Every finding on record at Danville Regional Rehabilitation

Based on interview and record review, the facility failed to ensure a resident, (Resident 94) had the right to formulate an advanced directive for 1 of 2 residents reviewed for advance directives. Findings include: On 06/19/25 at 11:44 a.m., Resident 94's medical record was reviewed. He was a long-term care resident with diagnoses which included, but was not limited to, peripheral vascular disease (PVD), a below the knee amputation of his left leg, surgical wound failure with necrosis, and dementia with unspecified severity. At the time of his admission, on 1/14/25, there was no Power of Attorney (POA) and/or guardianship documentation. Resident 94's face-sheet contact information was reviewed and revealed he was his own responsible party and received his Accounts/Receivable (AR) statements. Resident 94's family member was listed as an emergency contact. A social service progress note, dated 4/7/25 at 2:14 p.m., indicated a notary was scheduled to come to the facility to assist Resident 94 to establish a healthcare POA and the family is planning to change code status . son will be at the facility later today to make/discuss plans A social service progress note, dated 4/7/25 at 6:23 .m., indicated Resident 94's son came in to discuss POST form . Writer reviewed options with son. Son stated his wishes were for Resident to become DNR [do not resuscitate] with comfort measures in place. Post form signed Resident 94 had a significant change Minimum Data Set (MDS) assessment, dated 3/24/25, after his BKA. At the time of his assessment he was interviewed, and scored an 11 of 15 on the Brief Interview for Mental Status (BIMS) which indicated he was only moderately cognitively impaired. On 6/20/25 at 2:05 p.m., the Administrator (ADM) provided a copy of Resident 94's POA paperwork. The document was titled, Medical Power of Attorney, and was signed/sealed by a Notary Public on 4/7/25. The document indicated, .Even after you sign this document, you will be able to make your healthcare decision assuming you are still considered mentally competent. Your agent cannot act on your behalf until your physician has determined that you are no longer physically or mentally able to make medical decisions unless otherwise stated in this document . Duration: unless stated otherwise [NAME], this document shall remain in effect until I revoke it. I understand that I cannot revoke this document if I am considered incompetent to make my own decision . When My Agent's Authority Becomes Effective: . The only option for initial of acknowledgement of when the agent's authority was to become effective stated: Immediately to make health care decision on my behalf. The election for this option was left blank and was not initialed by the Resident. The document was signed by both the Resident and his son. Resident 94's POST form was prepared on 4/7/25 and signed by the Resident's son. The record lacked documentation that the physician had determined Resident 94 was incompetent. A Social Service progress note, dated 4/18/25 at 2:25 p.m., indicated that Resident 94's son made the decision to implement comfort measures, but did not specify if the resident assisted in making this decision as well. Resident 94 passed away on 5/14/25. During a confidential interview, it was indicated that Resident 94 was alert and oriented with minimal confusion. His confusion was usually worse in the afternoons or evenings when he was more tired. He remembered most of his daily staff members and engaged in meaningful conversation with staff and residents. He was compliant with care and kept talking about how he wanted to get better. He was alert and aware enough to make his own decision and should have had more say in the end. As soon as they stopped trying to fix his wounds, all decisions went through the son. During a confidential interview, it was indicated Resident 94 was very sweet, alert and oriented. He would have regular and appropriate conversations and understood that his condition was not good but wasn't sure what else they could do about it. The son made the decision not to do more surgery because they didn't want him to go under again. During an interview on 6/23/25 at 9:52 a.m., the Social Service Director (SSD) indicated Resident 94 was moderately cognitively impaired, but was alert and oriented. Most of his confusion was noted later in the evenings but during the morning and into the afternoon, his baseline was alert and oriented to his person, place and time. The SSD indicated, I feel like he did understand that [the severity of his medical condition and imminent demise] because he said things like, 'I've lived a good life.' There had been multiple conversations at bedside about changing his code status but he really didn't want to change his code status. Resident 94 was very hard of hearing, so his son would often have to explain back what was being said. Options for different DNR codes status was explained to the son, who indicated he didn't have a good understanding before that there were as many options for comfort/palliative DNR options, and after those options were explained, the son agreed to change Resident 94's code status. On 6/20/25 at 2:05 p.m., the ADM provided a copy of current, but undated facility policy titled, Your Rights and Protections as a Nursing Home Resident. The policy indicated, .at minimum, Federal law specified that nursing home must protect and promote the following rights of each resident: You have the right to: . to create advance directives (a health care proxy or power of attorney, a living will, after-death wishes) in accordance with State Law On 6/20/25 at 2:05 p.m., the ADM provided a copy of current facility policy titled, Advance Directive (POST, DNR, Health Care Rep), revised 7/2023. The policy indicated, .if the resident has capacity to make decision, the resident makes decision regarding their medical decision, advance directives, and healthcare appointments. Resident representatives, health care representatives and/or Power of Attorney should only make decisions when a resident no longer has capacity to make decisions on their behalf. The attending physician determines capacity of the resident to made decision; this assessment should be documented in the medical record 3.1-4(f)(7)

