches included but were not limited to: Administer oxygen as ordered, start date 11/14/25. Progress notes were reviewed and included, but were not limited to: 11/13/25 at 11:28 a.m., This nurse recieved (sic) report from [name of nurse]. Resident is a max 2 assist stand pivot transfer. O2 on 3 liters . 11/17/25 at 12:14 a.m., .Cardiac/ Respiratory Assessment: Breath sounds clear throughout, Resident uses Bi-Pap or C-Pap, Respirations are even and easy, Resident requires/uses oxygen (device/LPM) 2 L (liters) pr NC (nasal cannula) . 1/4/26 at 12:28 p.m., .resident on 2 L o2 via NC . The following dates were documented in progress notes that Resident B had oxygen on per nasal cannula: 11/13/2511/14/2511/15/2511/17/2511/21/2511/21/2511/22/2511/24/2511/26/2511/27/2511/29/2512/1/2512/3/2512/4/2512/28/251/1/26Physician orders for November and December 2025, January 2026, were reviewed. No orders for oxygen therapy to be applied or maintenance of equipment were in the clinical record. On 1/8/26 at 9:20 a.m., CNA 2 indicated Resident B had been on continuous O2 therapy per nasal cannula, CNA's filled the oxygen tank when needed, O2 was put on the resident when staff got him out of bed. On 1/8/26 at 9:27 a.m., LPN 3 indicated Resident B was on O2 when he was admitted , he used a C-Pap at night, she believed he was weaned off oxygen therapy, and was supposed to just use a C-Pap On 1/8/26 at 9:28 a.m., the DON indicated she would have to check Resident B's record, but was almost positive he was on continuous O2 therapy, and thinks it was an admission order. On 1/8/26 at 11:44 a.m., the DON indicated the facility did not have a policy on oxygen therapy; they follow the policy from the medical service they use to obtain supplies. This citation relates to Intake 2707908. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure residents dependent on staff for assistance with daily living (ADL) tasks were provided showers or baths for 4 of 6 residents reviewed for ADL care. (Resident 78, Resident 25, Resident 69, and Resident 12) Findings include: 1. On 5/28/25 at 10:30 A.M., Resident 78's clinical record was reviewed. Resident 78 was admitted on [DATE]. Diagnoses included, but were not limited to, type 2 Diabetes Mellitus. The most recent Admission MDS Assessment, dated 3/31/25, indicated Resident 78 was dependent on staff (staff do all of the work) for bathing and transfers. A shower schedule, provided by the Director of Nursing on 5/30/25 at 9:14 A.M., indicated Resident 78's scheduled shower days were Tuesday and Saturday. The point of care ADL report indicated Resident 25 had not received, or refused, a shower or complete bed bath on the following days during May 2025: 5/3-Saturday 5/17-Saturday 5/27-Tuesday 2. On 5/28/25 at 10:48 A.M., Resident 25's clinical record was reviewed. Resident 25 was admitted on [DATE]. Diagnosis included, but was not limited to, Alzheimer's disease. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 5/15/25, indicated Resident 25 was severely cognitively impaired and required maximal assistance from staff (staff do more than half of the work) for bathing. A physician order, dated 5/19/25, indicated Resident 25 was admitted to hospice on 5/19/25. A shower schedule, provided by the Director of Nursing on 5/30/25 at 9:14 A.M., indicated Resident 25's scheduled shower days were Tuesday and Friday. The point of care ADL report indicated Resident 25 had not received, or refused, a shower or complete bed bath on the following days during May 2025: 5/2-Friday 5/13-Tuesday 5/16-Friday 3. On 5/28/25 at 11:16 A.M. Resident 69's clinical record was reviewed. Resident 69 was admitted on [DATE]. Diagnosis included, but was not limited to, quadriplegia. The most recent Significant Change MDS Assessment, dated 4/28/25, indicated Resident 69 was dependent on staff for bathing. A shower schedule, provided by the Director of Nursing on 5/30/25 at 9:14 A.M., indicated Resident 69's scheduled shower days were Tuesday and Friday. The point of care ADL report indicated Resident 25 had not received, or refused, a shower or complete bed bath on the following days during May 2025: 5/2-Friday 5/9-Friday 5/13-Tuesday 5/27-Tuesday 48147 4. On 5/27/25 at 10:52 A.M., Resident 12 indicated she was supposed to get showers on Mondays, Wednesdays and Fridays, but she was not getting showers three times a week as care planned. She indicated that while diagnosed with COVID staff told her that she was not allowed to leave her room to have a shower. Staff offered to give her a bed bath once during her isolation, but never came to do it. On 5/28/25 at 10:54 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, chronic kidney disease and generalized anxiety disorder. The most recent Significant Change MDS Assessment, dated 4/21/25, indicated Resident 12 was cognitively intact and required partial to moderate assistance of staff (staff does less than half of the work) for bathing. A care plan conference was completed on 4/21/25. Care plans were reviewed and updated. A current ADL care plan, revised 4/24/25, included, but was not limited to, the following interventions: Assist with bathing as needed per resident preference. Offer showers three times per week, partial bath in between. Prefers day showers. Completed physician orders included, but were not limited to: Resident is in 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. All services provided in room, dated 5/3/25 and completed on 5/12/25 The Point of Care (a charting system for Certified Nurse Aides) Task Response for Bathing indicated Resident 12 did not receive a shower or bed bath on the following days in May 2025: 5/2/25-Friday 5/5/25-Monday 5/7/25-Wednesday 5/12/25-Monday 5/16/25-Friday 5/23/25-Friday 5/26/25-Monday During an interview on 5/29/25 at 12:05 P.M., the Memory Care Director indicated that when a resident was diagnosed with COVID the resident was still able to take a shower in the shower room. Staff would take the resident to the shower room in a gown and mask after all other resident's had received a shower and then clean the shower room. On 5/30/25 at 2:13 P.M., the Director of Nursing (DON) indicated the facility did not have a shower policy, and that it was the facility's policy to give showers as care planned. 3.1-38(a)(2)(A) 3.1-38(b)(2)

Based on observation, record review and interview, the facility failed to ensure person-centered care plans were developed and implemented for 3 of 3 random observations including 1 random observation for falls, 1 random observation for use of call bells, and 1 random observation for use of Wander Guard Security Device. (Resident 1, Resident 78, Resident 79) Findings include: 1. On 5/27/25 at 10:27 A.M., Resident 1 was observed in his room in bed. The bed was not in the lowest position and his reacher was on the small dresser next to the door not in the resident's reach. On 5/28/25 at 9:57 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, multiple sclerosis, muscle weakness, and repeated falls. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 4/21/25, indicated Resident 1 was not cognitively intact, required substantial to maximal assistance of staff (staff does more than half of the work) for rolling left to right, toileting, and bathing, and had no falls since the previous assessment. A fall risk assessment, dated 4/21/25, indicated Resident 1 was at high risk for falls. A care plan conference was completed on 4/21/25. Care plans were reviewed and updated. A risk for falls care plan, revised 4/23/25, included, but were not limited to, the following interventions: Bed in lowest position, dated 9/9/24 Reacher in room to assist with reaching for items, dated 9/5/17 Personal items in reach, dated 5/8/15 Physician orders included, but were not limited to: Bed in lowest position, dated 9/9/24 On 5/30/25 at 8:48 A.M., Resident 1 was observed in his room in bed. The bed was not in the lowest position and his reacher was on the small dresser next to the door not in the resident's reach. At that time, Qualified Medication Aide (QMA) 9 indicated the bed was not in its lowest position, and she was not sure how the bed was not supposed to be positioned for Resident 1. 48057 2. During an observation on 5/27/25 at 1:00 P.M., Resident 78 was sitting in his wheelchair next to the foot of the bed, and the call light was looped around the bed rail, out of the Resident's reach. On 5/28/25 at 10:30 A.M., Resident 78's clinical record was reviewed. Resident 78 was admitted on [DATE]. Diagnosis included, but was not limited to, type 2 Diabetes Mellitus. The most recent Admission MDS Assessment, dated 3/31/25, indicated Resident 78 was cognitively intact and dependent on staff (staff do all of the work) for transfers. Current care plans included, but were not limited to: Resident is at risk for falls, Call light in reach; Start date 3/31/25 Resident has impaired vision, Keep call light in reach at all times; Start date 3/25/25 During a resident council meeting on 5/29/25 at 2:35 P.M., Residents indicated staff often do not place their call lights within reach after providing care. 46758 3. During a random observation on 5/29/25 at 9:33 A.M., Resident 79 was observed sitting quietly in a chair talking to another resident with a Wander Guard (monitoring device) present on his right ankle. During a random observation on 5/30/25 at 9:55 A.M., Resident 79 was observer walking in the kitchen with a Wander Guard (monitoring device) present on his right ankle. On 5/28/25 at 1:14 P.M., Resident 79's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, and generalized anxiety disorder. The Current Admission MDS assessment dated [DATE] indicated Resident 79 was severely cognitively impaired. Resident 79 needed set up for eating, supervision for hygiene, toileting, and transferring, and exhibited wandering behaviors daily. The Admission Elopement assessment dated [DATE] at 1:13 P.M., indicated that Resident 79 did not have a security bracelet on at that time. The record lacked documentation of an order for a Wander Guard Device. The admission care plan was reviewed on 4/24/25. The current care plan lacks a care plan for a Wander Guard Security Bracelet. During an interview on 5/30/25 at 9:11 A.M., the Social Service Director indicated there should have been an order for a Wander guard and there should be a care plan for it. On 5/30/25 at 2:05 P.M., the Administrator provided a current policy Interdisciplinary Team (IDT) Comprehensive Care Plan Policy revised 8/2023. The policy indicated it is the policy of the facility that each resident will have an IDT comprehensive person center care plan developed and implemented based on Resident Assessment Instrument (RAI) process. 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 medical, nursing, mental, and psychological wellbeing. Physician orders are considered part of the comprehensive plan of care. 3.1-35(a) 3.1-35(d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 1 of 4 residents (Resident 233) observed during the medication pass. There were 29 opportunities observed with 8 medication errors. This resulted in a 27.59 percent medication error rate. Finding includes: On 5/29/25 at 10:21 A.M., Licensed Practical Nurse (LPN) 3 was observed preparing medication to administer to Resident 233. The following medications were placed in a medication cup: 1 tablet Allopurinol (medication used to lower uric acid levels in the blood) 100 milligrams (mg) 1 tablet Carvedilol (medication used to treat high blood pressure) 25 mg 1 tablet Clopidogrel (an anticoagulant) 75 mg 1 tablet Eliquis (an anticoagulant) 5 mg 1 tablet Famotidine (medication used to treat heart burn) 20 mg 1 tablet Furosemide (a diuretic) 40 mg 1 tablet Jardiance (medication used to treat diabetes mellitus) 25 mg 4 tablets [NAME]-Bid (a probiotic) 250 mg LPN 3 placed the tablets in a small bag, crushed them together, and then mixed them with 70 milliliters (ml) of water. LPN 3 flushed Resident 233's gastric tube with 10 ml of water, administered 50 ml of the medication and water mixture, added 20 ml of water to the medication/water mixture cup, administered 40 ml of the medication and water mixture, and then flushed the gastric tube with 30 mL of water. On 5/29/25 at 11:08 A.M., Resident 233's clinical record was reviewed. Diagnoses included, but were not limited to, dysphasia. The resident was admitted to the facility on [DATE] and the Admission Minimum Data Set (MDS) Assessment was still in progress. Physician orders included, but were not limited to: Allopurinol tablet 100 mg - Give once a day via gastric tube, dated 5/23/25 Carvedilol tablet 25 mg - Give twice a day via gastric tube, dated 5/22/25 Clopidogrel tablet 75 mg - Give once a day via gastric tube, dated 5/22/25 Eliquis (apixaban) tablet 5 mg - Give twice a day via gastric tube, dated 5/22/25 Famotidine tablet 20 mg - Give twice a day via gastric tube, dated 5/22/25 Furosemide tablet 40 mg - Give twice a day via gastric tube, dated 5/22/25 Jardiance (empagliflozin) tablet 25 mg - Give once a day via gastric tube, dated 5/22/25 [NAME]-Bid tablet 1 billion cell- 250 mg - Give four tablets once a day via gastric tube, dated 5/23/25 Flush G-tube (gastronomy tube) with 30 mL of water before and after medication administration, dated 5/23/25 Flush tubing with at least 15 ml of water between each medication administered, dated 5/23/25 May crush appropriate medications and administer per G-tube. Dissolve each crushed medication in at least 10 ml to 30 ml of water, dated 5/23/25 A current risk for complications related to tube feeding care plan, dated 5/23/25, included an intervention to provide water flushes as ordered. During an interview on 5/29/25 at 12:18 P.M., LPN 5 indicated that medications were supposed to be given separately via gastric tube with 10 ml of water flushed in between each medication. On 5/29/25 at 11:50 A.M., the Regional Support provided a current Enteral Tube - Medication Administration policy, revised 5/2025, that indicated Prepare medications: .dissolve each crushed medication in at least 10 ml - 30 ml of water . Flush tubing with 30 ml of water or per physician's order . Administer medication as ordered. Flush tubing with at least 15 ml of water between each medication or per physician's order. 3.1-48(c)(1)