Based on observations, record reviews, and interviews, the facility failed to accurately code the Minimum Data Set (MDS) for a suprapubic catheter (a hollow tube inserted through the abdomen into the bladder to drain urine, typically used when a urethral catheter is not feasible or desirable) and an coded an anticoagulant medication when the resident did not received an anticoagulant medication for 2 of 7 resident reviewed (Residents 39 and 13). Findings include: 1. On 6/19/25 at 9:54 a.m., a record review was completed for Resident 39. She had the following diagnoses which included but were not limited to dementia, hypertension, anxiety, and high cholesterol. Her MDS was not coded as her having a suprapubic catheter. She had an order, dated 5/5/25, for suprapubic catheter, size 18 French (FR), 30 milliliter (ML) bulb. She had an order, dated 5/5/25, to change suprapubic catheter and urinary collection bag as needed for dislodgement, leakage, or occlusion. She had a care plan, dated 5/7/25, that she required assistance with toileting due to assistance with transfers, hygiene, adjusting, catheter care. She had a care plan, dated 5/7/25, indicating she was at risk for falls related to catheter tubing. 2. On 6/19/25 at 11:38 a.m., a record review was completed for Resident 13. She had the following diagnoses which included but were not limited to multiple sclerosis (MS) (a chronic, often disabling disease that attacks the central nervous system, specifically the brain and spinal cord), depression, weakness, and major depressive disorder. Her MDS was coded that she took an anticoagulant medication. She was not prescribed an anticoagulant medication. On 6/19/25 at 1:46 p.m., the Executive Director (ED) provided a corrected copy of Resident 39's MDS. On 6/19/25 at 2:05 p.m., the ED provided a corrected copy of Resident 13's MDS and indicated the MDS coordinator inadvertently coded the wrong type of medication. A document from the RAI (Resident Assessment Instrument) manual, chapter 3 provided by the ED on 6/18/25 at 1:37 p.m. It indicated, .To facilitate accurate resident assessment using the MDS, each section is accompanied by screenshots, which display the item from the MDS 3.0 item set

Based on observations, interviews, and record review, the facility failed to prevent the potential for accidents with ongoing safety monitoring and assessments for a resident (Resident 62) who required the use of a seat belt in his wheelchair for 1 of 1 resident reviewed for the use of a seat belt. Findings include: On 6/19/25 at 11:41 a.m., Resident 62 was observed seated in his wheelchair (wc). A seat belt was observed across his lap but hung slack to the middle of his thighs. The left side of the belt was frayed nearly in half, as it appeared to rub against a sharp edge of the wc frame. On 6/20/25 Resident 62 was observed multiple times seated in his wc outside of the Activity Director's office door as he visited with staff and other residents. A seat belt was observed across his lap but hung slack and reached almost to the top of his knees. The left side of the belt was observed to rub against a sharp edge of his chair and remained frayed, nearly in half. On 6/23/25 at 9:41 a.m., Resident 62 was observed with the Social Service Director, (SSD). Resident 62 was asked to unbuckle his seat belt, which he demonstrated with ease, however he could not re-buckle it on his own. The SSD observed the frayed edge of the belt, and indicated it must have rubbed on the frame and was no longer in good repair. At that time, a Maintenance Staff member passed by and observed the belt. He indicated it needed to be replaced. On 6/20/25 at 1:26 p.m., Resident 62's medical record was reviewed. He was a long term-care resident with diagnoses which included, but were not limited to, cerebral palsy, shaken infant syndrome and intellectual disabilities. There was an initial Adaptive Device Review, dated 7/25/24, which indicated, Seatbelt on wheelchair. Seatbelt to wheelchair due to resident rocking per mom's request. Therapy evaluated and resident is able to remove seatbelt by self. The initial assessment did not specify the type of belt and/or parameters for ongoing assessment of placement, appropriateness and/or function/condition. He had a physician's order, dated 2/10/25, which indicated he could have a wheelchair with seatbelt. The order did not specify the type of belt and/or parameters for ongoing assessment of placement, appropriateness and/or function/condition. A comprehensive care plan, dated 5/15/25, indicated Resident 62 required assistance with activities of daily living (ADLS). An intervention was added on 5/15/24 which indicated he could be up in his wheelchair with a seatbelt. The care plan lacked implementation and/or revision to specify the type of belt and/or parameters for ongoing assessment of placement, appropriateness and/or function/condition. On 6/20/25 at 2:05 p.m., the Administrator (ADM) provided a copy of current facility policy titled, Adaptive Device Review Policy, revised 2/2020. The policy indicated, .It is the responsibility of the facility IDT team to review adaptive devices initially and on a quarterly basis to ensure the continued need and/or identify a new intervention . adaptive devised that do not meet the definition of a restraint must be reviewed on a quarterly basis by the IDT team to determine continued need . the use of the adaptive devise needs to be addressed in the resident's plan of care and appear on the resident profile 3.1-45(a)

Based on observations and interviews, the facility failed to store topical creams from medications, keep the medication cart clean, failed to remove expired insulin from use, and failed to date insulin and eye drops for 2 of 4 medications carts observed. Findings include: 1. On [DATE] at 12:04 p.m., the Cottage medication cart was observed. In the cart it was noted that wound gel was being stored next to eye drops and throat lozenges. Resident 197 had an insulin pen, Humalog, in the cart with no date to indicate when it was opened. There were approximately 50 various pills loose in the second drawer of the medication cart. 2. On [DATE] at 12:22 p.m., the Meadows medication cart was observed. In the cart nitroglycerin tablets was being stored with eye drops. Resident 12 had an insulin pen, Lispro in the cart. It was dated for [DATE]. The observations were confirmed by LPN 6 and LPN 8. A policy titled, Storage and Expiration Dating of Medications and Biologicals was provided by the Executive Director (ED) on [DATE] at 1:41 p.m. It indicated, .Topical (external) use medications or other medications should be stored separately from oral medication when infection control issues may be a consideration .The facility should ensure medications and biologicals that 1.) have an expiration date on the label 2.) have been retained longer than recommendations by manufacturer or supplier guidelines, or 3.) have been contaminated or deteriorated are stored separate from other medications until destroyed or returned to the pharmacy or supplier 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, interview, and record review, the facility failed to ensure a urinary catheter bag and catheter tubing did not touch the floor resulting in a urinary tract infection (UTI) for 1 of 2 residents observed for catheter acquired urinary tract infection (cauti) (Resident 81), and failed to ensure residents had diagnoses to support the insertion of urinary Foley catheters for 2 of 2 residents reviewed for urinary catheters (Resident 81 and 155). Findings include: 1. On 4/30/24 at 12:15 p.m., Resident 81's urinary Foley bag and catheter tubing were observed on the floor. On 5/1/24 at 12:15 p.m., Resident 81's records were reviewed. A care plan, dated 4/17/24, indicated Resident 81 required an indwelling urinary catheter related to urinary retention. The goal indicated she would have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection. A nursing approach was to not allow tubing or any part of the drainage system to touch the floor. An Infection Control Surveillance document, dated 4/29/24, indicated Resident 81 had a urinary catheter related infection and was on antibiotic therapy until 5/8/24. Her symptoms onset was 4/29/24 with acute change in mental status and suprapubic pain or costovertebral angle pain or tenderness. She was placed on enhanced barrier precautions. On 5/2/24 at 10:52 a.m., her record indicated she was scheduled to be given Macrobid (antibiotic) 100 mg every 12 hours for 7 days for a UTI from 5/1/24 to 5/8/24. A progress note, dated 4/17/24 at 5:07 p.m., indicated Resident 81 complained of back pain often. Her PVR (post-void residual) was obtained and she was retaining approximately 226 milliliters (mL) of urine. The Nurse Practitioner (NP) was notified and a new order to anchor a foley was received. Resident 81 tolerated it well. During an interview, on 4/30/24 at 10:24 a.m., the Moving Forward Unit Manager (MFUM) 5 indicated Resident 81 had a foley catheter due to urinary retention. Resident 81's record lacked documentation of a diagnosis of urinary retention. 2. During an interview, on 4/30/24 at 12:30 p.m., Resident 155's wife indicated he got a new Foley catheter that morning because his abdomen was distended. She indicated the nurse had to clamp it because there was so much urine. The nurse had to empty the catheter bag three times. On 5/1/24 at 10:51 a.m., Resident 155 record was reviewed. He was admitted on [DATE]. He had an admission diagnosis of retention of urine. A progress note, on 4/30/24 at 1:09 p.m., indicated a PVR was completed as ordered. Resident 155 was retaining approximately 800 mL of urine in his bladder. The NP was notified and a new order to I/O (in and out) catheter every 8 hours as needed (PRN) for abdominal distention and pain due to high PVR. The I/O drained 1400 mL in increments due to his hypotension. The NP was notified of the amount of urine drained and a new order to place a Foley catheter was received. A physician's order, dated 4/30/24, indicated to anchor a Foley catheter. A care plan, dated 5/1/24, indicated Resident 155 required an indwelling urinary catheter related to urinary retention. A care plan, dated 4/26/24, indicated Resident 155 was at risk for pain related to PVD. Resident 155's record lacked documentation of a diagnosis of urinary retention. A policy, titled, Bowel and Bladder Program, dated 5/2019, was provided by the Regional Nurse Consultant, on 5/3/24 at 12:11 p.m. A review of the policy indicated, .Indwelling Urinary Catheters - Suprapubic or Urethral .Assessment will include reason for indwelling Urinary Catheter 3.1-41(a)(1) 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure 1 of 4 treatment carts remained locked and medication remained inaccessible to residents and visitors (Residents 345, 11, 79, and 63). Findings include: One 4/30/24 at 9:48 a.m., the Rosewood treatment cart was observed unlocked. Several staff were observed to pass the treatment cart. Prescription medication found inside the treatment cart included: a. Resident 345 had SSD cream 1%. b. Resident 11 had thera-gel 0.5% shampoo. c. Resident 79 had diclofenac sodium 1% gel, one container in drawer one and one container in drawer two. d. Resident 63 had diclofenac sodium 1% gel. During an interview, on 4/30/24 at 10:03 a.m., Licensed Practical Nurse (LPN) 5 indicated the treatment cart should not be unlocked. She was observed locking it. During an interview, on 5/1/24 at 10:21 a.m., the Moving Forward Unit Manager (MFUM) 5 indicated all treatment carts should have been locked because it was a violation of resident's privacy because a resident or visitor could have been curious and looked at or taken medications from the treatment cart. On 5/1/24 at 2:58 p.m., the Director of Nursing (DON) indicated Resident 76 and Resident 108 were residents who wandered the building with severe cognitive abilities. A policy, titled, Storage and Expiration Dating of Medications, Biologicals, dated 7/21/22, was provided by the Regional Nurse Consultant, on 5/3/24 at 12:15 p.m. A review of the policy indicated, .Facility should ensure that only authorized Facility staff, as defined by Facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas 3.1-25(m)

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS) for 4 of 6 residents reviewed for MDS accuracy (Residents 34, 40, 69 and 102). Findings include: 1. A comprehensive record review was completed on 2/23/23 at 12:35 p.m. for Resident 34. He admitted to the facility on [DATE]. His diagnoses included but were not limited to, after care of joint replacement surgery, unspecified atrial fibrillation, encephalopathy, acute pyelonephritis, urinary retention, GERD (gastro-esophageal reflux disease), undifferentiated schizophrenia, and restlessness with agitation. Resident 34 had a notice of Pre-Admission Screening and Resident Review (PASSR) level II outcome in his medical record. The notification was dated 12/2/22 and indicated he had a diagnosis of schizophrenia. Resident 34's comprehensive MDS, dated [DATE], indicated that he did not require a level II assessment. 2. A comprehensive record review was completed on 2/22/23 at 10:40 a.m. for Resident 40. She admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, aftercare following joint replacement surgery, COPD (chronic obstructive pulmonary disease), panic disorder, emphysema, major depressive disorder, hyperlipidemia, other anxiety disorders, repeated falls, and muscle weakness. Resident 40 had a notice of PASRR level II outcome in her medical record. The notification was dated 5/13/21 and indicated she had a diagnosis of major depression, anxiety disorder and panic disorder. Resident 40's comprehensive MDS, dated [DATE], indicated she did not require a level II assessment. 3. A comprehensive record review was completed on 2/22/23 at 10:18 a.m. for Resident 69. He admitted to the facility on [DATE]. He had the following diagnoses, but not limited to COPD (chronic obstructive pulmonary disease), generalized anxiety disorder, agoraphobia with panic disorder, GERD (gastro-esophageal reflux disease), hyperlipidemia, sleep apnea, osteoarthritis of the hip, tobacco use, and acute hepatitis C. Resident 69 had a care plan, dated 8/20/19, indicating he was determined to be mentally ill per the PASRR level 2 assessment. Level 2 diagnosis were major depression and PTSD (post-traumatic stress disorder). Resident 40's MDS assessment, dated 7/3/22, diagnosis section of the MDS lacked documentation of PTSD on the assessment. On 2/28/23 at 10:39 a.m., the MDS Coordinator indicated she corrected Residents 34, 40, and 69's MDS assessments to reflect the accuracy of PASRR outcomes and diagnoses. 