Based on interview, observation, and record review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADLs) received showers for 6 of 7 residents reviewed for ADLs. (Resident 40, Resident 46, Resident 20, Resident 12, Resident 19, Resident 75) Findings include: 1. On 5/13/24 at 2:04 P.M., Resident 40 indicated he only got a shower once a week, but he would prefer to take a shower three times a week. At that time, Resident 40 was observed to have dandruff on his shirt. On 5/16/24 at 9:39 A.M., Resident 40's clinical record was reviewed. Diagnoses included, but were not limited to, primary hypertension and overactive bladder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 4/30/24, indicated Resident 40 had mild cognitive impairment, had no behaviors, and required partial to moderate assistance (staff does less than half) of staff for bathing. A current ADL (Activities of Daily Life) care plan, dated 11/14/19, included an intervention to offer showers two times per week and that the resident preferred showering in the evening. A January 2024 Point of Care (POC) (a charting system for CNAs [Certified Nurse Aide]) history indicated Resident 40 received a shower on 1/4/24, 1/14/24, 1/18/24, and 1/28/24. There were no complete bed baths documented in January. Resident 40 refused his shower on 1/9/24, 1/10/24, and 1/13/24. A February 2024 POC history indicated Resident 40 received a shower on 2/4/24, 2/8/24, 2/11/24, 2/22/24, and 2/29/24. There were no complete bed baths documented in February. Resident 40 refused his shower on 2/15/24 and 2/18/24. A March 2024 POC history indicated Resident 40 received a shower on 3/3/24, 3/10/24, 3/14/24, 3/24/24, and 3/28/24. There were no complete bed baths or refusals documented in March. An April 2024 POC history indicated Resident 40 received a shower on 4/4/24, 4/7/24, 4/19/24, 4/21/24, and 4/25/24. There were no complete bed baths documented in April. Resident 40 refused his shower on 4/11/24 and 4/28/24. A May 2024 POC history indicated Resident 40 received a shower on 5/5/24 and 5/16/24. There were no complete bed baths or refusals documented in May. A Shower assignment sheet, updated 5/14/24, indicated Resident 40 received showers on Thursday and Sunday during the day. 2. On 5/13/24 at 11:50 A.M., Resident 46 indicated she rarely got showers, but was supposed to get them twice a week. On 5/15/24 at 2:51 P.M., Resident 46's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, major depressive disorder, and anxiety disorder. The most current Significant Change MDS Assessment, dated 2/27/24, indicated Resident 46 had mild cognitive impairment, had no behaviors, and required substantial/maximal assistance (staff does more than half) of staff for bathing. A current ADL care plan, dated 7/24/23, included an intervention to offer showers two times per week and that the resident preferred showering in the evening. A January 2024 POC history indicated Resident 46 received a shower on 1/3/24, 1/6/24, 1/20/24, 1/24/24, and 1/31/24. There were no complete bed baths documented in January. Resident 46 refused her shower on 1/14/24. A February 2024 POC history indicated Resident 46 received a shower on 2/10/24, 2/18/24, and 2/26/24. There were no complete bed baths or refusals documented in February. A March 2024 POC history indicated Resident 46 received a shower on 3/3/24, 3/13/24, and 3/16/24. Resident 26 received a complete bed bath on 3/27/24. There were no refusals documented in March. An April 2024 POC history indicated Resident 46 received a shower on 4/3/24. There were no complete bed baths documented in April. Resident 46 refused her shower on 4/13/24. A May 2024 POC history indicated Resident 46 received a shower on 5/4/24. There were no complete bed baths or refusals documented in May. A shower assignment sheet, updated 5/14/24, indicated Resident 46 received showers on Monday and Thursday during the day. 46758 3. During an interview on 5/15/24 at 2:30 P.M., Resident 20 indicated showers were not received on a regular basis. On 5/16/24 at 10:24 A.M., Resident 20's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified dementia, without behavioral disturbance, and vascular dementia. A current Quarterly MDS Assessment, dated 5/10/24, indicated Resident 20 was moderately cognitively impaired and needed set up assistance with bathing and dressing. Current physician orders included, but were not limited to: Activity level of resident - up ad lib (as desired) with walker, dated 12/8/21. The current ADL care plan, dated 12/8/21, indicated the resident required help with the ADL. Interventions included, but were not limited to, assist with bathing as per resident preference, offer showers two times a week, in the evenings. On 5/16/24 at 2:00 P.M., Human Resources (HR) 4 provided a copy of the weekly shower sheets for [Unit Name] which indicated the resident received evening showers on Tuesdays and Fridays. On 5/15/24 at 3:00 P.M., the POC charting in Resident 20's EMR (Electronic Medical Records) indicated that, on the following days, Resident 20 received showers from January 2024 to May 2024: January 2, 6, 9, 13, and 20. The POC only recorded one refusal on 1/30/24. February 13, 20, 23, and 27. The POC only recorded one refusal on 2/2/24. March 5,12, and 5 April 9, 14, and 26 May 3 ,7, and 10 48057 4. On 5/15/24 at 8:09 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, vascular dementia, osteoarthritis, and osteoporosis. The most recent Quarterly MDS Assessment, dated 2/16/24, indicated Resident 12 was severely cognitively impaired, was dependent on staff for transfers, and required maximal assistance from staff for toileting. A care plan included, but was not limited to: (Resident) requires assistance with ADL's; Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Start date: 3/29/22. On 5/17/24 at 10:52 A.M., Resident 12's shower record from 1/1/24 to 5/17/24 indicated Resident 12 received a complete bed bath or shower for that time period, with one refusal of care documented on 2/28/24, for the following dates: January: 1/4, 1/11, 1/25, 1/31 February: 2/4, 2/7, 2/8, 2/11, 2/13, 2/25 March: 3/6, 3/10, 3/31 April: 4/15, 4/17, 4/21 May: 5/5, 5/12, 5/15 5. On 5/14/24 at 2:42 P.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side and chronic pain. The most recent Significant Changes MDS Assessment, dated 4/22/24, indicated Resident 19 was cognitively intact, was dependent on staff for bathing and toileting, and required maximal assistance for transfers. A care plan included, but was not limited to: Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Start date: 6/4/19. Hospice Aide visits three times per week to provide ADL's, nursing facility will provide scheduled Hospice care in the event Hospice unable to make visit. Start date: 4/16/24. On 5/17/24 at 10:29 A.M., Resident 19's shower record from 1/1/24 to 5/17/24 indicated Resident 19 received a complete bed bath or shower for that time period, with no refusal of care documented, for the following dates: January: 1/18, 1/22, 1/30 February: 2/3, 2/19, 2/22, 2/26 March: 3/1, 3/15, 3/18, 3/20, 3/22, 3/25, 3/27 April: 4/1, 4/3, 4/5, 4/27 May: 5/6, 5/9 6. On 5/15/24 at 11:07 A.M., Resident 75's clinical record was reviewed. Resident 75 was admitted on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, dysphagia, pneumonitis due to inhalation of food and vomit, and sepsis. The most recent Admission MDS Assessment, dated 3/25/24, indicated Resident 75 was cognitively intact, was completely dependent on staff for toileting, bathing, and transfers, and was receiving nutrition through a feeding tube. A care plan included, but was not limited to: Assist with bathing as needed per resident preference. Offer showers (prefers complete bed baths) two times per week, partial bath in between. Start date: 3/19/24. On 5/17/24 at 11:07 A.M., Resident 75's shower record from 3/19/24 to 5/17/24 indicated Resident 19 received a complete bed bath or shower for that time period, with no refusal of care documented, for the following dates: March: none April: 4/14, 4/17, 4/22 May: none On 5/16/24 at 2:53 P.M., the Director of Nursing (DON) indicated residents received a shower or complete bed bath 2 days a week. Partial bed baths were not an acceptable substitution because every resident received a partial bed bath during morning care every day. Some residents preferred showers three times a week which would be accommodated and documented in the care plan. Showers, complete bed baths, and refusals should be documented in the POC. She indicated shower sheets were to be used as a communication tool between the aide and nurse and did not necessarily need to be filled out. On 5/17/24 at 10:06 A.M., the Administrator indicated the QAPI (Quality Assurance and Performance Improvement) committee was aware there was an issue with residents getting their showers. They had been working on that issue for at least a year and it had improved. Now that they had staff documenting in POC, they needed to work on the accuracy of the documentation. At that time, he indicated there was no policy related to ADL care or showers. On 5/17/24 at 10:51 A.M., the Administrator provided a current Resident Care/ADL Sheet policy, dated 11/15, that indicated The Daily Living Flow Chart shall be used to document resident's daily care provided. On 5/17/24 at 11:21 A.M., the Administrator indicated that the facility did not have daily living flow charts. 3.1-38(a)(2)(A) 3.1-38(a)(3)(B) 3.1-38(b)(2) 3.1-38(b)(3)

Based on observation, interview, and record review, the facility failed to maintain a resident's dignity for 1 of 1 residents viewed during a random observation. (Resident 75) Finding includes: During an observation on 5/17/24 at 8:58 A.M., Resident 75's bedroom door was fully opened and Resident 75 was observed laying in bed and body was fully exposed. Resident 75 was not wearing pants, an incontinence brief, or covered with a bedsheet. QMA (Qualified Medication Aide) 22 was standing at the medication cart directly across the hall from Resident 75's room. She then took the medication cart towards the opposite end of the hall. At 9:01 A.M., CNA (Certified Nurses Aide) 15 responded to Resident 75's call light and placed an incontinence brief on Resident 75. On 5/15/24 at 11:07 A.M., Resident 75's clinical record was reviewed. Resident 75 was admitted on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, dysphagia, pneumonitis due to inhalation of food and vomit, and sepsis. The most recent Admission MDS (Minimum Data Set) Assessment, dated 3/25/24, indicated Resident 75 was cognitively intact, was completely dependent on staff for toileting, bathing, and transfers, and was receiving nutrition through a feeding tube. During an interview on 5/17/24 9:53 A.M., RN (Registered Nurse) 11 indicated residents should not be left exposed and CNA's should come get a nurse to pause feedings before performing incontinence care. On 5/17/24 at 10:51 A.M., a current policy titled Resident's Rights, dated 11/15, was provided by the Administrator and indicated Residents shall be assured of at least visual privacy in multi-bed rooms. Each resident shall be treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs. Residents have the right to be suitably dressed at all times. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure that documents were sent to the hospital upon transfer for 1 of 2 residents reviewed for hospitalization . (Resident 80) Finding includes: On 5/15/24 at 3:30 P.M., Resident 80's clinical record was reviewed. Diagnoses included, but were not limited to, epilepsy and COPD (Chronic Obstructive Pulmonary Disease). The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/16/24, indicated Resident 80 was severely cognitively impaired, needed partial to moderate assistance for bathing, transferring, and mobility, and had epilepsy. Physician orders included, but were not limited to: Keppra (seizure medication) 750 mg (milligrams) 1 by mouth 2 times a day for seizures, dated 2/1/24. Namenda (a cognition-enhancing medication) 5 mg 1 by mouth twice a day for psychotic disturbance, dated 11/1/23. The most recent seizures care plan, dated 10/25/23, indicated Resident 80 had a seizure disorder and interventions included, but were not limited to, administer medications as ordered, notify MD (Medical Doctor) of any seizure activity, and provide oxygen as ordered. A nursing progress note, dated 2/23/2024 at 4:38 P.M., indicated . Resident on his way to the hospital for evaluation. The nurse's noted lacked documentation of sending transfer paperwork and bed hold policy. On 5/16/24 at 10:30 A.M., the Medical Records for Resident 80 was received from [Hospital Name]. The records indicated that EMS (Emergency Medical Services) arrived at 4:14 P.M. and the resident was taken to the ER (emergency room ) at [Hospital Name]. The medical and clinical records lacked documentation of transfer information and a bed hold policy. The hospital record indicated [Hospital name] had called the facility and the medical transfer paperwork lacked code status information. The clinical record lacked transfer and bed hold paperwork for the hospital transfer on 2/23/24. During an interview on 5/16/24 at 9:29 A.M., RN (Registered Nurse) 3 indicated when residents were sent to the hospital, an order was received, and face sheet, lab work, current orders, and bed hold policy was sent. The staff would notify the family, DON (Director of Nursing), and ED (Executive Director). During an interview on 5/16/24 at 10:08 A.M., RN 3 indicated the facility could not find proof that the packet was sent with the resident on the requested day. During an interview on 5/16/24 at 2:30 P.M., the DON indicated the transfer and bed hold paperwork was not in the medical records. On 5/17/24 at 10:51 A.M., the Administrator provided a current Hospital Transfer policy, dated 11/15, that indicated . staff at the Community has the responsibility of ensuring pertinent information about the resident and the actions taken to receive treatment at a hospital are properly documented .Copies of all information sent with the resident shall be placed in the resident record under the miscellaneous tab . 3.1-12(a)(6)(A) 3.1-12(a)(9)(D)

Based on observation, record review, and interview, the facility failed to ensure physician orders were followed and resident's nutritional feedings were administered for 2 of 2 residents reviewed for tube feedings. (Resident 75, Resident 68) Findings include: 1. During an observation on 5/17/24 at 8:58 A.M., Resident 75's bedroom door was fully opened and Resident 75 was observed laying in bed and body was fully exposed. Resident 75's feeding pump was running at a rate of 75 mL (milliliters) per hour, and the bottle containing the nutritional formula was dated 5/16/24 6:00 A.M. The gauze surrounding the base of the feeding tube was dated 5/15. On 5/15/24 at 11:07 A.M., Resident 75's clinical record was reviewed. Resident 75 was admitted on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, dysphagia, pneumonitis due to inhalation of food and vomit, and sepsis. The most recent Admission MDS (Minimum Data Set) Assessment, dated 3/25/24, indicated Resident 75 was cognitively intact, was completely dependent on staff for toileting, bathing, and transfers, and was receiving nutrition through a feeding tube. Current physician orders included, but were not limited to: Elevate HOB (head of bed) 30 degrees at all times every shift; start date 3/19/24. Cleanse G-tube (feeding tube) site with soap and water, pat dry, and apply gauze every shift; start date 3/19/24. Continuous feeding x22 hours formula: Jevity 1.5 mL per hour: 75 mL; twice a day 5/9/24. During an interview on 5/17/24 9:53 A.M., RN (Registered Nurse) 11 indicated CNA's (Certified Nursing Aide) should alert a nurse to pause feedings before laying a resident flat to perform incontinence care, and that she had not been notified to pause Resident 75's feeding during that day. During an interview on 5/17/24 at 9:55 A.M., CNA 15 stated she had paused the continuous feeding machine herself while performing incontinence care for Resident 75. 48147 2. On 5/13/24 at 10:04 A.M., Resident 68 was observed in her room laying on her bed with enteral nutrition running through a feeding tube at 38 mL/hr (milliliters per hour). The head of the bed was flat, and the nutrition was not labeled or dated. On 5/14/24 at 10:15 A.M., the enteral nutrition was observed turned off in Resident 68's room. Resident 68 was not in her room at that time. On 5/14/24 at 1:24 P.M., Resident 68 was observed in the Gardens lounge in her wheelchair and was not hooked up to enteral nutrition. On 5/15/24 at 2:06 P.M., Resident 68 was observed in the main lounge with a family member and was not hooked up to enteral nutrition. On 5/13/24 at 1:29 P.M., Resident 68's clinical record was reviewed. Diagnoses included, but were not limited to, spastic quadriplegic cerebral palsy, dysphagia, Barrett's esophagus, and profound intellectual disabilities. The most current Quarterly MDS Assessment, dated 3/21/24, indicated Resident 68 was rarely or never understood, was dependent on staff for eating and bed mobility, did not have weight loss, and received 51% or more of calories through a feeding tube. A current enteral feeding care plan, dated 6/28/23, included interventions to elevate the head of the bed and give tube feedings as ordered. Physician orders included, but were not limited to: Continuous Feeding Jevity 1.5 (a calorically dense liquid food) - 38 mL per hour x 22 hours, turn off daily between 2:00 A.M. and 4:00 A.M., dated 9/02/23. Elevate HOB 30 degrees at all times, dated 6/27/23. The MAR (Medication Administration Record) and TAR (Treatment Administration Record) for May did not include documentation of the Jevity 1.5 being turned on or off except for as it was ordered at 2:00 A.M. and 4:00 A.M. The clinical record lacked documentation that the enteral nutrition was turned off outside off the times ordered by the physician. On 5/16/24 at 11:50 A.M., Licensed Practical Nurse (LPN) 7 indicated that when the nutrition got turned off during the day it should be documented in the progress notes. On 5/17/24 at 10:57 A.M., the Administrator provided a current Enteral Therapy policy, revised 1/2016, that indicated a licensed nurse will take, note, and implement physician orders for enteral therapy. 3.1-44(a)(2)

Based on interview and record review, the facility failed to ensure routine medications were available and dispensed according to physician's orders for 1 of 5 residents reviewed for unnecessary medications. (Resident 71) Finding includes: On 5/15/24 at 8:45 A.M., Resident 71's clinical record was reviewed. Diagnosis included, but was not limited to, gastro-esophageal reflux disease (GERD). The most current Admission Minimum Data Set (MDS) Assessment, dated 2/14/24, indicated Resident 71 had mild cognitive impairment, had no behaviors, and required setup assistance for eating. A current GERD care plan, dated 2/16/24, included an intervention to administer medications as ordered. Physician's orders included, but were not limited to: omeprazole (medication to treat acid reflux) capsule, delayed release (DR) 20 mg (milligrams) orally once a day, dated 5/10/24. pantoprazole (medication to treat acid reflux) tablet, DR 40 mg orally once a day, dated 5/10/24. The May 2024 MAR (Medication Administration Record) indicated omeprazole and pantoprazole was not administered from 5/12/24 through 5/16/24 because the drug was unavailable. A review of the order administration indicated omeprazole and pantoprazole was reordered from the pharmacy on 5/10/24. A list of medications in the EDK (Emergency Drug Kit) indicated the following drugs were available: omeprazole DR, 20 mg - 15 available pantoprazole DR, 40 mg - 5 available On 5/16/24 at 11:50 A.M., Licensed Practical Nurse (LPN) 7 indicated medications ordered usually arrived on the same day because pharmacy came to the facility twice daily. If the medication didn't come, then staff should call the pharmacy. If the medication was in the EDK, it should be given from the EDK. On 5/16/24 at 2:53 P.M., the Director of Nursing (DON) indicated if a medication was unavailable, it should be given from the EDK. Staff should document why the medication was unavailable and should follow up with the pharmacy if it was not received by the next day. At that time, she indicated documentation related to the unavailability of Resident 71's omeprazole and pantoprazole was not in the clinical record like it should have been. On 5/17/24 at 10:52 A.M., the Administrator provided a current Reordering, Changing, and Discontinuing Orders policy, revised 1/1/22, that indicated facility staff should review the transmitted re-orders for status and potential issues and Pharmacy response. 3.1-25(a)