37982 4. On 2/27/23 at 03:59 p.m., the closed medical record was reviewed for Resident 102. A nurses' progress note, dated 12/12/22 at 11:33 a.m., indicated Resident 102 had discharged from the facility by private car with her family to home. Resident 102 discharged from the facility fully clothed with shoes on. The resident's family member reviewed and signed the discharge paperwork and copies were sent with the resident. The resident inventory sheet was signed, and all belongings accounted for. Resident 102 was sent home with a 3 day supply of medication. A review of the discharge Minimum Data Set (MDS) assessment, dated 12/12/22, indicated Resident 102 had been discharged to an acute hospital. On 2/28/23 at 9:50 a.m., during an interview, the MDS coordinator indicated Resident 102 had come to the facility from an acute hospital, she had discharged home. The discharge MDS assessment had been coded wrong. The facility followed the Resident Assessment Instrument (RAI) Manuel for coding of the MDS. On 2/28/23 at 1:14 p.m., the Administrator provided a current policy titled, RESIDENT ASSESSMENT (RAI), dated 10/2019. This policy indicated, It is the policy of (Name of Corporation) to ensure MDS assessments accepted into the QIES ASAP [automated system for payment] system accurately reflects the resident's identification, location, overall clinical status, and payment status. If inaccuracies are identified processes will be followed to ensure the information is corrected 3.1-31(i)

Based on observation, interview, and record review, the facility failed to prevent the potential for accidents by maintaining safe hot water temperatures in the secured memory care unit. This deficient practice had the potential to effect 26 of 26 residents who resided on the memory care unit (Residents 24, 53, 54, 88, and 59). Findings include: On 2/22/23 at 9:45 a.m., Resident 24 was observed. She was seated in a recliner chair in the memory care TV lounge area. Her eyes were closed, her head was bowed, and she appeared to be asleep. During an interview on 2/22/23 at 9:50 a.m., Certified Nursing Assistant (CNA) 20 indicated Resident 24 was not a resident on the secured memory care unit, but that since her admission, a couple days prior, she had trial days on the unit due to her confusion and behaviors. Particularly, the night before, she had been found in her bathroom. She had left the bathroom sink running until it overflowed and wandered around the unit. Staff brought her to memory care early that morning and she seemed to have settled down. When asked if there were other residents on the memory care unit who would run the water and forget that it was on, CNA 20 indicated Resident 24 was notorious for it. Resident 24 would often clog up her toilet or sink with paper towels, turn on the water and forget it was running until the sink overflowed. On 2/22/23 at 10:00 a.m., Resident 24's bathroom hot water temperature was checked. After the water ran for approximately 2 minutes, steam was visible and rose to fog the mirror. An initial temperature check registered the water temperature at 125 degrees Fahrenheit (F). Two additional rooms were sampled for hot water temperatures at opposite ends of the memory care unit: Residents 53 and 54's room had the initial water temperature register at 126 degrees F. Residents 88 and 59's room had the initial water temperature register at 131 degrees F. On 2/22/23 at 10:45 a.m., the Administrator (ADM) was made aware of the hot water temperatures. The ADM indicated the Maintenance Director (MD) had been off work since the previous Thursday for medical reasons and was not anticipated to return until recovered. In the meantime, the ADM, Housekeeping Supervisor (HKS) and a Regional Maintenance Support Technician (RMST) were responsible for maintaining daily and as needed responsibilities. On 2/22/23 at 10:50 a.m., the ADM and HKS were accompanied to the memory care unit to re-check the water temperatures. The HKS indicated she had worked in the facility for 8 years and was familiar with the residents. Upon entering Resident 24's room, the HKS indicated, she had often had to clean up after Resident 24 when she clogged the toilet or sink with paper towels and had collaborated with the nursing staff to come up with the idea of placing a doorbell alarm to the top of the bathroom door, which sounded upon entrance to alert staff that Resident 24 may need assistance in the bathroom. On 2/22/23 at 10:55 a.m., the HKS re-checked the water temperatures in room noted above. She indicated the temperatures should be between 116-120, not to exceed 120 degrees F. Resident 24's room, the temperature registered 134 degrees F. Residents 53 and 54's room, the temperature registered 131 degrees F. Residents 88 and 59's room, the temperature registered 136 degrees F. On 2/22/23 at 11:00 a.m., the ADM indicated all water use on the memory care unit would be suspended until the temperatures could be stabilized, however, all resident showers were already taking place off the unit, as the memory care unit shower room was under construction at that time. The ADM indicated she suspected the problem was the new hot water tank which had been installed back in December after several plumbing issues. She indicated she would also call the service who installed the hot water tank and have a technician out by the end of the day. On 2/22/23 at 2:15 p.m., a third check of the hot water temperatures was conducted with the HKS for the memory care unit. In the rooms noted above, the water temperatures did not exceed 100 degrees F. The HKS indicated, it was better to run a little colder than too hot, but she and the equipment technician were still working on adjustments. On 2/23/23 at 12:45 p.m., an equipment service technician from a local plumbing service and repair company indicated he had been out all morning working with the HKS to adjust the hot water tank. He indicated there were three components to the adjustments which involved precise calibration of the hot water valve, cold water valve and the mixing valve. He indicated the water was not running over 120 degrees F any longer, but they were making final adjustments to maintain temperatures between 116-120 degrees F. On 2/22/23 at 11:30 a.m., the ADM provided copies of the MD hot water temperature monitoring logs. She indicated, and the logbook documentation gave instructions; Hot water temperatures were randomly checked on each unit at least once a week. The logs for the previous 4 weeks in the memory care unit were all within safe operating temperatures. The logbook documentation instructions indicated, Ensure patient room water temperatures are between 105 [degrees] and 115 [degrees] F (or specified by state requirements) . Indiana - 100-120 degrees F. On 2/22/23 at 3:00 p.m., the ADM indicated all resident on the memory care unit were at risk due to the hot water temperatures given their mental capacities. At that time, she provided a copy of current facility policy titled, Resident Rights, dated 3/2017. The policy indicated, .Safe Environment: You have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure urinary catheter bags were kept off the floor for 2 of 4 residents reviewed for urinary catheters (Resident 18 and 41). Findings include: 1. During an observation on 2/22/23 at 10:02 a.m., Resident 18 was lying in her bed. She indicated she had a supra-pubic catheter to drain her bladder. The catheter collection bag was lying on the floor. On 2/22/23 at 3:15 p.m., a comprehensive record review was completed for Resident 18. She had the following diagnoses, but not limited to COPD (chronic obstructive pulmonary disease), sacral spina bifida with hydrocephalus (occurs when the bones in the spine do not properly form and hydrocephalus is extra fluid in and around the brain), paraplegia, major depressive disorder, neuromuscular dysfunction of the bladder, anxiety, constipation, and tobacco use. Resident 18's care plan dated 10/29/20, indicated she required a supra-pubic urinary catheter related to neuromuscular dysfunction of the bladder and she is at risk for infection. The goal dated, 3/5/23, indicated her catheter care would be managed appropriately as evidence by not exhibiting signs of urinary tract infection or urethral trauma. An intervention dated 10/29/20 indicated not to allow the tubing or any part of the drainage system (bag) to touch the floor. 2. During an observation on 2/24/23 at 9:42 a.m. Resident 41 was wheeling himself down the hall. His catheter bag was dragging on the floor. During an observation 2/24/23 at 10:08 a.m., Resident 41 was sitting next to the nurse's cart and LPN 10 as she passed her medication. Resident 41's catheter bag was halfway full and was lying on the ground under his wheelchair. At this time, LPN was interviewed about Resident 41's catheter bag lying on the ground. She did not respond and addressed Resident 41 indicating she needed to reposition his catheter bag. On 2/27/23 at 10: 55 a.m., a comprehensive medical record review was completed for Resident 41. He had the following diagnoses but not limited to unspecified spina bifida with hydrocephalus, infection and inflammatory reaction due to indwelling catheter, essential hypertension, low potassium, pain and muscle weakness. Resident 41's care plan included a problem with a date of 3/30/21 indicating he required an indwelling catheter related to obstructive and reflux uropathy (disease of the urinary system), and that he is at risk for infection. The care plan addressed Resident 41 will hang his catheter bag on his wheelchair above his bladder. The goal dated 5/21/23 indicated he will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection or urethral trauma. An intervention dated 3/30/21 indicated not to allow the catheter tubing or any part of the drainage system (bag) to touch the floor. The ED (Executive Director) provided a policy titled, Indwelling Urinary Catheters-Suprapubic or Urethral, with no date. The policy did not address the positioning or placement of catheter bags. 3.1-41(a)(1)

Based on observations, interview, and record review, the facility failed to ensure infection control procedures were followed by staff in the main dining room while assisting residents with eating for 5 of 5 randomly observed residents during a dining services observation, (Residents 9, 159, 163, 305, and one unidentified resident). Findings include: On 2/21/23 at 12:25 p.m., Licensed Practical Nurse (LPN) and Unit Manager (UM) 4 were observed in the Moving Forward dining room. LPN 4 moved Resident 159's walker with her bare hands and did not wash or gel her hands before she moved Resident 163's walker. Resident 163 was prepared to leave the dining room. LPN 4 walked with Resident 163 to her room. On 2/21/23 at 12:31 p.m., UM 4 indicated, LPN 4 should have performed hand hygiene before she touched Resident 163's walker. On 2/21/23 at 12:36 p.m., Certified Nursing Aide (CNA) 5 was observed as she touched Resident 305's arm. She did not perform hand hygiene before she returned to assist an unidentified resident with her meal. On 2/21/23 at 12:37 p.m., CNA 6 was observed as she touched the arm of her chair with her left hand, then continued to assist Resident 9 with her meal. She pulled Resident 9's hand away from the resident's face with her potentially contaminated left hand. CNA 6 touched both arms of her chair with both bare hands and continued to assist Resident 9 with eating. On 2/21/23 at 12:42 p.m., CNA 6 was observed as she touched the arm of her chair with her left hand and pulled her chair closer to the table, then continued to assist Resident 9 with her meal. On 2/23/23 at 12:45 p.m., CNA 5 was observed as she touched and fixed her hair. She failed to perform hand hygiene before she removed Resident 305 clothing protector, unlocked her wheelchair and took her to the nurse's station. On 2/21/23 at 12:48 p.m., CNA 6 was observed as she stood up, moved an empty chair with her bare hand, did not perform hand hygiene and continued to assist Resident 9 with their meal. During an interview, on 2/24/23 at 11:11 a.m., the Infection Preventionist, (IP) indicated staff have been instructed to hand gel and hand washing between touching residents. During an interview, on 2/24/23 at 11:12 a.m., Regional Clinical Consultant (RCC) indicated basic hand hygiene is needed after touching a resident, their chair, or environment. A current policy, titled, Hand Hygiene Policy, dated 12/2021, was provided by the Administrator on 2/24/23 at 11:15 a.m. A review of the policy indicated, .Indications for Hand-rubbing but not limited to: Before having director contact with a resident and/or equipment .After each resident contact and after contact with a resident's belongings, environmental surfaces, touching items on the floor, and resident care equipment 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure a new resident had a baseline care plan initiated to identify problems related to pain and insomnia (Resident 204) for 1 of 22 residents reviewed for care planning. Findings include: On 2/27/23 at 2:55 p.m., Resident 204's medical record was reviewed. The resident's admitted was 2/24/23. The diagnoses included, but were not limited to, rhabdomyolysis (a breakdown of muscle tissue that releases damaging protein into the blood), laceration of the head, chronic heart failure, neuropathy (nerve pain), pain in left hip, sacroiliitis (a painful condition that effects one or both sacroiliac [joints at base of the spine] joints that results in lower back pain), primary insomnia, and a wedge compression fracture of the fourth lumbar (back) vertebra (bone of spine). Resident 204's care plans did not include a care plan for pain management or insomnia. Resident 204's Admission pain, observation report, was dated 2/24/23 and showed In Progress. None of the questions had been answered on the Pain Interview. On 2/27/23 at 3:45 p.m., Resident 