Based on interview and record review, the facility failed to maintain accurate medical records for 1 of 5 residents reviewed for unnecessary medications and 1 of 2 residents reviewed for tube feeding. (Resident 14 and Resident 75) Findings include: 1. On 5/16/24 at 10:01 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's, anxiety disorder, and recurrent depressive disorders. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 3/12/24, indicated Resident 14 was mildly cognitively impaired, required partial assistance with toileting and transfers, and was receiving antianxiety and antidepressant medications during the seven day lookback period. A social service note dated 2/21/24 12:16 P.M., indicated (Resident) participated in psychotherapy that day. During an interview on 5/17/24 08:47 A.M., Social Services indicated Resident 14 was in the hospital from 2/18/24 through 2/23/24, and the psychotherapy visit was documented in error. 2. On 5/15/24 at 11:07 A.M., Resident 75's clinical record was reviewed. Resident 75 was admitted on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, dysphagia, pneumonitis due to inhalation of food and vomit, and sepsis. The most recent Admission MDS (Minimum Data Set) Assessment, dated 3/25/24, indicated Resident 75 was cognitively intact, was completely dependent on staff for toileting, bathing, and transfers, and was receiving nutrition through a feeding tube. On 5/17/24 at 9:52 A.M., the DON (Director of Nursing) provided procedure documents that indicated Resident 75 was out of the building from 9 A.M. to 2:30 P.M. on 5/15/24 for an endoscopy, and from 9:15 A.M. to 2:30 P.M. on 5/16/24 for a colonoscopy. The clinical record from 5/15/24 to 5/17/24 lacked documentation of the departure from the facility and arrival back to the facility for Resident 75 on 5/15/24 and 5/16/24. On 5/17/24 at 10:52 A.M., the Administrator provided a document titled Documentation Guidelines for Nursing, revised date 6/23, that indicated the purpose: (is) to accurately document in an organized manner all information related to the resident in the medical record. On 5/17/24 at 10:52 A.M., the Administrator provided a document titled Leave of Absence, revised date 6/19, that indicated The licensed nurse will document resident status upon leave from the facility and upon return from leave, and any other pertinent information. 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure routine catheter care was provided and infection control measures were maintained to prevent the development of urinary tract infections for 3 of 4 residents reviewed for catheter care. Routine catheter care and monthly catheter changes were not provided as ordered by a physician and catheter tubing was observed on the floor during 2 of 2 days of the survey. (Resident C, Resident D, Resident F, Resident G) Findings include: 1. During record review on 11/28/23 at 11:20 A.M., Resident C's diagnoses included, but were not limited to dementia, urinary tract infection, severe sepsis, hydroureter, type II diabetes, obstructive and reflux uropathy, and chronic kidney disease. Resident C's most recent annual MDS (Minimum Data Set) assessment, dated 9/21/23, indicated the resident had severe cognitive impairment and had an indwelling catheter. Resident C's physician orders included, but were not limited to; Foley catheter care every shift (started 6/4/19) and change Foley catheter first Monday of every month (started 5/15/20). Resident C's care plan included, but was not limited to; resident has history of taking prophylactic antibiotic for chronic urinary tract infections (started 3/28/18), resident requires an indwelling urinary catheter for obstructive and reflux uropathy. Resident often pulls catheter apart and opens bag at times, spilling urine on bed and floor. Resident is at risk for infection and skin breakdown. (started 11/27/16). Care plan interventions included, but were not limited to change catheter per physician order, do not allow tubing or any part of the drainage system to touch the floor, and provide assistance with Foley catheter care. Resident C's medication administration (MAR) / treatment administration record (TAR) was reviewed from 7/1/23 through 10/25/23. The following orders were not documented as administered on the following dates: Foley catheter care every shift (started 6/4/19) was not provided on 7/2/23 (night shift), 7/8/23 (night shift), 8/21/23 (night shift), 8/25/23 (night shift), 8/27/23 (night shift), and 9/1/23 (night shift). Change Foley catheter first Monday of every month (started 5/15/20) was not completed on 8/7/23 and 10/2/23. Resident C's progress notes from 7/1/23 through 10/25/23 included the following: 8/5/23 - Resident on antibiotic for UTI 10/12/23 - Resident not responding to staff and will not take anything by mouth. Orders received for stat labs and urinary analysis. 10/12/23 - Orders received to send to hospital. Resident C's hospital discharge summary, dated 10/17/23, included that Resident C's admitting diagnoses included UTI and sepsis. A discharge diagnosis included UTI associated with indwelling urethral catheter. The Hospital Course included, He was sent to the emergency department where he was noted to have significant urinary tract infection. Urine is very dark with considerable sediment and strong odor . Workup in [emergency room ] shows white count of 13.8, temp 100.8 (degrees Fahrenheit), pulse of 92 with a lactate of 1.3. However given his altered mental status and worsening kidney function, patient does meet criteria for severe sepsis . 2. During an observation on 11/29/23 at 9:25 A.M., Resident D was sitting in a wheelchair in his room on the [NAME] hall. The resident's catheter bag was clipped to the bottom of his wheelchair and the tubing was resting on the floor. During an observation on 11/29/23 at 9:45 A.M., Resident D was wheeling himself in his wheelchair from the [NAME] hall to the East hall to a common TV area in front of the East hall nurse's station. Resident D's catheter tubing was dragging the hall floor as he wheeled himself. During an observation of care on 11/29/23 at 10:15 A.M., QMA 5 provided catheter care to Resident D. Following the completion of care, QMA 5 assisted Resident D back to his wheelchair and clipped the resident's catheter bag to the bottom of the wheelchair. The catheter tubing was resting on the resident's room floor. During record review on 11/29/23 at 10:20 A.M., Resident D's diagnoses included, but were not limited to chronic kidney disease, neuromuscular dysfunction of bladder, retention of urine, and overactive bladder. Resident D's most recent annual MDS (Minimum Data Set) assessment, dated 8/18/23, indicated the resident had an indwelling catheter. Resident D's physician orders included, but were not limited to catheter care every 4 hours due to excessive intake and output (started 3/20/23). Resident D's care plan included, but was not limited to; Resident requires a supra pubic catheter due to retention of urine due to neuromuscular dysfunction of bladder and is at risk for infection (started 9/29/21). Care plan interventions included, do not allow tubing or any part of the drainage system to touch the floor, and provide assistance with catheter care. Resident D's medication administration (MAR) / treatment administration record (TAR) was reviewed from 10/1/23 through 11/29/23. Catheter care every 4 hours (started 3/20/23) was not provided on 10/1/23 ( 5:00 P.M.), 10/2/23 (1:00 A.M. and 9:00 A.M.), 10/10/23 (5:00 P.M.), 10/14/23 (1:00 A.M.), 10/16/23 (1:00 A.M.), 10/20/23 (9:00 A.M.), 10/27/23, (9:00 A.M.), 11/3/23 (9:00 A.M.), 11/4/23 (1:00 P.M.), 11/5/23 (1:00 P.M.), 11/6/23 (9:00 A.M.), 11/11/23 (9:00 P.M.), 11/17/23 (9:00 A.M.), 11/19/23 (9:00 A.M.), 11/20/23 (9:00 P.M.), 11/21/23 (9:00 A.M. and 9:00 P.M.) and 11/27/23 (9:00 A.M.). 3. During an observation on 11/29/23 at 9:30 A.M., Resident F was lying in bed in his room. The resident's catheter bag and tubing were lying on the floor next to the bed. During record review on 11/29/23 at 10:03 A.M., Resident F's diagnoses included, but were not limited to neuromuscular dysfunction of bladder and multiple sclerosis. Resident F's most recent significant change MDS (Minimum Data Set) assessment, dated 11/1/23, indicated the resident had an indwelling catheter. Resident F's physician orders included, but were not limited to supra pubic catheter care every shift (started 6/4/19). Resident F's care plan included, but was not limited to; Resident has history of urinary tract infection (UTI) recurrent with supra pubic catheter due to neurogenic bladder and multiple sclerosis (started 6/15/19) and resident requires a supra pubic catheter due to neurogenic bladder, at risk for infection, recurrent UTI, due to multiple sclerosis. Resident at times will remove his catheter bag and put on floor, will also put in lap (started 5/8/15). Care plan interventions included, do not allow tubing or any part of the drainage system to touch the floor, and provide assistance with catheter care. Resident F's medication administration (MAR) / treatment administration record (TAR) was reviewed from 10/1/23 through 11/29/23. Supra pubic catheter care every shift (started 6/4/19) was not provided on 10/1/23 (day shift), 10/11/23 (night shift), 11/6/23 (night shift), and 11/13/23 (day shift). 4. During a random observation on 11/28/23 at 12:25 P.M., Resident G was sitting in a wheelchair in her room. The resident's catheter tubing was resting on the room floor. During an interview on 11/29/23 at 9:50 A.M., RN 2 indicated staff should ensure that residents with a catheter have their catheter bags and tubing up off of the floor to help prevent UTI's. During an interview on 11/29/23 at 10:15 A.M., QMA 5 indicated catheter care should be charted each shift or more often if ordered, and that staff should document if a resident refuses catheter care. During an interview on 11/29/23 at 10:45 A.M., CNA 6 indicated staff should clean the residents catheters every day and empty the catheter drainage bag every shift. On 11/29/23 at 2:30 P.M., the facility administrator supplied a facility policy titled, Nursing, dated 6/2023. The policy included, Policy: The nursing staff shall follow infection control guidelines to prevent the spread of infection . 2. Resident Care equipment: a. Licensed nursing staff is responsible for the insertion/removal of medical devices, including but not limited to, indwelling urinary catheters . b. Urinary catheters should have a catheter bag cover over them or a wash basin underneath them as a barrier to prevent catheter bag or tubing from touching the ground. This citation relates to complaint IN00421148. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to provide ADL's (activities of daily living) care to 4 of 4 residents reviewed. Bathing and bathing preferences were not provided to residents. (Resident D, Resident E, Resident F, Resident H) Findings include: 1. On 10/30/23 at 10:02 a.m., Resident D indicated they are supposed to get showers but only get bed baths, and staff are not doing it at all. On 10/30/23 at 10:45 a.m., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, paraplegia, traumatic brain injury. A quarterly MDS (Minimum Data Set) assessment, dated 7/25/23, indicated cognition intact, shower/bathe self substantial/maximal assistance. Care plans were reviewed and included, but were not limited to: Self care deficit including bed mobility, transfers, eating and toileting related to: decreased mobility related to paraplegia, spastic movements, extensive assist needed for transfers, noted to refuse assistance at times, B&B incontinence, neurogenic bladder with HX of urinary retention, use of psychotropic medication, attention deficit related to TBI (traumatic brain injury), start date 10/23/15. Approach: assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Encourage resident to make choices in care such as clothing, shower time preference, etc . POC (point of care) was reviewed for October 2023 and the following were recorded for bathing: 10/1- PBB (partial bed bath) 10/2- PBB 10/3- activity did not occur 10/4- activity did not occur 10/5- PBB 10/6- activity did not occur 10/7- PBB 10/8- no documentation 10/9- PBB 10/10- PBB 10/11- no documentation 10/12- no documentation 10/13-no documentation 10/14- PBB 10/15- no documentation 10/16- PBB 10/17- no documentation 10/18- CBB (complete bed bath) 10/19- no documentation 10/20- no documentation 10/21- no documentation 10/22- no documentation 10/23- no documentation 10/24- no documentation 10/25- CBB 10/26- no documentation 10/27- no documentation 10/28- no documentation 10/29- CBB 10/30- no documentation 10/31- no documentation but observed a PBB A current shower schedule was reviewed and Resident D's shower days were listed as Wednesday and Sunday evenings. Shower dates for October were: 10/4 10/8 10/11 10/15 10/18 10/22 10/25 10/29 Shower sheets were reviewed and contained the following dates: 10/18/23 - CBB marked 10/25- CBB 10/29- CBB No refusals were documented in the clinical record. 2. On 11/1/23 at 8:53 a.m., Resident H indicated they were supposed to get a bed bath yesterday, did not receive it, it's like that quite often, sometimes goes 2 or 3 weeks without a bath, and sometimes wears the same clothes for a week. Resident D indicated they never refuse, if lucky only get a bath twice a week, at home they took a shower every day, sometimes two a day, administration had been told but it went in one ear and out the other. On 11/1/23 at 10:05 a.m., Resident H's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, peripheral vascular disease. A quarterly MDS (Minimum Data Set) assessment, dated 10/30/23, indicated Resident H's cognition was intact, shower/bathe self substantial/maximal assistance. Care plans were reviewed and included, but were not limited to: Resident requires assistance with ADL's including bed mobility, transfers, eating and toileting related to: osteomyelitis, rt foot 5th metatarsal amputation, encounter for surgical aftercare following surgery on the circulatory system .hemiplegia and hemiparesis following cerebral infarction affecting right dominant side .start date 7/21/23. Approach: assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between, Prefers AM complete bed baths. POC (point of care) was reviewed for October 2023 and the following were recorded for bathing: 10/1- not documented 10/2- not documented 10/3- CBB 10/4- activity did not occur 10/5- activity did not occur 10/6- refused 10/7- PBB 10/8- PBB 10/9- activity did not occur 10/10- CBB 10/11- activity did not occur 10/12- activity did not occur 10/13- CBB 10/14- no documentation 10/15- activity did not occur 10/16- PBB 10/17- CBB 10/18- activity did not occur 10/19- activity did not occur 10/20- PBB 10/21- activity did not occur 10/22- activity did not occur 10/23- activity did not occur 10/24- CBB 10/25- no documentation 10/26- activity did not occur 10/27- CBB 10/28- not documented 10/29- not documented 10/30- PBB 10/31- not documented A current shower schedule was reviewed and Resident H's shower days were listed as Tuesday and Friday days complete bed bath. Complete bed bath dates for October were: 10/3 10/6 10/10 10/13 10/17 10/20 10/24 10/27 10/31 Shower sheets were reviewed and contained the following dates: 10/3- CBB 10/10- CBB 10/13- CBB 10/17- CBB 10/24- CBB 10/27- 10/27 No refusals were documented in the clinical record for the days documented as activity did not occur or days not documented. 3. On 10/31/23 at 1:19 p.m., Resident E indicated they sometimes only get 1 shower a week and have to remind staff to do. On 11/1-23 at 10:34 a.m., Resident E's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson disease without dyskinesia, primary osteoarthritis unspecified shoulder, muscle weakness, tremor unspecified, age related debility, other abnormalities gait and mobility. An admission MDS (Minimum Data Set) assessment, dated 7/31/23 indicated Resident E's cognition was intact, bathing physical help in part of bathing support of one. Care plans were reviewed and included, but were not limited to: Resident requires assistance with ADL's including bed mobility, transfers, eating and toileting related to: Parkinson's disease, chronic obstructive pulmonary disease, essential tremor .start date 7/24/23. Approach: assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Current preference for bathing/shower/bed bath PM. POC (point of care) was reviewed for October 2023 and the following were recorded for bathing: 10/1- PBB 10/2- PBB 10/3- activity did not occur 10/4- shower 10/5- PBB 10/6- activity did not occur 10/7- CBB 10/8- PBB 10/9- activity did not occur 10/10- PBB 10/11- CBB 10/12- activity did not occur 10/13- not documented 10/14- refused 10/15- activity did not occur 10/16- PBB 10/17- activity did not occur 10/18- shower 10/19- activity did not occur 10/20- PBB 10/21- activity did not occur 10/22- PBB 10/23- activity did not occur 10/24- activity did not occur 10/25- shower 10/26- activity did not occur 10/27- PBB 10/28- not documented 10/29- not documented 10/30- PBB 10/31- PBB A current shower schedule was reviewed and Resident E's shower days were listed as Wednesday and Saturday evenings. Shower dates for October were: 10/4 10/7 10/11 10/14 10/18 10/21 10/25 10/28 Shower sheets were reviewed and contained the following dates: 10/4- shower 10/7- CBB 10/11- CBB 10/14- refused 10/18- shower 10/21- refused 10/25- shower No refusals were documented in the clinical record for the days documented as activity did not occur or days not documented. 4. On 11/1/23 at 11:50 a.m., Resident F was observed sitting in a wheel chair in a common area. Resident F indicated they were not always getting their showers. On 11/1/23 at 11:05 a.m., Resident F's clinical record was reviewed. Diagnoses included, but were not limited to, muscle weakness (generalized), unsteadiness on feet, epilepsy. An admission MDS (Minimum Data Set) assessment , dated 8/16/23, indicated Resident F's cognition was intact, bathing total dependence two assist. Care plans were reviewed and included, but were not limited to, ADL's functional status/rehabilitation potential resident requires assistance with ADL's including bed mobility, transfers, eating and toileting related to: weakness, impaired balance, HX of falls, fall risk .start date 8/16/23. Approach: assist with bathing as needed per resident preference. Offer showers two times per week partial bath in between. POC (point of care) was reviewed for October 2023 and the following were recorded for bathing: 10/1- PBB 10/2- PBB 10/3- activity did not occur 10/4- activity did not occur 10/5- activity did not occur 10/6- CBB 10/7- PBB 10/8- PBB 10/9- activity did not occur 10/10- PBB 10/11- activity did not occur 10/12- activity did not occur 10/13- refused 10/13- 10/20- resident was out to the hospital 10/21- activity did not occur 10/22- no documentation 10/23- no documentation 10/24- shower 10/25- no documentation 10/26- activity did not occur 10/27- CBB 10/28- no documentation 10/29- no documentation 10/30- PBB 10/31- activity did not occur A current shower schedule was reviewed and Resident F's shower days were listed as Tuesday and Friday days. Shower dates for October were: 10/3 10/6 10/10 10/13 10/17 10/20 10/24 10/27 10/31 Shower sheets were reviewed and contained the following dates: 10/6- CBB 10/13- refused 10/20- LOA 10/24- shower 10/27- CBB No refusals were documented in the clinical record for the days documented as activity did not occur or days not documented. On 11/1/23 at 1:52 p.m., RN 1 indicated if a CNA tells nursing that a resident refuses their shower, they go in and try to get the resident to take a shower, CNA's are supposed to document refusals in the computer, also on the shower sheets, the nurse signs the shower sheet nursing should document a refusal in the progress notes. An anonymous interview indicated they are not always able to get resident showers done,1 resident assigned did not get their complete bed bath, the main areas were cleaned, one resident assigned did not receive their shower that day, they had spoken with administration and they said just do the best you can. No specific policy was obtained on activities of daily living from the facility. This citation relates to Complaint IN00419136. 3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene and glove use was done for 2 of 2 residents observed for care. Hands were not washed and gloves not changed. (Resident B, Resident D) Findings include: 1. On 10/30/23 at 9:34 a.m., CNA 2 was observed to provide incontinence care to Resident B. With gloved hands CNA 2 was observed to remove a bed bolster from under Resident B's legs, unfasten the brief, use incontinence wipes to clean the penis, roll resident to both side cleaning a large amount of feces off buttocks and scrotum, put the dirty wipes in a trash bag, put a clean brief under the resident, obtain a tube of barrier cream and apply it the buttocks, obtain a tube of anti fungal cream and apply it to the scrotum. Gloves were not changed during the tasks or hand hygiene done. 2. On 10/31/23 at 9:54 a.m., CNA 3 was observed to provide care to Resident D. CNA 3 was observed to take Resident D's pants off with gloved hands, put in a trash bag, clean Resident D's penis and scrotum with an incontinence wipe and wet washcloths, roll Resident D to his side and clean and dry buttocks, apply barrier cream to the buttocks, put a new brief under Resident D, roll Resident D over and apply cream to the groin and scrotum area, put deodorant on the resident, obtained socks out of the drawer and put on feet. CNA 3 was observed to pull his own pants up with same gloved hands, put a clean pair of pants on the resident, tuck the Hoyer pad under the resident, use the bed control to raise the bed, take off gloves and throw in the trash. CNA 3 was observed to use a incontinence wipe to wipe the palm of his gloved hands after applying the cream to the buttocks and groin area. Gloves were not changed during the tasks. CNA 3 left the room, came back and donned gloves no hand hygiene before was observed. On 11/1/23 at 11:55 a.m., CNA 3 indicated after entering a resident room, hands should be washed before applying gloves, change gloves if viably soiled, definitely change gloves after changing a resident for incontinent care. On 11/1/23 at 2:25 p.m., the Administrator provided the current hand hygiene policy with a revision date of 12/2021. The policy included, but was not limited to: healthcare personnel should use an alcohol -based hand rub or wash with soap and water for the following clinical indications: Before moving from work on a on soiled body site to clean body site on the same resident immediately after glove or PPE removal. The Administrator indicated the facility did not have a specific policy on glove use. 3.1-18(b) 3.1-18(l)