204's care plans and admission pain assessment were requested. On 2/28/23 at 9:00 a.m., the Administrator provided copies of all of Resident 204's care plans and Admission Pain Assessment Interview. The pain assessment had been completed by the Minimum Data Set (MDS) Coordinator on 2/27/23 at 4:02 p.m. Resident 204's care plans, dated 2/27/23, created by the MDS Coordinator, included, but was not limited to, Resident is at risk for pain related to: Rhabdomyolysis, laceration to the head, neuropathy, sacroiliitis, wedge compression fracture of the fourth lumbar vertebra. The goal, with a target date of 5/27/23, indicated Resident will be free from adverse effects of pain. A second care plan, dated 2/27/23, created by the MDS Coordinator indicated, Resident is at risk for adverse side effects related to use of psychotropic medication, antidepressant, and hypnotic. The goal, with a target date of 5/27/23, indicated, Will have no adverse side effects. On 2/28/23 at 11:43 a.m., during an interview, in his room, Resident 204 indicated he did not get all his medication until yesterday. They did not have his ambian (for sleep), norco (for pain), or the lyrica (for nerve pain). They finally had given him generic medicine for his sleeping medication, and it helped last night. He had trouble sleeping, had been taking that for years. He fell 5 years ago and landed on his leg. The orthopedic surgeon had put a plate and rod in his leg. He has been on lyrica and norco for the past 5 years. He had pain the whole time he was at the facility since admission. When he asked about it they indicated it took several days to get all the medicine from pharmacy. They said it was the hospital's fault and there was a problem with not having all the prescriptions to get the medicines from pharmacy. They gave him pain medicine last night, for the first time, and it helped. He indicated I'm getting ready to ask for some more now. On 2/28/23 at 10:12 a.m., the Regional Clinical Consultant (RCC) provided a current policy, dated as revised 10/19, titled, IDT Comprehensive Care Plan Policy. This policy indicated, It is the policy of this facility that each resident will have a comprehensive person-centered care plan based on comprehensive assessment .Create an organized, resident-centered review on a routine basis to improve communication with residents 3.1-30(a)

Based on observation, interview, and record review, the facility failed to ensure a resident had a new and/or revised comprehensive care plan to address a new diagnosis for 1 of 22 residents reviewed for care planning (Resident 59), and failed to revise a resident's care plan to include fall interventions for 1 of 22 residents reviewed for care planning (Resident 95). Findings include: 1. On 2/23/23 at 1:30 p.m., Resident 59's medical record was comprehensively reviewed. She had been a long-term care resident and resided on the secured memory care unit since 10/29/2020. She had previously lived at two separate Assisted Living (AL) facilities before she was admitted to long-term care. She had active diagnoses which included but were not limited to, dementia and psychotic disorder with hallucinations due to known physiological condition, and on 6/4/2022 a new diagnosis of Herpes viral vulvovaginitis (HSV) was added. Her physician's orders were reviewed and revealed she took Valacyclovir, an antiviral medication, on a regular basis, every other day. A nursing progress note, dated 7/28/21 at 3:17 p.m., indicated Resident 59 returned from her private doctor with a new order for an antiviral medication to complete a course over 7 days and to follow up in November. A nursing progress note, dated 8/5/21 at 9:01 p.m., indicated Resident 59 had completed her antiviral course with no issues. After her follow up in November, a nursing progress note dated 11/4/21 at 8:26 p.m., indicated, Resident 59 remained on Valtrex (an antiviral medication) for HSV. Her comprehensive care plan lacked documentation of new and/or revised interventions related to her genital herpes diagnoses. Although she had comprehensive care plan which addressed her as being at risk for skin breakdown due to her cognition and incontinence, the care plan lacked revision to include a diagnoses of genital herpes or for increased monitoring due to outbreaks, rashes and//or flare ups. During an interview on 2/23/23 at 2:54 p.m., Resident 59 indicated, she had lived at the facility almost three years. She had resided on memory care for a long time, but she was excited that she would soon move to a new private room on the other side of the facility. She indicated since she started taking a daily medication, she had not had any more problems with her genital herpes. During an interview on 2/23/23 at 3:05 p.m., the Memory Care Support Specialist (MCSS) indicated Resident 59 was going to move off the memory care unit to a private room as she was no longer considered a risk for elopement and displayed no exit seeking behaviors. When Resident 59 first moved in he didn't even know she had genital herpes, but she kept getting a rash. They sent her to her doctor which was when she got the new diagnosis and she had been on medicine for it since with no concerns. 46414 2. On 2/22/23 at 2:15 p.m., Resident 95 was sitting in her wheelchair with her right arm in a sling. Her bed was not against the wall. On 2/24/23 at 3:15 p.m., Resident 95 was sitting up in her wheelchair with her right arm in a sling. Her bed was not against the wall. A comprehensive record review was completed on 2/24/23 at 11:26 a.m. for Resident 95. She admitted on [DATE] after sustaining a fractured right arm. Her diagnoses included, but were not limited to, other displaced fracture of upper end of right humerus, dementia, Alzheimer's disease with late onset, asthma, major depressive disorder, anemia, GERD (gastro-esophageal reflux disease), muscle weakness, unsteadiness on her feet, and pain of her right shoulder. Her orders included to have her bed against the wall, dated 1/18/23. Her care plan had a problem dated 1/19/23 for Resident 95. It indicated she was at risk for falls due to lack of understanding one's physical and cognitive limitations, history of falls, advanced age, incontinent, on two or more high risk medications, needs assistance with mobility and has an unsteady gait (walking). The goal, dated 5/1/23, indicated her fall risk factors would be reduced to avoid significant fall with injury. The care plan did not address an intervention to have the bed against the wall. On 2/28/23 at 10:12 a.m., the Regional Clinical Specialist provided a copy of current facility policy titled, IDT [interdisciplinary team] Comprehensive Care Plan Policy, revised 10/2019. The policy indicated, It is the policy of this facility that each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental and psychosocial needs .Care plan problems, goals and interventions will be updated based on changes in resident assessment/condition, resident preferences or family input 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to properly place and change a gauze/transparent dressing for a PICC line (peripherally inserted central catheter) for 1 of 1 resident reviewed for a vascular access device (Resident 154). Findings include: On 2/23/23 at 8:41 a.m., a PICC line was observed in Resident 154's left upper arm. It had gauze applied at the insertion site and was covered with a transparent dressing dated 2/9/23 and initialed, AB. On 2/23/23 at 1:00 p.m., Resident 154's PICC line to the left upper arm was observed a second time, and remained dated 2/9/23 and initialed, AB. On 2/24/23 at 3:53 p.m., Resident 154's record was reviewed. She admitted to the facility on [DATE] with active diagnoses, which included, but were limited to infection and inflammatory reaction due to indwelling urethral catheter, peripheral vascular disease (disease of the blood vessels), presence of vascular implants and grafts (artificial medical device in the body), diabetes mellitus (blood sugar disorder), and acute myocardial infarction (heart attack). A nursing progress note, dated, 2/8/23 at 9:18 a.m., indicated the nurse notified a family member and Resident of new PICC being placed. They informed the nurse she had an axillary-femoral bypass graft AFBG) (tubing from the axillary artery to the femoral artery to allow more blood flow) on her left side and showed the nurse the scar in her forearm. The provider was notified and ordered a peripheral line placed. Nurse charted, unable to start the peripheral vascular (PV) line. Provided indicated to contact the hospital to confirm the location of the AFBG and to start the antibiotic upon confirmation. A nursing progress note, dated, 2/9/23 at 1:01 p.m., indicated orders were obtained to remove the right upper extremity (RUE) PICC line and place it in the left upper extremity (LUE). Awaiting stat arterial doppler for RUE to verify integrity of AFBG. A nursing progress note, dated, 2/9/23 at 3:03 p.m., indicated, the pharmacy had come to remove the current PICC line (RUE) and place it in the LUE. A physician's order, dated 2/8/23, gave instructions for the nurse to initial every shift that the PICC line site was free of warmth, redness or swelling. A physician's order, dated 2/8/23, gave instructions to change transparent dressing, as needed, if integrity of the dressing was compromised (wet, loose, or soiled). The record lacked documentation of a physician's order to monitor/maintain the dressing until 2/17/23. A physician's order, dated, 2/17/23, gave instructions to change PICC line dressing every 7 days with transparent dressing. The nurse was to measure (in centimeters) the PICC catheter length (from insertion site to catheter hub) and the nurse was to measure the upper arm circumference (10 cm above antecubital fossa) (inside the elbow), once a day, every 7 days. A physician's order, dated 2/8/23, gave instructions to give piperacillin-tazobactam (an antibiotic medication) 3.375 gram reconstituted solution, every 8 hours by IV, due to infection and inflammatory reaction due to indwelling urethral catheter with an end date of 2/17/23. A nursing progress note, dated, 2/10/23 at 3:10 a.m., indicated Resident 154 had a vascular access device, PICC line, in her LUE. A nursing progress note, dated, 2/12/23 at 1:48 a.m., Resident 154 continued on antibiotic therapy for UTI (urinary tract infection) and wounds. A nursing progress note, dated, 2/14/23 at 9:48 a.m., Resident 154 continued on antibiotic therapy for UTI. A nursing progress note, dated, 2/25/23 at 12:28 a.m., Resident 154 continued on IV antibiotics, PICC line flushed well. A physician's order, dated 2/24/23 at 3:18 p.m., gave instructions to give meropenem 1 gram reconstituted solution, every 8 hours by IV. Resident 154's Treatment Administration Record (TAR) for the month of February was reviewed and revealed: a. On 2/17/23 at 5:11 a.m., Licensed Practical Nurse (LPN) 25 charted on 2/16/23, the order was not completed. b. On 2/17/23 at 1:29 p.m., LPN 26 charted the order was not completed. The piperacillin-tazobactam antibiotic was ordered on 2/8/23 but was not started until 2/9/23 at 10:00 p.m., LPN 27 charted it was due to the PICC line needing to be place in the LUE. The PICC line was inserted in the LUE on 2/9/23. The TAR indicated the PICC line dressing was not changed until 2/24/23 by LPN 27. On 2/27/23 at 11:56 a.m., Resident 154's care plan, dated 2/9/23, indicated she had IV access and was at risk for infection/complications due to her PICC line. The goal was to keep her free from complications associated with IV access. An approach to the issue was to change the dressing as ordered. During an interview, on 2/24/23 at 11:04 a.m., with the Administrator, Director of Nursing Services (DNS), and the Regional Clinical Consultant (RCC) present, the only statement proffered as to why Resident 154 did not get her PICC line dressing order until 2/17/23 and the dressing was not changed until 2/24/23, was by the RCC. She indicated maybe the resident refused. A current policy, titled, Central Vascular Access Device (CVAD) Dressing Change, dated 6/1/21, was provided by the Administrator, on 2/24/23 at 12:18 p.m. A review of the policy indicated, .The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice .Central vascular access devices (CVADs) include peripherally inserted central catheter (PICC) .The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection .Perform sterile dress changes .at least weekly .what a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed upon admission .every two days 3.1-47(a)(2)

Based on observation, interview, and record review, the failed to ensure a resident with difficulty sleeping due to acute and chronic pain received medications, prescribed by the physician, to control pain and aid in ability to sleep, when they did not follow up after admission to obtain written prescriptions for the pharmacy to provide the prescribed medications (Resident 204) for 1 of 1 residents reviewed for pain. Findings include: On 2/27/23 at 2:55 p.m., Resident 204's medical record was reviewed. The resident's admitted was 2/24/23. The diagnoses included, but were not limited to, rhabdomyolysis (a breakdown of muscle tissue that releases damaging protein into the blood), laceration of the head, chronic heart failure, neuropathy (nerve pain), pain in left hip, sacroiliitis (a painful condition that effects one or both joints at base of the spine, that results in lower back pain), primary insomnia, and a wedge compression fracture of the fourth lumbar (back) vertebra (bone of spine). The admission Minimum Data Set (MDS) assessment, dated 12/24/23, indicated Resident 204's Brief Interview for Mental Status (BIMS) assessment was 15 out of 15 which was cognitively intact. On 2/27/23 at 8:58 a.m., during a random medication pass observation, with Registered Nurse (RN) 18, she was observed as she prepared and passed morning medications to Resident 204. The resident received the following