Based on observation and interview, the facility failed to ensure proper storage of medications in 2 of 2 medication storage rooms, 2 of 2 resident treatment carts, and 4 of 4 medication cart observations. Resident treatment carts and medication carts were left unlocked and unattended. Loose pills were found in the bottom of the medication cart drawers. Discontinued/expired medications were stored in the storage rooms and not appropriately disposed. (Veteran's Hall, Willow hall, Moving Forward Hall) Findings include: On 2/13/23 at 10:05 A.M., the resident treatment cart for the Moving Forward hall was observed at the nurse's station unlocked without staff present. On 2/14/23 at 8:07 A.M., the resident treatment cart for the Moving Forward hall was observed at the nurse's station unlocked without staff present. On 2/14/23 8:13 A.M., the resident treatment cart in the Veteran's hall by nurse's station was observed unlocked without staff present. On 2/14/23 at 8:13 A.M., the medication cart on the Willow hall was observed unlocked without staff present. On 2/21/23 at 8:18 A.M., the medication cart in the Veteran's hall was observed unlocked. The narcotic box was also unlocked without staff present. At this time, the Veteran's hall treatment cart was also observed unlocked without staff present. On 2/15/23 at 12:40 P.M., a bag laying on the counter in the Moving Forward hall medication storage room was observed with the following medication bottles inside: rosuvastatin 40 mg (milligram) ferrous sulfate 325 mg citalopram 20 mg donazepril 10 mg tamsulosin 0.4 mg lisinopril 5 mg Multivitamin memantine 10 mg latanoprost 0.005% eye drops During an interview on 2/15/23 at 12:53 P.M., RN (Registered Nurse) 6 indicated this resident passed away approximately 2 (two) weeks ago, the medications looked like they are from the VA (Veteran's Association), and they were not sure what should be done with them. On 2/15/23 at 1:00 P.M., medication cart 1 of 2 on the Moving Forward hall was observed to have the following medications laying loose in the bottom of the drawer: 5 (five) ipratropium vials 1 (one) small, green pill with D01 on one side 1/2 (half) of a small blue pill On 2/15/23 at 1:07 P.M., medication cart 2 of 2 on the Moving Forward hall was observed to have the following medication laying loose in the bottom of the drawer: 1/2 (half) of a rectangular light green pill On 2/15/23 at 1:10 P.M., RN 6 indicated he was unable to identify the pills observed and he would put them in the pharmacy return bag if found. At that time, he indicated a pharmacy representative for (pharmacy name) comes in periodically and does a complete audit of all medications and carts. He further indicated that the carts should always be locked when staff walk away. On 2/15/23 at 1:15 P.M., a bag containing multiple medication bottles and the following medications laid on the counter in the Veteran's hall medication storage room: wixela inhaler 250 mcg (micrograms)/50 mcg in box, labeled opened 1/10/23 wixela inhaler 250 mcg/50 mcg, unopened latanoprost 0.005% eye drops, unopened fluticasone nasal spray 50 mcg systane balance 0.6% eye drops Advair diskus 250 mcg/50mcg in box, labeled opened 12/23/22 brimonidine 0.2% eye drops in box, labeled opened 11/26 vitamin D3 2000 units pill pack with 28 pills inside small bag albuterol inhaler 90 mcg in box, labeled opened 8/2/22 budesonide formoterol inhaler 80/4.5 mcg 2 (two) fluticasone nasal sprays 50 mcg fluticasone nasal spray 50 mcg in box, dated 10/15/22 fluticasone inhaler 50 mcg Advair 250 mcg/50 mcg in box, dated 11/9/22 zinc sulfate 50 mg (milligram) pill pack with 15 capsules inside small bag vitamin D3 2000 units pill pack with 18 pills inside small bag 2 (two) lovenox 120 mg/0.8 ml (milliliter) syringes in small bag flextouch tresiba insulin pen, dated 1/21/23 On 2/15/23 at 1:25 P.M., the refrigerator inside the Veteran's hall medication storage room was observed unlocked with medications in it. A bag labeled lorazepam 2 mg/ml was observed in the bottom drawer and contained 1 (one) 1 ml vial with expiration date 3/2022 and a unopened box of 25 lorazepam 2 mg/ml vials with expiration date 4/2022. During an interview on 2/15/23 at 1:30 P.M., RN 10 indicated the bag of pills were from a VA resident that was discharge and had been there for a while. They further indicated that all the medications should be discarded and since the lorazepam is a controlled medication, they should get a witness and they will discard because it's expired. On 2/15/23 at 1:45 P.M., medication cart 1 of 2 on the Veteran's hall was observed with the narcotic box unlocked and to have the following medications laying loose in the bottom of the drawer: 1/2 (half) white rectangular pill with 5 on one side 1 (one) medium, round, peach pill with 124 on one side 1 (one) small oblong pill with A10 on one side 1 (one) refresh vial On 2/15/23 at 1:52 P.M., medication cart 1 of 2 on the Veteran's hall was observed with the narcotic box unlocked and to have the following medications laying loose in the bottom of the drawer: 1 (one) large white pill with J75 on one side 1 (one) round white pill with Cl40 on one side 1 (one) oval peach pill with A on one side 1 (one) small blue pill with E5 on one side 1 (one) oval white pill with TV on one side 1 (one) tiny white oval pill withTV on one side On 2/15/23 at 1:58 P.M. resident treatment cart 1 of 1 on the Veteran's hall was observed to have 2 (two) packages of Puracol Plus AG+ wound dressings with expiration of 3/2020. During an interview on 2/15/23 at 2:00 P.M., RN 8 indicated they were not sure what the loose pills were but loose pills laying in the cart should all be discarded, they were unsure if any residents were using the wound dressings but they were expired and should be discarded, and the narcotic box should be locked inside a locked medication cart and you should not be able to get medications from it without a key. During an interview on 2/21/23 at 10:49 A.M., the DON (Director of Nursing) indicated a pharmacist does medication cart audits and the last one done was November 1-3, 2022 and the facility paid extra to get expired, discontinued, and loose pills out of the carts. In between pharmacy audits, the floor nurses should discard these as they see them. The medication fridge and all carts should be locked and the boxes containing narcotics should be locked. The medications not being used for residents on the counter in the storage room should be discarded appropriately. Medical record staff usually will go through them bi-weekly and dispose of or scan to return to pharmacy. Usually when the pharmacy representatives come to drop off medications, the medications to be returned should be sent with them. A current Storage of Medications policy, dated January 2022, was provided by regional staff on 2/20/23 at 2:25 P.M., and indicated . 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access . 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . 9. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received . 16. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals . 3.1-25(m)

Based on observation and interview, the facility failed to ensure food was stored appropriately for 1 of 1 kitchen observations. Food containers were not labeled with the complete date in the dry storage area, refrigerator, and shelves in the kitchen area. (Kitchen) Findings include: On 2/13/23 at 9:19 A.M., the following was observed in the kitchen: Dry storage: spaghetti noodles wrapped in saran wrap without a label an opened bag of chocolate chips, dated 11/5 Refrigerator: an unopened gallon of 2 % milk, expiration date of February 10, 2023 an opened tub of cherries with use by date 2/13 an opened tub of bite size meat with use by date 2/13 an opened tub of pork fritters with use by date 2/14 an opened tub of gravy with use by date 2/16 an opened tub of bologna with use by date 2/16 an opened tub of butterscotch pudding with use by date 2/16 an opened tub of pimento cheese with use by date of 2/20 an opened tub of small curd cottage cheese dated 2/5 a jar of sweet pickle relish with date 12/30 marked out and 1/31 put in place on lid a bottle of lemon juice 1/3 full with visible sediment in bottom dated 2/1 and 2/11 an opened tub of caesar dressing opened 12/6, dated 11/4, 2/1 and 3/1 an opened bag of parmesan cheese with use by date of 2/10 an opened bag of mozzarella cheese with use by date of 2/17 an opened tub of salami dated 1/30 In kitchen area on shelves: lemonade beverage mix open to air sitting on shelf above sink unlabeled 1 (one) opened bag of shredded wheat cereal, 1/4 full unlabeled 1 (one) opened bag of cinnamon toasts, 1/2 full unlabeled and a slit in package 1 (one) opened bag of Cheerios, 1/2 full unlabeled 1 (one) opened, bag of Rice Krispies, 1/4 full unlabeled 5 (five) cereal containers (1 shredded wheat, 1 Rice Krispies, 1 Fruit Loops, 1 Frosted Flakes, 1 Cheerios) all have use by date 3/1, prepared date 2/1 oatmeal in big dry storage bin prepared 12/2/22 use by date 5/2 On 2/13/23 at 10:26 A.M., in the Memory Care Unit refrigerator, a pitcher of orange/reddish liquid half full-no label was observed. At that time, above the sink in the cabinet, 2 (two) cereal containers were observed, 1 (one) 1/2 full of Frosted Flakes and 1 (one) 1/2 full of Cheerios were unlabeled. During an interview on 2/20/23 at 12:16 P.M., Kitchen Staff 1 indicated newly opened item will go in a container with a label containing the date of preparation, the use by date . They further indicated they usually just put month and day but don't put the year on it. During an interview on 2/20/23 at 12:18 P.M., the Kitchen Manager indicated dates on the label should contain month, day, and year. At this time, she indicated that the kitchen staff usually try to go through the items and discard them if it's past use by date at the end of each day. A current Food Storage policy, dated October 2017, provided by Regional Staff on 2/20/23 at 2:20 P.M., indicated . 4. All containers must be accurately labeled and dated . 12. The food must clearly be labeled with the name of the product, the date it was prepared and marked to indicate the date by which the food shall be consumed or discarded . 13. Refrigerated, ready-to-eat, potentially hazardous food . shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure completed staffing sheets were posted daily for 7 of 7 days during the survey. Findings include: On 2/13/23 at 11:41 A.M., a nurse staffing sheet was observed across from the front desk on the bottom shelf of a sofa table at foot level, dated 2/10/23. The sheet included, but was not limited to, the following information: Shift hours for RN (Registered Nurse), LPN (Licensed Practical Nurse), and CNA (Certified Nurse Aid) Total number of licensed nursing and unlicensed nursing staff Total hours of RN, LPN, and CNA for each shift Total hours worked The sheet did not specify which hours were worked by each discipline during the specified shift. On 2/14/23 at 12:27 P.M., a nurse staffing sheet was observed across from the front desk on the bottom shelf of a sofa table at foot level, dated 2/13/23. On 2/16/23 at 11:51 A.M., a nurse staffing sheet was observed sitting at the front desk, dated 2/15/23. On 2/21/23 at 9:30 A.M., staffing sheets for dates 2/13/23, 2/14/23, 2/15/23, 2/16/23, 2/17/23, 2/20/23, and 2/21/23 were reviewed. Each date lacked the specific hours worked by each discipline during the specified shift. At that time, the DON (Director of Nursing) indicated the column on the staffing sheets titled total number of licensed and unlicensed nursing staff actually listed the total number of hours worked by staff. She indicated the actual number of staff in the building was not listed on the forms. On 2/20/23 at 2:25 P.M., a current Posted Nurse Staffing policy, dated 7/2019, indicated It is the policy of [company] to make staffing information readily available in a readable format and publicly posted to residents and visitors at any given time . The facility must post the following information at the beginning of each shift . The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses ii. Licensed practical nurses iii. Certified nurse aides . The Total Hours columns should be all hours worked during each specific shift. Total hours should include the total actual hours worked on each shift including partial shifts

Based on interview and record review, the facility failed to ensure that a resident's vascular wounds were measured and assessed weekly; and failed to clarify orders and perform dressing changes and apply antibiotic ointment as recommended by the wound clinic, resulting in hospitalization for a wound infection, for 1 of 3 residents reviewed with wounds, in a sample of 5. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 1/2/18 at 11:30 A.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 8/30/17, indicated the resident scored a 15 out of 15 for cognition, with 15 indicative of no memory impairment, and had 1 venous/arterial ulcer. A Care Plan, dated 7/27/17 with a goal target date of 12/1/17, indicated, Resident has impaired skin integrity: Venous ulcer on Right LE (lower extremity). The Approaches included: Assess wound weekly documenting measurements and description. Notify MD of worsening or no change in wound or for signs of infection. Nursing Progress Notes included the following information: 11/17/17 at 8:48 A.M.: Resident continues with venous ulcer on R (right) LE that measures 5.4 cm x 6.1 cm x 0.1 cm .Resident is receiving oral ATB (antibiotic) Therapy for R LE [MEDICAL CONDITION] (skin infection). She stated that she is no longer being seen at the wound clinic as of last week as wound was closed at that time. She has requested that she resume care with (name of wound clinic). (Name of physician) updated on wound and orders requested to 1.) Cleanse wound with NS (normal saline) apply Ca Alginate AG (ointment) and cover with foam dressing daily and PRN (as needed). 2.) (Name of wound clinic) to eval (evaluate) and treat wound per residents (sic) request. Awaiting response. Documentation in the Wound Management section regarding the resident's wounds was not found after 11/17/17, which indicated the wounds were healed. A Wound Review, dated 11/24/17 at 2:26 P.M., indicated, .current wound sites and types: Venous on Right LE .site and treatment for [REDACTED].List current wound interventions in place .Requested referral to (name of wound clinic) Documentation of wound measurements, drainage, or other characteristics of the wounds was not found in the clinical record. Documentation of a wound assessment after 11/24/17 was not found in the clinical record. Progress notes continued: 11/29/17 at 12:13 P.M.: Resident declined assessment of venous ulcer on R LE as she has an appointment at wound clinic this afternoon. R LE is wrapped weekly at wound clinic. A Wound Clinic note, dated 11/29/17, indicated, Keep wrap clean and dry .Return in about 1 week. Done Today: Collagen (ointment) for Skin ulcer .Antibiotic ointment/cream for Pseudomonas aeruginosa infection .Compression Wrap for Skin ulcer . The note did not contain information regarding wound measurements or wound characteristics. Progress Notes continued: 11/29/17 at 4:15 P.M.: N.O. (new order) for resident to start [MEDICATION NAME] (antibiotic) .times 10 days for [MEDICAL CONDITION]. 12/6/17 at 6:04 P.M.: Resident went to Wound clinic today. Four compression dressing noted on her right leg. Continue to monitor. A Wound Clinic note, dated 12/6/17, was not found in the clinical record. A Wound Clinic note, dated 12/6/17, was provided by the Director of Nursing (DON) on 1/2/18 at 3:15 P.M. The note included: .R LE: Ulceration to pretib (lower leg) previously measuring 35 x 125 x 1 mm deep. Today it is 60 x 125 x 3 mm deep .Plan: .Cleanse wound with [MEDICATION NAME] (wound cleanser), apply [MEDICATION NAME] (antibiotic) ointment and Kerracel AG (ointment). Apply [MEDICATION NAME] (dressing) as usual. Pt (patient) would benefit from twice weekly wrap changes with cleansing of wound with Antiseptic or Acetic acid. Nurse to call LTC (long term care facility) and see if they can do this possibly Saturday or Sunday Further documentation regarding the wound clinic's recommendation was not found until after the resident was hospitalized . Progress Notes continued: 12/13/17 at 5:40 A.M.: Appointment and (sic) wound clinic facility to transfer @ 1:00 pm. A Wound Clinic note, dated 12/13/17, was not found in the clinical record. A Wound Clinic note, dated 12/13/17, was provided by the DON on 1/2/18 at 3:15 P.M. The note indicated, .She has been treated for [REDACTED]. I think she is a little bit worse .She has got more open wounds, a lot of scale, a lot of [MEDICAL CONDITION] (swelling) and a lot of redness .She has a lot more pain today than usual .Medication Changes: Added: [MEDICATION NAME] ointment Apply topically daily for 30 days to affected area Documentation that the [MEDICATION NAME] was applied to the resident's wounds was not found on the Treatment Administration Record (TAR), nor in the clinical record. Progress Notes continued: 12/14/17 at 6:35 P.M.: Noted large amount of clear drainage through the Drsg (dressing) on R LE. Clean and dry dressing placed. c/o (complains of) pain on rt (right) leg PRN percocit (sic) (pain medication) given with effective result. 12/18/17 at 11:00 P.M.: Resident and her daughter requested resident to be sent to ER due to right leg being red and large amount of drainage from venous ulcer on right ankle .received order to sent (sic) to ER. A Progress Note, dated 12/21/17 at 4:47 P.M., and written by RN 1, indicated, Recorded as late entry from 12/7/17: Returned call to wound clinic. Nurse at wound clinic gave list of supplies used for residents tx (treatment) and inquired if the facility would be able to complete tx on Saturdays if the order was given. Ensured the nurse at the wound clinic that if the facility received an order to complete tx in house that we would ensure supplies were available and that tx would be completed. Awaiting wound clinic orders. A hospital ER note, dated 12/18/17 at 9:12 P.M., indicated, .Pt (patient) here for right lower leg wound that has increased drainage. The current dressing is saturated with yellow drainage. Pt complaining of pain in this lower leg. A hospital Physician's note, dated 12/18/17 at 9:54 P.M., indicated, Chief Complainant: Patient presents with Wound Check .The patient has been treated for [REDACTED]. She went to wound clinic last week, and they took a culture .her daughter noticed that the leg was looking much worse. She was seeping green fluid through her dressing, and for this reason they called an ambulance to bring her to the emergency department. She had slight temperature elevation earlier today .Extremities: .Diffuse [DIAGNOSES REDACTED] (redness) present over the lower right foot and leg. Large ruptured bulla (blister-type area) present on the lower right posterior calf. Weeping and oozing green fluid from the right anterior lower leg .needs to be admitted for IV antibiotics .Final Impression: 1. Right lower extremity [MEDICAL CONDITION], 2. Pseudomonal wound infection. Plan - Patient is admitted to floor .Her wound looks infected. It is draining greenish discharge On 1/3/18 at 10:40 A.M., the Office Manager at the Wound Clinic was interviewed. She indicated the Clinic had documentation, dated 12/6/17 at 4:01 P.M., that indicated, Spoke with (RN 3) at (facility) to inquire whether [MEDICATION NAME] regular could be removed and reapplied on weekend. (RN 3) states they have wound nurse Monday through Friday, but she will speak with them to see if options are available. She will call me back. An additional Wound Clinic note, dated 12/8/17 at 3:50 P.M., indicated, Spoke with (RN 4) at (name of facility) yesterday to follow up on prior days call to (RN 3) at (name of facility) re: can they change wraps on weekend. Today (RN 1) from (facility) returned call to state that they can change wraps on weekend, but will have to order supplies .Gave (RN 1) wound change orders. (RN 1) voiced understanding. On 1/3/18 at 10:55 A.M., RN 1 was interviewed. RN 1 indicated she was not the wound care nurse on 12/7/17 or 12/13/17. She indicated the previous wound care nurse, LPN 1, was no longer employed at the facility. She indicated she only called the clinic for LPN 1 to see what supplies were needed for Resident B. She indicated she was unaware of the wound clinic's orders on 12/6/17 and on 12/13/17. On 1/3/18 at 12:40 P.M., the DON and Corporate Nurse were interviewed. The DON indicated the Wound Clinic notes from 12/6/17 and 12/13/17 were not in the clinical record, and that staff would usually follow up with whatever orders were sent from the Clinic. The DON indicated the previous wound care nurse thought that since the resident was being seen at the Wound Clinic, and that they performed the dressing changes, that she did not have to measure and assess the wounds. On 1/3/18 at 1:00 P.M., the DON provided the current facility policy, Skin Management Program, updated 11/2017. The policy included: .Procedure for Alterations in Skin Integrity - Pressure and Non-Pressure .2. Treatment order will be obtained. 3. All alterations in skin integrity will be documented in the medical record .4 The facility must have an assigned wound nurse that assesses the wounds on a weekly basis .The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day (i) Wound Management for ulcers (arterial, diabetic, pressure, or venous) (1) Updated weekly until resolved This Federal tag relates to Complaint IN 369. 3.1-37(a)

Based on interview and record review, the facility failed to administer Cardiopulmonary Resuscitation (CPR) to a resident who had a full code status for 1 of 1 residents reviewed with a physician's orders [REDACTED]. (Resident 97) The Immediate Jeopardy began on [DATE] when the staff failed to provide CPR for a resident who had a full code status. The Administrator, DON (Director of Nursing, Nurse Consultant, and AIT (Administrator in training) were notified of the Immediate Jeopardy on [DATE] at 4:20 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: On [DATE] at 11:15 a.m., Resident 97's clinical record was reviewed. Resident 97 was admitted to the facility on [DATE]. Resident 97's [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) Assessment, dated [DATE], indicated Resident 97 had severe cognitive impairment. Resident 97's Care Plans lacked a care plan and interventions for code status. A physician's orders [REDACTED]. Resident 97's medical record lacked an Advanced Directive by the resident or representative. A Progress note, dated [DATE] at 3:15 a.m., indicated Noted resident in bed with eyes closed, no distress noted .Noted Glucerna feeding with approx.(sic) 45 minutes remaining. Noted good amount of humidifier water, good mist noted. Will replace feeding in approx. (sic) ,[DATE] minutes. A Progress Note, dated [DATE] at 4:05 a.m., indicated: Entered room noted resident left eye fixed, staring blankly. Pale skin, cyanosis (blue discoloration) around the lips. Did not respond to verbal or tactile stimuli. Noted no pulse, respirations. Warm to touch, no pooling of blood noted in lower extremities. Call placed RN in house to confirmed (sic) by RN no pulse no respirations. Resident noted to be full code. A Progress Note, dated [DATE] at 4:20 a.m., indicated: EMT arrived at facility, assessed resident, applied monitor for internal data. Informed will call in for further instructions d/t (due to) death. Noted call placed to coroner (Coroner Name), information given of health condition. Coroner inform (sic) EMT to call death and have attending MD sign death certificate, no s/o (signs of) foul play. On [DATE] at 12:50 p.m., a physician's note, dated [DATE], indicated: Cause of death: Patient was found in bed without a pulse or respiration at about 4:05 a.m. on [DATE]. Patient reportedly was mottled, with perioral cyanosis. The patient progress notes appeared to be okay at about 3 a.m. paramedics were called, but CPR was not initially initiated in the facility. Paramedics found the patient pulseless and without respirations. It is unlikely that CPR initiated at the time the patient was found by the nursing staff would have been successful. This morning I signed the patient's death certificate and listed acute on chronic [MEDICAL CONDITION] as the cause of death. On [DATE] at 12:55 p.m., a review of a written statement by RN 1, dated [DATE], untimed. It indicated: . I was going to do a treatment when LPN 1 called over and asked me to verify a death with her .We both went in the room, no pulse, no respirations, no breath sounds, or heartbeat. The resident's eyes were glazed over, no signs of life, skin was bluish discoloration. LPN 1 and I closed the door, she went to call triage, family, and coroner. I proceeded back to my unit and notified the DON (Director of Nursing). An interview with the DON on [DATE] at 11:27 a.m., indicated the facility policy was to initiate a code on all full code residents, even if found cyanotic, with rigor, or pulseless. She indicated staff was to check code status, if a DNR (Do not Resuscitate) to verify time of death and vitals, and if a Full Code to initiate CPR and grab the AED (Automatic External Defibrillator). She indicated the facility terminated a nurse for not following this policy and not initiating CPR (Cardiac [MEDICAL CONDITION] Resuscitation) when finding a resident unresponsive in her room. During interviews of 11 nursing staff, on [DATE] at 11:23 a.m. through 11: 56 a.m., all were able to appropriately respond to a Code Blue, except for LPN 2. LPN 2 was currently working her last shift at the facility, and indicated on [DATE] at 11:46 a.m. she did not know the facility policy and did not know what she would do in the situation of finding a resident unresponsive in their room. She attempted to ask a fell ow nurse during the interview. During a review of the facility training inservices, dated ,[DATE]-[DATE], on [DATE] at 12:10 p.m., all facility staff were trained in Code Blue, CPR initiation, and honoring code status. During an interview on [DATE] at 12:31 p.m., the Nursing Consultant indicated: The facility followed the AHA (American Heart Association) guidelines when it came to finding a deceased resident. If a resident was found in rigor, cyanotic, or mottled that CPR was not initiated. He further indicated the nurse was to contact the physician to get an order to discontinue the CPR order, and indicated this was not followed with Resident 97. During an interview on [DATE] at 1:20 p.m., the SSD (Social Services Director) indicated Resident 97 did not have an Advanced Directive due to not being able to make the decision herself, due to her cognitive status. She further indicated the family had not yet made a decision on her code status so she was defaulted to a Full Code status. The clinical record lacked documentation that the SSD had attempted to obtain the family's declaration of code status. During an interview on [DATE] at 1:28 p.m., the DON (Director of Nursing) indicated RN 1 did not document her findings in the clinical chart because the chart was closed after the death. When questioned about the late entries by LPN 1 she indicated she did not know why RN 1 did not enter her documentation as a late entry instead of a written statement. During an interview on [DATE] at 1:33 p.m., the Nursing Consultant indicated RN 1 did not document her assessment of Resident 97 in the clinical record due to being uncomfortable due to the death and chose to come in and write a written statement. He acknowledged the discrepancies of LPN 1 and RN 1's assessments and indicated RN 1 was the correct assessment. He acknowledged the written statement was not part of the clinical record. A review of the current policy, Code Blue Drill, revised ,[DATE], on [DATE] at 1:12 p.m., indicated: . AHA urges all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place, 2) obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. A review of the current policy, Advanced Directives, revised ,[DATE], on [DATE] at 2:52 p.m., indicated: .the facility's care will reflect the resident's wishes as expressed in the Directive, in accordance with state law. The signed form will be kept in the medical record. In the event that an adult is incapacitated at the time of admission, information regarding Advanced Directives may be given to the resident's representative. Advanced Directives will be reviewed quarterly in the care plan conference with the IDT and resident/responsible party as applicable. The Past Noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and corrected on [DATE] when the facility completed inservicing of all nursing staff for CPR competency and Code Blue, and institituted random audits of all nursing staff for Code Blue. The correction date was prior to the start of the survey and was therefore Past Noncompliance. 3XXX,[DATE](f)(5)

Based on observation, interview, and record review, the facility failed to obtain an order for [REDACTED]. Findings include: 1. The clinical record of Resident A was reviewed on 5/12/15 at 10:35 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Admission Physician orders for the foley catheter were not found in the clinical record. A Nursing Admission Assessment, dated 3/20/15, indicated, Alert, Orientation: Person, Place, [MEDICAL CONDITION]: F/C (foley catheter). A Catheter Plan of Care, dated 3/24/15, indicated, Contributing [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 3/27/15, indicated Resident A scored a 15 out of 15 for cognition, indicating no memory impairment. The resident required extensive assistance of two + staff for bed mobility, transfer, and toilet use. The Bladder and Bowel section indicated: Urinary continence - Not rated, resident had a catheter (indwelling or condom), urinary ostomy, or no urine output for the entire 7 days. A Physician's order, dated 4/1/15, indicated, D/C (discontinue) Foley. Documentation that the foley catheter was d/c'd was not found in the clinical record. CNA documentation indicated the resident continued to have an Indwelling Catheter from 4/1/15-5/5/15. The last measured urine output was 5/5/15 at 6:52 A.M., and was documented as 100 cc. The May 2015 Physician orders did not include orders for a foley catheter. Documentation in the Nursing Progress Notes regarding the foley catheter was not found after 4/1/15. Documentation regarding the flushing or care of the foley catheter was not documented on the April 2015 or the May 2015 Treatment Administration Record (TAR). Nursing Progress Notes, dated 5/5/15 at 7:15 A.M., indicated, (Resident A) c/o (complains of) SOB (shortness of breath), chest discomfort.Organized transport to (hospital). A hospital Emergency Department (ED) note, dated 5/15/15 at 8:10 A.M., indicated, Pt (patient) arrives to the ED.with complaints of abdominal pain and chest pain.Pt requests to go to a different facility due to the way the pt has been treated and neglection (sic). An ED note, dated 5/5/15 at 8:15 A.M., indicated, Pt requests he does not go back to the facility of (name of facility) due to the treatment that he received there. Pt reports he felt neglected stating 'Workers said they would come back and never came back.' An ED note, dated 5/5/15 at 8:20 A.M., indicated, Foley was in place from (name of facility). Site was not clean and was retaped on his leg several times. Foley had no insertion date and was removed by this RN and replaced with new foley per Dr. An ED note, dated 5/5/15 at 8:27 A.M., indicated, (Name) from social work called and informed her of the patient's condition on arrival to the ED. Pt had foley and PICC and was not kept cleaned. Pt requested not to go back to (name of facility). A hospital ED physician note, dated 5/5/15, indicated, .Patient with positive C.Difficile test last week. Has been on generous supply of antibiotics over the past couple of months related to diabetic wound infection.(Lab work) WBC 52.1 (normal range 4.1-10.9).Final Impression: 1. Septic shock. A hospital History and Physical, dated 5/5/15, indicated, .Assessment/Plan: [MEDICAL CONDITION] with acute organ dysfunction.Condition is guarded. On 5/12/15 at 9:45 A.M., during an interview with EMS staff # 1, he indicated he was called to the facility on [DATE] for Resident A's complaint of chest pain. He indicated he observed that the resident's catheter bag was empty, and had old dried sediment inside the catheter tubing. He indicated the resident told him, Don't let me go back there. On 5/13/15 at 2:15 P.M., during an interview with the Administrator and Interim Director of Nursing (DON), the Administrator indicated the facility had become aware of concerns regarding Resident A's foley catheter the previous week and had retrained staff on correct foley catheter care. The Administrator indicated staff were also retrained on reporting any unusual appearance of the catheter and/or urine to the licensed nurse 2. On 5/12/15 at 8:55 A.M., during the initial tour, the Interim DON indicated Resident B had a foley catheter. On 5/12/15 at 9:40 A.M., the Administrator provided a list of residents, indicating those residents considered interviewable. Resident B was highlighted as being interviewable. On 5/12/15 at 1:20 P.M., the clinical record of Resident B was reviewed. A quarterly MDS assessment, dated 4/7/15, indicated the resident scored a 15 out of 15 for cognition, indicating no memory impairment. A Physician's order, dated 8/14/14 and on the current May 2015 orders, indicated, Catheter care every shift. A Catheter Plan of Care, dated 8/14/14, indicated: Contributing [DIAGNOSES REDACTED]. Devices: Uretheral catheter. Interventions: Daily Indwelling Catheter Care. Nursing Progress Notes, dated 5/10/15 at 2:00 P.M., indicated, Resident c/o (complains of) penile pain at his catheter insertion site. Catheter noted to have 'build-up' around insertion site. Catheter changed.Will monitor. A Treatment Administration Record (TAR), dated May 2015, indicated: Catheter care every shift. From 5/1/15-5/12/15, there were 8 shifts that were left blank, indicating the lack of care. On 5/12/15 at 2:00 P.M., Resident B was observed lying in bed, with a foley catheter drainage bag hanging from the bed frame. Resident B was interviewed at that time. Resident B indicated he thought the staff was supposed to clean around the insertion site of his catheter once a day, but that sometimes it's every other day. On 5/13/15 at 9:50 A.M., during interview with QMA # 1, he indicated, We make sure catheter care is done every shift. We either do it ourselves or make sure the CNAs did it. QMA # 1 indicated the nursing staff initials the treatment record, indicating the care was completed. On 5/13/15 at 9:55 A.M., during an interview with CNA # 2, she indicated the CNAs did the catheter care every time they provided care. On 5/13/15 at 3:05 P.M., the Administrator provided the current facility policy on Indwelling Urinary Catheters, dated July 2012. The policy included: .All residents with an indwelling catheter require a medical justification for the initiation and continuing need for catheter use. A comprehensive assessment includes underlying factors.and development of a plan for appropriate indications for continuing use of an indwelling catheter beyond 14 days.Residents admitted to the center with an indwelling catheter that was placed elsewhere need a provider order and medical justification for the catheter to remain in place. The Administrator also provided at that time the facility procedure Providing Catheter Care, undated, which she indicated was provided to the staff, to retrain the staff on correct catheter care. This Federal tag relates to Complaint IN 064. 3.1-41(a)(1)

Based on observation, interview, and record review, the facility failed to change and flush a PICC (a type of intravenous, or IV) line as ordered by the physician, resulting in hospital staff being unable to use the line and needing to insert a new intravenous line to provide medication and fluids, including that for septic shock, for 1 of 2 residents sampled with IV medications, in a sample of 3. Resident A Findings include: 1. The clinical record of Resident A was reviewed on 5/12/15 at 10:35 A.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Nursing Progress Note, dated 3/20/15 at 1:45 P.M., indicated, (Right) SL (single lumen) PICC in place, drsg (dressing) (changed 3/17/15, CDI (clean, dry, intact). Physician orders, initially dated 3/23/15 and on the May 2015 orders, indicated, Change PICC line (dressing) every 7 days and PRN (as needed). Flush PICC line with 10 ml normal saline once a shift. An admission Minimum Data Set (MDS) assessment, dated 3/27/15, indicated Resident A scored a 15 out of 15 for cognition, indicating no memory impairment. The resident required extensive assistance of two + staff for bed mobility, transfer, and toilet use. Documentation indicated the resident received IV fluids on 4/1/15 and on 4/2/15 due to abnormal lab work. A Treatment Administration Record (TAR), dated April 2015, indicated the resident's PICC dressing was changed on 4/13/15. Boxes marked 4/20/15 and 4/27/15, were left blank, indicating the dressing was not changed on those dates. The May 2015 TAR had no documentation that the PICC dressing was changed. The April 2015 TAR and May 2015 TAR indicated, Flush PICC line with 10 ml normal saline once a shift. There were no times or initials indicating the line was flushed. A care plan regarding the care of the PICC line was not found in the clinical record. Documentation indicated the resident was transferred to the hospital emergency department (ED) on 5/5/15 at 7:15 A.M., due to chest pain. A hospital Emergency Department (ED) note, dated 5/15/15 at 8:10 A.M., indicated, Pt (patient) arrives to the ED.with complaints of abdominal pain and chest pain.Pt requests to go to a different facility due to the way the pt has been treated and neglection (sic). An ED note, dated 5/5/15 at 8:15 A.M., indicated, Pt requests he does not go back to the facility of (name of facility) due to the treatment that he received there. Pt reports he felt neglected stating 'Workers said they would come back and never came back.' A hospital ED note, dated 5/5/15 at 8:15 A.M., indicated, Pt (patient) has PICC line in place has not been checked since 4/13. PICC line wound not draw blood. IV consult order placed. An additional ED note, dated 5/15/15 at 8:27 A.M., indicated, (Name) from social work called and informed her of the patients (sic) condition on arrival to the ED. Pt had foley and PICC and was not kept cleaned. Pt requested not to go back to (name of facility). The hospital ED notes indicated an IV was placed in the resident on 5/5/15 at 8:51 A.M. An hospital history and physical, dated 5/15/15, indicated, .He was transferred to the emergency room and found to be in [MEDICAL CONDITION] and having intense abdominal pain.found to be hypotensive his been (sic) given fluid bolus.Labs: WBC 52.1 (normal 4.1-10.9).Assessment/Plan: [MEDICAL CONDITION] with acute organ dysfunction.He is getting fluids aggressively.Condition is guarded. On 5/12/15 at 9:45 A.M., during an interview with EMT staff # 1, he indicated when arrived at the facility on 5/5/15 to transport the resident to the hospital, he noted that the resident's PICC dressing was dirty with a lot of old dried blood under a [MEDICATION NAME] dressing. He indicated it appeared that the PICC line had been pulled out slightly, and he didn't want to try and use it. He indicated he wanted to give Resident A some IV medication for his nausea, but that he didn't want to use the PICC line due to the condition of it. He indicated the resident told him, Don't let me go back there. On 5/13/15 at 2:15 P.M., during an interview with the Administrator and the Interim Director of Nursing (DON), the Administrator indicated they had identified the concern regarding Resident A's PICC line the following week, and had retrained staff on correct PICC line care, including dressing and flushing. On 5/13/15 at 3:05 P.M., the Administrator provided the current facility policy Peripheral Catheter Flushing, revised July 1, 2012. The policy included: To Be Performed By: Licensed nurses according to state law and facility policy. The nurse shall be competent in the safe delivery of infusion therapy.Specific flush orders must be documented.Flushing is performed to ensure and maintain catheter patency.Documentaiton in the medical record includes, but is not limited to: Date and time, Prescibed flushing agent, Site assessment. At that time, the Administrator also provided the current facility policy Peripheral Catheter Dressing Change, revised July 1, 2012. The policy included: .The peripheral catheter insertion site is a potential entry site for bacteria that could produce a catheter-related infection.Licensed nurses caring for residents receiving infusion therapies are expected to follow infection control and safety compliance procedures.Transparent dressings are changed with each site rotation, or sooner if the integrity of the dressing is compromised (wet, loose, soiled).Assessment of the peripheral catheter site is performed: During dressing changes, Every 2 hours during continuous therapy.At least once a shift when not in use. This Federal tag relates to Complaint IN 064. 3.1-47(a)(2)

Based on interview and record review, the facility failed to ensure a bed alarm was in place, as ordered by the physician, resulting in a fall with a laceration requiring sutures, for 1 of 3 residents reviewed for falls, in a sample of 7. Resident A Findings include: The closed clinical record of Resident A was reviewed on 4/9/15 at 11:55 A.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 1/29/15, indicated the resident scored a 13 for cognition. A score of 15 indicated no memory impairment. The MDS assessment indicated the resident required extensive assistance of one staff for transfer and ambulation in the room. A test for balance while moving from seated to standing position, moving on and off of the toilet, and surface-to-surface transfer indicated the resident was Not steady, only able to stabilize with staff assistance. Physician orders, initial date unknown but written on the March 2015 recertification orders, indicated, Bed and chair alarm for safty (sic). A care plan, initially dated 12/2/14 and updated 3/3/15, indicated: Fall/Injury Risk related to: History of Falls, pain, unsteady, poor weight bearing.bladder incontinence at x's (times).Interventions: Transfer 2A (assistance of two), Resident Supervision General, Non-skid socks 2/13/15, Obtain Medication Regimen Review with consulting pharmacists PRN (as needed), Non-skid adhesive to floor 3/02/15. The intervention of a bed and chair alarm was not documented on the care plan. Nurse's Notes included the following notations: 2/13/15 at 5:00 P.M.: fell while trying to transfer self from w/c (wheelchair) to bed, had on reg (regular) socks. Talked with daughter (name), informed her and that she needed to wear gripper socks. She wants resident to have an alarm on to alert staff when she is trying to get up. 2/15/15 at 6:30 A.M.: Resident on fall f/u (follow-up).Reminded to use call light when getting out of bed. Resident now has gripper socks. Bed alarm is on.Will continue to monitor. 2/16/15 at 11:00 A.M.: Res alert (with) confusion. Not using call light to have assistance to BR (bathroom).call light in reach. 2/27/15 at 9:00 P.M.: Resident continues to get OOB (out of bed) (without) assistance, bed alarm on. 2/28/15 at 8:00 P.M.: Resident cont to get OOB (without) assistance. Sitting at nurse desk. 2/28/15 at 10:40 P.M.: Found resident on the floor sitting by the bed.4 cm (centimeters) x .5 cm x 0.3 cm (laceration). Documentation did not indicate if the bed alarm was on and/or sounding. The resident was transferred to the hospital emergency roiagnom on [DATE] at 10:50 P.M., and returned to the facility at 2:40 A.M. Nurses notes, dated 2/28/15 (sic) at 2:40 A.M., indicated: Resident return to facility per w/c (with) family. (6) staples head (no) drainage.Instructed to call for assistance. A Daily Clinical Review entry, dated 3/2/15, indicated: .Resident observed on floor on 5 @ 2240 (10:40 P.M.) - had attempted to go to BR (with) out calling for assist.resident had laceration 4 cm x .5 cm x 0.3.returned to facility (with) 6 staples to (right) back of head - non adhesive strips applied to floor @ bedside, in front of recliner, (and) in front of commode - reminded resident again to wear gripper socks.reminded again to use call light. Documentation did not indicate if the bed alarm was on and/or sounding. On 4/10/15 at 6:25 A.M., the Corporate Nurse Consultant provided an accident report, dated 2/27/15. The report included: .Resident yelling out and found her sitting on the floor by the foot of the bed. Laceration to scalp.resident report that slid out of bed (sic).Conclusion: resident had increased confusion due to UTI (urinary tract infection) which was being tx (treated). Documentation did not indicate if the bed alarm was on and/or sounding. On 4/10/15 at 9:00 A.M., during an interview with Resident A's family member, he/she indicated that the facility usually used one alarm for the resident, which they would switch between her bed and her wheelchair, depending on where the resident was located at the time. The family member indicated when the family accompanied Resident A back from the hospital following her head laceration, the alarm was observed to be in the resident's wheelchair and not in her bed. The family member indicated that a staff member admitted a couple of days later that she had forgotten to move the alarm from the wheelchair to the bed. On 4/13/15 at 10:30 A.M., the Administrator provided the current facility policy on Fall/Injury Assessment: Prevention and Management Care Plan, revised October 2014. The policy included: (The corporation) revises the residents Care Plan and/or center practices to reduce the likelihood of another fall. Determining causal factors leading to a resident fall is necessary to provide consistent intervention to help prevent future occurrences. Causal factors may include, but are not limited to:.Unsteady gait.Dizziness.Acute infection.Antidepressant, Sedative/hypnotic.Procedure:.Determine appropriate interventions for identified risk factors. This Federal tag relates to Complaint IN 430. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to accurately assess a leg ulcer, resulting in wound infections which required 2 hospitalization s, for 1 of 4 residents assessed with [REDACTED]. Resident B Findings include: 1. On 3/4/13 at 9:10 A.M., during the initial tour, the Assistant Director of Nursing (ADON) indicated Resident B had a wound vac for a stasis ulcer on his leg. On 3/4/13 at 10:00 A.M., Resident B was observed lying in bed. A wound vac was attached to a wound in his right lower calf area. The clinical record of Resident B was reviewed on 3/4/13 at 11:15 A.M. [DIAGNOSES REDACTED]. A Physical Therapy Plan of Care, dated 11/19/12, included: "...The patient exhibits R (right) foot ulcer: lateral malleolus measuring: 2.8 cm (centimeters) x 2.1 cm x 0.1 cm with 50% necrotic tissues and R lateral heel: 0.8 cm x 0.4 cm x 0.1 cm...." A Skin Grid indicated: "Right Ankle...12/3/12, Length 1.8, Width 2.0, Depth 1.0, Color of Drainage S (Serosanguinous), Color R (red)...Wound bed macerated (and) sanguinous (sic) (with) 50% necrotic tissue present." The wound was measured on 12/10/12, 12/16/12,12/26/12, and 1/1/12. The measurements, dated 1/1/13, indicated: "1.8 x 1.4 x 0.4...Area is healing...." A Skin Grid indicated: "12/17/12, Was the wound present on admission? No, Site: Rt (right) lat (lateral) lower leg, Trauma...Dimensions (in cm) Length 0.6, Width 1, Depth 0.1..." The Skin Grid indicated the wound was measured on 12/26/12, and again on 1/2/13. The measurements, dated 1/2/13, indicated: "0.8 x 0.9 x 0.1, Color of Drainage (Serosanguinous), Color (red)...." A Skin Grid for the right lateral lower leg prior to 12/17/12 was not documented. A physician's orders [REDACTED]." A physician's orders [REDACTED]." Nurses notes included the following notations: 1/7/13 at 10:49 P.M.: "Res. (resident) stated he wanted to go to the hospital to have his wound checked out. This nurse writer paged to have (physician) call facility to get order to send to ER." 1/8/13 at 12:20 A.M.: "(Ambulance) here to take res to (hospital)...." A PT Progress Note, dated 1/8/13, included: "...The patient exhibits ankle ulcer, 2 lateral leg ulcers (superior and inferior with necrotic tissues present at periwound...(Right) lateral malleolus (R ankle): 1.0 cm x 1.4 cm x 0.4 cm, R lateral superior ulcer: 3.0 cm x 2.0 cm x 0.2 cm, R lateral inferior ulcer: 1.0 cm x 1.4 cm x 0.2 cm...effective yesterday, patient's ulcer on the R lateral malleolus was very foul and oozing very dark red blood which therapist had recommended for a bone scan to rule out osteo[DIAGNOSES REDACTED]...." A hospital discharge note, dated 1/12/13, included: "...Active Hospital Problems, Diagnoses, Ulcer of right leg, Teno[DIAGNOSES REDACTED] of right ankle...Hospital Course:...Came with worsening of pressure ulcers on right leg/foot...Was put on VANC and [MEDICATION NAME] (antibiotics), provided with wound care. Cultures showed...E. Coli/Proteus Mirabilis/MRSA in wound...." Nurses notes included the following notations: 1/12/13 at 4:20 P.M.: "Resident returned from (hospital)...." A Skin Grid indicated the resident's right lateral lower leg was assessed and measured on 1/12, 1/15, 1/22, and 1/29/13. The resident's measurements on 1/29/13 indicated: "1.8 x 1.6 x 0.2, Color of Drainage S, Color R...." There was no skin assessment again until 2/14/13. The Skin Grid, dated 2/14/13, indicated: "...10 cm x 6 cm x 0.3, Color of Drainage P (purulent), Color R, Odor M (mild)...." Nurses notes continued: 2/14/13 at 11:00 A.M.: "Resident's right distal lower leg - lateral aspect - drsg (dressing) changed - area @ wound base red, beefy (with) no drainage also single area lateral (illegible)area of right ankle - small (with) no drainage - (name) DON (Director of Nursing) in to observe wound." 2/18/13 at 2:50 P.M.: "Wound (right) distal lower lateral leg appears larger today - measured @ approx 9.2 cm x 4.6 cm; 0.04 deep (with) some yellowish foul-smelling drainage. (Physician) called, message left to ask for wound clinic evaluation. (Name) DON is aware." 2/19/13 at 10:30 A.M.: "Appt (appointment) made (with) (Name) Wound Clinic for Feb. 27...." 2/22/13 at 4:14 P.M.: "Resident wanted dressing to leg changed. I explained it was supper time and I needed to do (illegible) (and) assist residents to eat. He said that was not ok and he was getting up." 2/22/13 at 5:00 P.M.: "Resident asking people on phone to take him to the hospital." 2/22/13 at 5:10 P.M.: "Called (physician). Message left RE: Resident wanting to go to hospital." 2/22/13 at 5:15 P.M.: "Resident called 911." 2/22/13 at 5:20 P.M.: "Resident said he was afraid 'I might lose my leg' and that he could die." 2/22/13 at 5:39 P.M.: "(Physician) called. I told him resident had left by ambulance (911) to (hospital) ER. (Physician) said that was fine." A hospital discharge summary, dated 2/26/13, included: "...Hospital Course:...The patient comes in today because he felt that he was not being well taken care of at the nursing home. He feels that his wound is getting worse and has foul, smelling odor...He had a CT scan of his right lower extremity which showed possible underlying abscess with associated osteo[DIAGNOSES REDACTED] as well...The following is the patient's hospital course: Infected ulcer of the right leg with possible osteo[DIAGNOSES REDACTED]. status [REDACTED]." Nurses notes, dated 2/26/13 at 4:45 P.M.: Resident arrived via wheelchair van from hospital. He has a wound VAC and power PICC...." On 3/4/13 at 2:15 P.M., during interview with Resident B, he indicated, "(On 2/22/13) I asked the nurse to change my (leg) dressing, but she wouldn't. It was dripping blood. I called the ambulance myself." Resident B indicated the drainage was very foul smelling. Resident B indicated, " I was afraid I was going to have my leg amputated." On 3/5/13 at 2:20 P.M., during interview with the Director of Nursing (DON), he indicated he had only been at the facility for 2 weeks. He indicated he looked at Resident B's leg on 2/14/13, and wanted the physician notified at that time to obtain a wound consultation. The DON indicated he was unable to find a complete, accurate assessment on Resident B's leg wounds. 2. On 3/5/13 at 1:25 P.M., the Education Director provided the current facility policy on "Wound Prevention and Treatment," revised April 2009. The policy included: "...Progression of wound healing will be documented by length, width, and depth measurements. Documentation shall also include: Drainage/Exudate, Color, Odor, Tunneling/undermining, Periwound condition, Wound edges, Location, Pain, S/S (signs and symptoms) of infection, Wound base...Regardless of who is doing the wound treatment, Nursing Services will do the weekly assessment...." This federal tag relates to Complaint IN 920. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident at risk for falls was provided the proper supervision and proper placement of bolsters to prevent falls; and failed to ensure he was transferred correctly by staff, in that the resident was being pushed in a wheelchair by staff when he fell out of the wheelchair and sustained an abrasion to his forehead requiring 3 sutures, for 1 of 3 residents reviewed for falls, in a sample of 5. Resident D Findings include: On 3/4/13 at 9:10 A.M., during the initial tour, the Assistant Director of Nursing (ADON) indicated Resident D had recently fallen. On 3/5/13 at 9:10 A.M., Resident D was observed sitting in a wheelchair near the nursing station with his eyes closed. The clinical record of Resident D was reviewed on 3/5/13 at 9:20 A.M. [DIAGNOSES REDACTED]. Physician orders, initially dated 9/16/12 and on the current March 2013 orders, indicated, "Pressure alarm to bed, check placement (and) function every shift. Pressure alarm to chair, check placement (and) function every shift." A care plan, dated 5/29/12 and updated 1/6/13, indicated: "Fall/Injury Risk related to: pain, unsteady...cardiovascular diagnosis, bladder incontinence...Dementia...Hx (history) of Fall/Injury: 1/30/12 - (no) injury, 5/2/12 - (no) injury, 9/16/12, 9/18/12, 10/18/12, 10/23/12, 11/6/12, 12/3/12, 12/9/12..." Interventions included: "...Resident Supervision General...Chair alarm 9/16, Bed alarm sensor 9/16, Floor sensor 9/18...." Nurses notes included the following notations: 11/6/12 at 7:45 P.M.: "Resident fell out of bed. Found by CNA. DON (Director of Nursing), (Physician) notified. Pt. (patient) assessed no injury. Bed to have bolsters...." 12/3/12 at 9:50 A.M.: "Resident in wheelchair, leaning forward and fell on to right side. Head did not hit floor...." A Progress Note, dated 12/4/12 and untimed, indicated, "...Incident report r/t (related to) fall (witnessed). Resident sleeping in chair...Staff inserviced to place resident in bed (after) breakfast for AM nap...." 12/9/12 at 4:05 P.M.: "Laying on floor next to bed...." A Progress Note, dated 12/10/12 and untimed, indicated, "...fall on 12/9/12. Res (resident) was noted laying on floor next to bed. Bed bolsters in place, alarm was sounding; nurse reported that bed was in low position (with) mat in place...Nurse reported that slow response time to alarm resulted in fall. Staff educated on proper response time...." A Minimum Data Set (MDS) assessment, dated 1/7/13, indicated Resident scored a 2 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated Resident D required extensive assistance of two+ staff for bed mobility and transfer, and extensive assistance of one person physical assist for locomotion on and off of the unit. A test for balance during transitions and walking indicated, "Not steady, only able to stabilize with staff assistance." The MDS assessment indicated the resident had fallen 2 times since the prior assessment. A Progress Note, dated 1/14/13 and untimed, indicated, "...resident had a fall on 1-13-13 alarm was sounding, resident found face down on floor mat next to bed. Intervention is to educate staff on proper placement of bolsters." 1/21/13 at 5:45 P.M.: "Resident lying on floor mat next to his bed on his right side. CNA kneeling next to him...." A Physician Communication Note, dated 1/29/13 at 6:00 P.M., indicated: "...Res. (resident) fell forward out of his w/c (wheelchair), hitting his face on the floor. Has a laceration on the (left) brow. Sent to ER for (evaluation and treatment)." Nurses notes continued: 1/29/13 at 10:55 P.M.: "Res. (resident) returned from hospital @ this time has 3 sutures on (left) brow. Will cont. (continue) to monitor." A Progress Note, dated 1/30/13 and untimed, indicated: "DCR review R/T (related to) resident had a witnessed fall on 1-29-13 (with) a bruise and abrasion to his left eye was sent to ER for treatment...intervention is to ensure resident is in upright position before pushing resident in wheelchair." Nurses notes continued: 2/2/13 at 6:00 P.M.: "We heard resident scream 'Hey, Hey' loudly. I looked in the direction of the voice and noticed resident lying on his right side at an angle to the wall. He was not able to explain how he fell . His wheelchair was by his side." On 3/5/13 at 9:55 A.M. and 11:00 A.M., Resident D was observed sitting in the activity room, in a wheelchair, asleep. On 3/5/13 at 2:20 P.M., during interview with the Director of Nursing (DON), he indicated he had only been at the facility for 2 weeks. The DON indicated he had no further documentation regarding Resident D's falls; whether alarms were sounding or not, and how the resident fell out of his wheelchair on 1/29/13. The DON indicated he was told that Resident D usually kept his legs elevated when being transferred in his wheelchair, but put them down on 1/29/13, which caused him to fall out of the wheelchair and hit his head. This federal tag relates to Complaint IN 920. 3.1-45(a)(1)

Based on observation, interview and record review, the facility failed to ensure treatment and services to prevent pressure sores were provided and on-going treatment for [REDACTED]. The lack of preventive treatment resulted in the development of a stage III heel pressure area. (Residents X, Resident Z, Resident V) Findings include: 1. Resident X's clinical record was reviewed on [DATE] at 11:10 a.m. The [DIAGNOSES REDACTED]. Resident X had a "Resident Lifting, Transferring and Repositioning Data Collection" document, dated [DATE], which indicated the resident required "extensive assist of ,[DATE] with transfers" and "extensive assist ,[DATE] with bed mobility R/T (related to) generalized weakness. The resident had a care plan, dated [DATE], for skin integrity, prevention and treatment. The care plan indicated the resident had a Braden score (scale used to predict risk for pressure areas) of 16, indicating minimal risk. The care plan included, but was not limited to, the following: The care plan was a pre-written care plan with the facility placing check marks beside assessments, goals and interventions they were using. Assessment options for a resident with a score of 16 on the Braden assessment included frequent turning, maximal remobilization, protect heels, manage moisture, nutrition, friction and shear, and pressure-reduction support surface if bed or chair-bound. The only items checked for this resident were maximal remobilization, manage moisture, nutrition, friction and shear, and pressure-reduction support surface. Goals identified were remaining free of open areas and being cooperative with position changes. Interventions checked were the following: Complete Braden Scale upon admission and weekly times 4 wks, quarterly, and with change of condition. Use commercial moisture barrier Use absorbent pads or diapers that wick and hold moisture Consult dietitian prn (as needed) Monitor nutrition and hydration status Monitor weight as applicable Monitor nutrition/hydration status with each meal Bathe with mild soap, rinse, and dry thoroughly Moisturize skin Keep skin clean, dry and free of body wastes, perspiration, and wound drainage Encourage ambulation Implement an individualized turning schedule Keep linen dry and wrinkle free Provide a pressure reduction or pressure relief surface for bed and/or wheelchair... Involve Therapy when indicated Instruct and encourage to reposition self at ,[DATE] minute intervals as able Monitor wound weekly and PRN See Skin Grid Provide treatment per MD order Update MD within 2 weeks if no evidence of healing Intervention options on the care plan that were not selected for this resident included, but were not limited to, skin protection interventions, "Protect elbows and heels as needed." The record indicated the resident was hospitalized from [DATE] to [DATE]. The Admission Skin Assessment, completed on [DATE], indicated the resident had a bruise on the left arm and was slightly red on the buttocks. Nurses' notes included, but were not limited to, the following: [DATE] at 1400 (2:00 p.m.) indicated the following: "resident returned from hosp. Family accompanied and (one) van attendant. Transferred per 2 assist, diff (difficult) to transfer alert to self et attempted to help transfer...skin free of o/a (open areas)..." [DATE] 1000 (10:00 a.m.) "...non-wt (weight) bearing cont...(continues)" [DATE] 1435 (2:35 p.m.) "New orders for PT (physical therapy)/OT (occupational therapy) to treat..." [DATE] 0650 (6:50 a.m.) "Res. has rested quietly. T (and) R (turn and reposition) q (every) 2 (hours). Abd (abdomen) soft, BS X 4 (bowel sounds in all four quadrants). Resp (respirations) even et non labored. ii (two) assist for transfers et toileting..." [DATE] (no time) "New area noted to outer Rt. (right) heel MD (Medical Doctor) notified..." [DATE] 1415 (2:15 p.m.) "Paged (physician's name) and spoke with on call doctor (name). He was informed that resident had an open area resulting from a blister that now had a dark spot in the center of wound..." "Resident had a blister that has popped and now has a black spot measuring approximately 1XXX,[DATE].3 cm (centimeters) in the middle..." [DATE] 2305 (11:05 p.m.) "...Pt. has a nickel size necrotic area (with) surrounding [DIAGNOSES REDACTED] and [MEDICATION NAME] peeling, dressing applied per previous nurse. "(Family member) educated on all pressure areas...Heel elevated and education done (with) pt. and family on (no) pressure on her (L) (left) heel..." [DATE] 1430 (2:30 p.m.) "...(L) heel elevated will continue to monitor..." [DATE] 1730 (5:30 p.m.) "PT (physical therapy) eval completed for wound (L) medial heel..." The physical therapy evaluation, dated [DATE], indicated the following: "Patient has a necrotic pressure ulcer on L medial heel measuring: 4 cm (centimeters) X 6.4 cm with black eschar in the middle measuring: 2.2 cm X 1.8 cm X 0.1 cm. Has moderate serosanguineous exudate with moderate [MEDICAL CONDITION] on L foot going up to mid leg. Peri wound is very red." The physical therapist identified the area as a stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss..." Facility documentation on their Skin Grid, indicated the following: [DATE], wound found on the left heel, not present on admission. Identified as a Suspected Deep Tissue Injury "(Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear)." 3 cm long by 2 cm wide by less than 0.1 cm deep. No drainage or odor. [DATE], stage unable to determine, 2.3 cm by 1.8 cm, no depth, red and black in color "Area assessed has now progressed to unstageable pressure area. Peri wound is clean with granulation present. Eschar is soft..." [DATE], 3.4 cm by 4.8 cm by 0.1 cm, serosanguineous drainage, red and black in color, "Black eschar in middle." [DATE], 3.3 cm by 4.8 cm by 0.1 cm, serosanguineous drainage, red and black in color. [DATE], 3.3 cm by 4.8 cm by 0.1 cm, serosanguineous drainage, red and black in color [DATE], 1.8 cm by 3.0 cm by 0.1 cm, serosanguineous drainage, red and black in color [DATE], stage III 1.7 cm by 3.0 cm by 0.1 cm, serosanguineous drainage, no color The treatment to Resident X was observed being done by RN #3 and the Physical Therapist on [DATE] at 8:35 a.m. RN #3 removed the dressing. The resident indicated she was having pain with the wound. The area was on the medial aspect of the left heel. It was approximately 3 centimeters in diameter. The wound bed had 25% coverage of yellow slough. The edges of the wound were white in color. The surrounding skin was pink. The Physical Therapist indicated the wound had improved. She indicated the first time she saw the wound, it was like a blister had ruptured and had black necrosis in the center of the wound. The Physical Therapist completed the treatment and dressing change using Santyl (a [MEDICATION NAME] agent) on the slough, skin prep around the edge of the wound, and calcium alginate (a wound dressing) over the wound, covered the area with a gauze pad and wrapped it with a gauze dressing. Assistant Director of Nursing #2 (ADoN #2) was interviewed on [DATE] at 10:30 a.m. She indicated she had just taken over supervision of the unit where Resident X resided. When queried about preventive measures to protect the heels when the resident returned from the hospital in a weakened condition, she indicated they were turning and repositioning the resident and the resident was on a pressure reducing mattress. The first indication the facility was relieving pressure from the heels was [DATE] when the pressure area was discovered. The policy and procedure for Wound Prevention and Treatment, dated [DATE] and revised [DATE], was provided by the Director of Nurses on [DATE] at 11:25 a.m. The procedure included, but was not limited to, the following: "(Name of company) strives to ensure that a resident entering the center without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates unavoidable skin breakdown." "(Name of company) will consider all residents as at risk for skin impairment and will implement the following interventions to prevent the development of pressure ulcers: -Reduce occurrence of pressure over bony prominence to minimize injury. -Protect against the adverse effects of external mechanical forces (pressure, friction, shear). -Increase the awareness of pressure ulcer prevention through educational programs. -Braden Risk Assessment." "(Name of company) also recognizes even the most vigilant nursing care may not prevent the development and/or worsening of pressure ulcers in some residents. In those cases, intensive efforts will be directed at the following: -Managing risk factors -Providing preventive interventions -Providing treatment" "...A resident with pressure ulcers will receive continued preventive interventions and necessary treatment and services to promote healing and prevent infection." 2. Record review of Resident Z on [DATE] at 11:21 a.m., The [DIAGNOSES REDACTED]. During initial tour on [DATE] at 10:00 a.m., Resident Z was observed to be lying in bed with his lower extremities elevated and bolsters on each side of the upper part of the bed. Interview with the ADoN (Assistant Director of Nursing) on [DATE] at 10:00 a.m., indicated the resident was total care for his ADLs (Activities of Daily Living), was incontinent, and the resident was receiving IV (intravenous) antibiotics (medications used in the treatment of [REDACTED]. On observation of Resident Z during his bath on [DATE] at 9:40 a.m., the resident's mattress was observed to be wet and had a urine odor. The CNA's had 2 basins on the overbed table, one containing water with soap and one basin containing water for rinsing. CNA #1 was observed to wash the resident with soapy water but the resident was never rinsed before being dried with a towel. The resident was not given pericare during his bath and no oral care was observed. The resident had heel protectors on, but the protectors were never removed during his bath nor were his toes washed. (the heel protectors were on the resident to provide protection for his heels which had dressings on them) The bed linen under the resident was changed and a clean, dry sheet was placed on the wet mattress next to the resident. After turning the resident to his left side, a pillow was placed under the resident's back. The bed bolsters were picked up off of the resident's floor. CNA #1 wiped the left bolster with a dry washcloth but CNA #2 did not clean the right bolster. CNA #1 pulled the Velcro strap which was between the mattress and the bottom sheet on the bed and proceeded to secure the bolster onto the left side of the bed. CNA #2 pulled the Velcro and secured it to the bed. Interview with ADoN #1 on [DATE] at 10:20 a.m., indicated he noticed CNA #1 did not rinse the resident while giving his bath and he also noticed the wet area on the resident's bed. ADoN #1 indicated he did not know the Velcro straps were used to hold the bed bolsters in place. The guidelines for bathing obtained on [DATE] at 11:25 a.m. from the DoN, indicated the skin is to be rinsed thoroughly to remove all soap. The guidelines also indicated the perineal area is to be washed during a full or partial bath. During record review, the areas of documentation for pressure areas listed Resident Z's bilateral heels. Resident Z had an order dated [DATE] for a weekly skin assessment. Resident Z had an order, dated [DATE], indicating his bilateral heels were to be cleansed with Normal Saline, Calcium Algernate (a dressing used to promote wound healing) was to be applied, the wounds were to be covered with Allevyn (a type of foam wound dressing), Kerlix (a type of gauze dressing) was to be wrapped around his bilateral heels and secured with Coban (a type of stick on wrap) every other day. During initial tour on [DATE] at 10:00 a.m., Resident Z was observed lying in bed with his bilateral lower extremities elevated. ADoN (Assistant Director of Nursing) #1 indicated Resident Z had 2 stage 2 pressure areas (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. It may present as an intact or open/ruptured serum filled blister.) on his bilateral heels related to his [MEDICAL CONDITION]. Observation during Resident Z's bath on [DATE] at 9:40 a.m., indicated the resident had an stage 2 area on his right buttock which was open and bleeding. The left side of his buttock had an area which was dark brown in color but was not open. ADoN #1 indicated he was not aware of the open area on Resident Z's buttock. Interview with the DoN (Director of Nursing) on [DATE] at 11:30 a.m., indicated the resident had excoriation on his buttocks in the past and was receiving [MEDICATION NAME] (an ointment used for treating skin wounds). The DoN indicated she was unaware of any open areas on the resident's buttocks. During observation of the dressing change on Resident Z's bilateral heels on [DATE] at 1:45 p.m., the dressings on the resident's bilateral heels were marked the dressing was last changed on [DATE] and initialed. Interview of ADoN #2 on [DATE] at 2:00 p.m. indicated the dressing on Resident Z's bilateral heels indicated the dressings had not been changed since [DATE]. 3. A closed clinical record review on [DATE] at 11:30 a.m. of Resident V, indicated the resident had been admitted to the facility on [DATE] and expired at the facility on [DATE]. An admission skin assessment dated [DATE] indicated the resident had no areas if skin impairment on admission. Included in resident V's clinical record was a document titled nursing-therapy communication and dated [DATE] indicating Resident V had a skin condition to the coccyx. No description was present on the form. There were no nursing notes available for the time frame from [DATE] to [DATE]. The resident had a care plan dated [DATE] and updated [DATE] indicating interventions of but not limited to monitor wound weekly and PRN, See skin grid and provide treatment per MD. The treatment record for the month of July indicated weekly skin assessments were done on [DATE], 24 and 31 with no skin issues documented. There was no documented skin assessment for the week of [DATE]. A document titled nursing-therapy communication and dated [DATE] indicated the resident had a skin condition to the coccyx 1 inch in diameter which was open. A nursing note dated [DATE] at 12:45 p.m. indicated the nurse had completed a skin assessment and a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough may also present as an intact or open/ruptured serum filled blister) pressure ulcer had been found to the right buttock which measure 2 cm in length and 2 cm in width. On [DATE] a document titled skin grid- pressure/[MEDICAL CONDITION] ulcer/other indicated a stage 2 pressure area on the resident's right buttock. The area was 2 cm (centimeter a unit of measurement) in length by 2 cm in width. A doctors order dated [DATE] indicated the resident was to have a treatment and dressing change every 3 days and as needed. The treatment record for August indicated Resident V had a dressing change on [DATE], but not another dressing change for 5 days. The date was [DATE]. Dressing changes were then documented as done on [DATE], and 14, 2012. The treatment record for the month of August indicated the resident did not have a skin assessment until [DATE] even though the resident was care planned for weekly and as needed wound monitoring. The skin grid-pressure assessment dated [DATE] indicated the area on the coccyx had progressed to unstageable ( full thickness tissue loss in which the base of the ulcer is covered by slough and or eschar in the ulcer bed) 10 cm in length by 9 cm in width. On [DATE] a doctor's order indicated that physical therapy was to evaluate and provide treatment to Resident V's right buttock pressure area. In an interview with the Director of Nursing (DoN) on [DATE] at 11:25 a.m. she indicated she did not know why there was documentation of a skin condition on the nurse therapy communication document dated [DATE] and "could not ask the nurse who signed the document, because she know longer works here." The DoN also indicated she did not know why the weekly skin assessment had not been documented on [DATE], or in August until [DATE]. This federal tag relates to complaint # IN 303. 3XXX,[DATE](a)(1) 3XXX,[DATE](a)(2)

Based on interview and record review, the facility failed to ensure a resident's complaints of back pain and a raised flank mass not present on admission were thoroughly assessed and followed-up, which resulted in a hospitalization for a right flank abscess, for 1 of 3 residents reviewed for a change in condition, in a sample of 3. Resident B Findings include: The closed clinical record of Resident B was reviewed on 2/7/12 at 12:20 P.M. An "Admission Skin Assessment," dated 6/24/11, indicated there were no raised areas on the resident's back or flank areas. A physician's orders [REDACTED]." A Minimum Data Set (MDS) assessment, dated 7/1/11, indicated the resident scored an 11 out of 15 for cognition, with 15 indicating no memory loss, required extensive assistance of one staff for bed mobility and transfer, and hygiene and bathing. The MDS assessment indicated there were no skin impairments. Speech Therapy notes included the following notations: 7/14/11, untimed: "Res (resident) seen for cog/comm tx (cognition/communication treatment). Res. was fixated again on problem - c/o (complains of) pain in the back. Nsg (nursing) notified. Difficult to redirect from this pain. Res. was unsure what was giving him the problem...." 7/15/11, untimed: "Res. seen for cog/comm tx. Res. conts. (continues) to be fixated on 'problems.' c/o spot on back 'that hurts.' Nsg notified...." Documentation that nursing notified the physician or family, or did an assessment of the resident's pain was lacking in the clinical record. Nurses Notes included the following notations: 7/17/11 at 8:30 A.M.: "...Noted area to (right) flank - as large as my palm - raised - sl (slightly) firm - no warmth/redness or bruising. Unsure what happened - thinks might have hit back on toilet. Denies pain at this time - states area been there x 5 days." A Speech Therapy note, dated 7/18/11 untimed, indicated, "...Complains of back pain...Prognosis for Further Progress: Fair due to onset on new confusion...." Nurses Notes continued: 7/19/11 at 3:00 P.M.: "...Area to (right) flank remains non-tender on palpation, (no) redness or warmth...." Documentation of family or physician notification of the area was lacking in the clinical record. A Physical Therapy note, dated 7/19/11 an untimed, indicated, "...Pt. (patient) display (sic) (with) (increased) confusion (with) activities compared to last week." Speech Therapy notes included: 7/20/11 untimed: "...Did not recall directions for use (within) few minutes of giving them to him verbally...." 7/21/11 untimed: "Res. got lost trying to find the therapy room this am...." A Speech Therapy discharge summary, dated 7/21/11 and untimed, indicated, "Analysis of Functional Outcome/Clinical Impression:...Complains of pain in back. Overall physical and cognitive abilities have declined this week...Complicating factors that prevented the patient from achieving all established goals include new onset of confusion and physical decline with ADL (activities of daily living) performance and with gait/balance...." A Nurses Note, dated 7/22/11 at 1:00 P.M., indicated, "...Reported (by the son) that res (resident) was supposed to have been running a temp last noc (night) per staff, replied that what I had been notified of was that res had room overly warm and air conditioning had been adjusted to moderate room temp...." The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was discharged to an assisted living facility on 7/22/11. A hospital history and physical, dated 7/24/11 at 5:40 P.M., indicated, "...The patient...presents to our ED (Emergency Department) today with complaints of R (right) flank mass...Tender, bigger than 6 inches across and 1 inch high...Family unsure how long it has been there but he had been complaining of back pain for at least a week...Was at NH (nursing home) recently...Associated symptoms: Fever, chills, SOB (shortness of breath), confusion, diarrhea, poor urine output...Temp 101.7...R Flank: soft mass with some inferior [DIAGNOSES REDACTED] (redness) and warmth...About the size of my hand extended...." A hospital discharge summary, dated 7/29/11 at 12:57 P.M., indicated, "...Diagnoses, Abscess, retroperitoneal, Abscess of flank, right, [MEDICAL CONDITION]/Interventions/Operations: Incision and drainage of right retroperitoneal and flank abscess....Hospital Course: The patient presented [MEDICAL CONDITION] picture as well as pain in the right flank...an incision and drainage by (name of physician)...Wound VAC has been applied...still requires rehabilitation and ongoing monitoring as well as intravenous antibiotics...Admission Condition: poor, Discharge condition: good...." On 2/8/12 at 9:10 A.M., during interview with the MDS Coordinator, she indicated she was the Assistant Director of Nursing (ADON) in July 2011, and did not remember hearing that Resident B had a large raised right flank mass or had complained of right flank pain. On 2/8/12 at 10:20 A.M., the MDS Coordinator indicated the 24 hour report sheets from July 2011, regarding Resident B, did not document further information other than what was documented in the chart. This federal tag relates to Complaint IN 336. 3.1-37(a)

Based on interview and record review, the facility failed to ensure an enteral tube feeding was maintained at an infusion rate as specified by the physician for 1 of 3 residents reviewed with tube feedings in a sample of 12. This deficient practice resulted in vomiting and symptoms of aspiration after the resident received five times the prescribed amount of feeding for a period of three hours. Resident A Findings include: On 10/11/11 at 1:10 P.M., the clinical record of Resident A was reviewed. [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set assessment) dated 8/30/11, indicated the following for the resident: cognitive skills for decision making are severely impaired, feeding tube, range of motion was impaired on both sides, and bed mobility - required extensive assistance. A physician order [REDACTED].M.) - 1000 (10 A.M.) and 1800 (6 P.M.) - 2000 (8 P.M.)." Nurses' notes, dated 9/24/11 at 8 A.M., indicated the following: "CNA (certified nursing assistant) reported resident was vomiting up what looked like 'watered down feeding.' At that time, it was observed the peg tube feeding was running at 300 cc/hr (same as ml/hr). Feeding was immediately stopped. Res (resident) was set up as much as tolerated and placed on R (right) side...Crackles heard in L (left) lower post (posterior) lung field...." Nurses' notes, dated 9/24/11 at 9:45 A.M., indicated the following: "Order for STAT CXR (chest x ray) received...crackles heard in left lower post lung field." Nurses' notes, dated 9/24/11 at 8:30 A.M. (sic), indicated "Late entry: Dr. (name) notified of situation. Gave order to leave feeding off for 10 hours, (ADON (Assistant Director of Nursing) name) to inform daughter." Nurses' notes, dated 9/24/11 at 3 P.M., indicated, "...Few scattered rhonchi with some exp (expiratory) wheezes heard...." At 4 P.M."...Few scattered rhonchi et (and) faint exp wheezes heard, B (bilaterally). Lungs dimin (diminished) B (bilateral) bases...." The chest xray, dated 9/24/11 (no time documented) indicated the following: "...no evidence of an active [MEDICAL CONDITION] parenchymal or pleural disease process...." Nurses' notes, dated 9/25/11 at 6:30 P.M., indicated, "...crackles in rt (right) upper lobe, diminished left and right bases...." A chest xray, dated 9/27/11, indicated the following: "...appears to be an area of early infiltrate in the right lung base...." A physician order [REDACTED]." The chest xray, dated 10/1/11, indicated the following: "...compared to previous examination there is some resolution of the previously described infiltrate in the right lung base. Small amount of residual infiltrate persists...." On 10/11/11 at 9:15 A.M., the Administrator provided a copy of the "Fax/Incident Report." This form was faxed to the ISDH (Indiana State Department of Health) on 9/25/11 initially, and a final report was faxed on 9/30/11 before 8 A.M. and included, but was not limited to, the following information: At 8 A.M. on 9/24/11, it was reported to the RN (registered Nurse) by a CNA the resident was noted to have vomited. HOB (head of bed) was at 30 degrees. On 9/29/11- Investigation results: "Validation of enteral feeding rate at 300 cc per hour per feeding pump as reported. It was determined through the interview process, the LPN administering the enteral feeding at 0500 (5 A.M.) had primed the tubing at 300 cc/hr. Upon connecting the tubing to the resident's gastrostomy tube, the LPN unintentionally left the pump set at 300 cc/hr. Resident received enteral feeding at a rate of 300 cc/hr for approximately 3 hours; Type of injury: vomiting; 9/29/11: CXR taken on 9/24/11 = no active disease; 9/27/11 CXR results = early infiltrate in right lung base. Upon review of resident's history of chest x ray results, the resident exhibits intermittent infiltrates. Immediate action taken: Enteral feeding immediately turned off, MD contacted, orders received to hold feeding x 10 hours, stat chest x ray. Respiratory and gastrointestional (GI) assessment completed...resident placed at 45 - 90 degree angle, side to side turning every 2 hours and increased monitoring implemented of respiratory assessment q 2 hours. Family notified of occurrence, MD orders, resident assessment, and current clinical status. 9/29/11: MD on site visit, on 9/28/11 new orders received for antibiotic therapy related to 9/27 chest x ray results. Family aware of resident's clinical history and current clinical status related to event. Family (daughter), voices understanding and is in agreement with current investigative procedure and results. LPN in question is no longer employed with (this facility). Preventative measures taken: Re-education of licensed personnel regarding enteral feeding, policy and procedure with competency testing to include return demonstration completed. The following preventative monitoring systems were implemented immediately: Respiratory assessment to be completed every 2 hours; verification via 2 nurses for accuracy of enteral feeding rate per continuous feeding pump; resident observation rounds for those residents receiving continuous feed per 2 nurses upon shift change to ensure policy and procedure compliance, and accuracy of MD orders. 9/29/11: Every 2 hour respiratory assessments were continued during the 5 day investigation period. Respiratory assessments to resume every 8 hours routinely. Continue 2nd nurse verification for accuracy of enteral feeding rate per continuous feeding pump, and shift change observation rounds. Enteral Feeding clinical competency validation is now included with the new hire nurse orientation." On 10/11/11 at 3:20 P.M., a copy of the resident's total fluid intake for September 2011 was received. From 9/9/11 to 10/10/11, the resident's total fluid intake ranged from 580 cc to 3290 cc. On 10/11/11 at 3:20 P.M. a copy of the policy and procedure for "enteral tubes" was received from the DON. The procedure was dated July 2010. The policy and procedure included, but was not limited to, the following: "For continuous tube feeding, fill bag with 4 hours of tube feeding, flush tubing, attach to volume control infuser...." The DON was interviewed at this time. She indicated the way to prime the tubing would not be to set the infusion at 300 cc/hr. The DON indicated the policy and procedure didn't specifically say how to infuse the tubing, but at 300 cc/hr was not it, and the LPN #1 shouldn't have left the rate at 300 cc/hr. On 10/12/11 at 10 A.M., the DON (Director of Nursing) was interviewed. She indicated LPN #1 is the LPN who left the tube feeding running at a rate of 300 cc/hr for 3 hours. The DON indicated LPN #1 stated she hung the new bottle of tube feeding at 5 A.M. The DON indicated a total of 900 cc of tube feeding infused in a 3 hour period via the gastrostomy into the resident. The DON provided a copy of the resident's September 2011 MAR. This form included, but was not limited to, the following: "Glucerna 1.2 at 60 cc/hr." This Glucerna was initialed as given on the 11-7 shift for 9/9/11 to 9/30/11. LPN #1 had documented for the 11 - 7 shift on 9/24/11. A physician order, dated 9/8/11, indicated the following: "Glucerna 1.2 at 60 ml/hr off at 0800 (8 A.M.) - 1000 (10 A.M.) and 1800 (6 P.M.) - 2000 (8 P.M.)." At this time, the DON indicated LPN #1 was no longer employed by the facility. She indicated the reason LPN #1's name appeared on the current employee roster was because "paperwork had not been completed" to remove her from the roster. The DON indicated the last day LPN #1 worked was 9/24/11. At this time, the DON indicated on the final report to ISDH, where it stated "Every 2 hour respiratory assessments were continued during the 5 day investigation period", that she only intended for the 2 hour assessments to be continued for 24 hours and not the 5 day investigative period. On 10/12/11 at 11:30 A.M., the DON was interviewed regarding the range of fluid intakes for the gastrostomy tube. The DON indicated for a 24 hour period, the resident's total intake should be 1200 cc of Glucerna plus 1500 cc of water given with medications and flushes for a 24 hour total of 2700 cc. She indicated she was unable to explain the discrepancy of the daily 24 hour fluid total intakes. This federal tag relates to complaint IN 498. 3.1-44(a)(2)