medications, from RN 18: 81 milligrams (mg) aspirin, 20 mg furosemide (a diuretic), 25 mg metoprolol (for blood pressure), 20 mg omeprazole (for acid reflux prevention), and Miralax (for bowels) 17 gram (gm) in water. Resident 204 had an order for lyrica (pregabalin) 25 mg capsule, twice a day for pain in left hip. The medication was not available in the medication cart. She marked the medication administration record not given, medication unavailable. RN 18 told Resident 204, when she administered his other medications, the lyrica for his pain had still not arrived from the pharmacy, she would have to call them. The resident indicated they had told him it was not available; he needed all his medication. Upon returning to the hall, RN 18 opened the narcotic book and indicated there were no narcotic sheets in the book for Resident 204. The locked narcotic drawer contained no narcotic medications for him either. RN 18 then went to the nurses' station desk and phoned the pharmacy. After talking to the pharmacy, she indicated they had told her when the resident admitted to the facility they required paper prescriptions for all narcotic medications. None had been faxed over to the pharmacy, so they were unable to supply the medication. Without the pharmacy authorization she could not obtain the medication from the facility's emergency supply, either. She would have to call the physician to obtain written prescriptions for the narcotic medications. A review of Resident 204's MAR indicated lyrica (pregabalin) was not administered on 2/24/23 at 9:03 p.m., due to not available. It was not administered on 2/25/23 at 7:13 a.m. or 5:00 p.m., because it was not available. It was not administered on 2/26/23 at 6:49 a.m., because it was not available. It was not administered on 2/27/23 at 11:38 a.m., because it was not available. The record indicated Resident 204 received lyrica on 2/26/23 at 5:00 p.m., by Licensed Practical Nurse (LPN) 13. The record reflected Resident 204 had an order for hydrocodone-acetaminophen 7.5-325 mg prn (as needed). This medication, also a narcotic pain medication, was not charted on the MAR as ever having been administered. Resident 204 had an order for zolpidem (a narcotic sleeping pill) 5 mg at bedtime prn (as needed). On 2/28/23 at 10:10 a.m., during an interview, the Regional Clinical Consultant (RCC) indicated traditionally the hospital should have sent prescriptions for medications, then they would have been faxed to pharmacy. If they did not send a written prescription the facility needed to contact the doctor to obtain one. If the medication was not available at medication pass the nurse should not have charted it as given. She was going to contact the nurse, LPN 13, who documented it as given on Sunday 2/26/23 evening. The MAR would have to be corrected because the medication was not available. Resident 204's care plans did not include a care plan for pain management or insomnia. Resident 204's Admission pain, observation report, was dated 2/24/23 and showed In Progress. None of the questions had been answered on the Pain Interview. On 2/27/23 at 3:45 p.m., Resident 204's care plans and admission pain assessment were requested. On 2/28/23 at 9:00 a.m., the Administrator provided copies of Resident 204's care plans and Admission Pain Assessment Interview. The pain assessment had been completed by the MDS (Minimum Dataset) Coordinator on 2/27/23 at 4:02 p.m. Resident 204's care plans, dated 2/27/23, created by the MDS Coordinator, included, but was not limited to, Resident is at risk for pain related to: Rhabdomyolysis, laceration to the head, neuropathy, sacroiliitis, wedge compression fracture of the fourth lumbar vertebra. The goal, with a target date of 5/27/23, indicated Resident will be free from adverse effects of pain. A second care plan, dated 2/27/23, created by the MDS Coordinator, indicated, Resident is at risk for adverse side effects related to use of psychotropic medication, antidepressant, and hypnotic. The goal, with a target date of 5/27/23, indicated, Will have no adverse side effects. On 2/28/23 at 11:43 a.m., during an interview, in his room, Resident 204 indicated he did not get all his medication until yesterday. They did not have his ambian (for sleep), norco (for pain), or the lyrica (for nerve pain). They finally had given him generic medicine for his sleeping medication, and it helped last night. He had trouble sleeping, had been taking that for years, fell 5 years ago landed on his leg. The orthopedic surgeon put a plate and rod in his leg. He has been on lyrica and norco for the past 5 years. He had pained the whole time he was here (at the facility) since admission. When he asked about it they indicated it took several days to get all the medicine from pharmacy. They said it was the hospital's fault, there was a problem with not having all the prescriptions to get the medicines from pharmacy. They gave him pain medicine last night, for the first time, and it helped. He indicated I'm getting ready to ask for some more now. 3.1-25(g)(2)

Based on observation, interview, and record review, the facility failed to ensure an approved psychiatric diagnosis was included in a resident's (Resident 82) comprehensive medical record for the use and indication of antipsychotic medications and failed to ensure ongoing monitoring for improving/worsening symptoms were documented to justify the medications continued use for 1 of 5 resident reviewed for unnecessary medications. Findings include: During an observation on 2/21/23 at 1:48 p.m., Resident 82 was sitting up in a Geri chair (a recliner on wheels) with the legs elevated. Her eyes were closed. She was unresponsive to verbal stimuli. During an observation on 2/22/23 at 10:02 a.m., Resident 82 was sitting up in a Geri chair with the legs elevated. Her eyes were closed. She did not respond to verbal stimuli or touch. During an observation on 2/23/23 at 3:41 p.m., Resident 82 was sitting up in a Geri chair with the legs elevated. She opened her eyes when her name was called. She did not verbally respond. During an observation on 2/27/23 at 9:23 a.m., Resident 82 was sitting up in a Broda chair (a recliner chair on wheels). She was unresponsive to verbal stimuli. An interview was conducted with RN 8 on 2/23/23 at 2:30 p.m. RN 8 indicated she was not familiar with Resident 82 due to being a float nurse. An interview was conducted with UM 9 (Unit Manager) on 2/23/23 at 2:38 p.m. UM 9 indicated Resident 82 had not been awake much and did not eat much since transferring to her unit. UM 9 had not reviewed Resident 82's admission orders because she had admitted to another unit. When UM 9 reviewed Resident 82's medication, she indicated she would notify the physician due to resident's sedation. During an interview with LPN 16 on 2/27/23 at 9:30 a.m., she indicated Resident 82 did not eat breakfast, indicating she would not open her mouth. During an interview with Resident 82's family representative on 2/27/23 at 9:35 a.m., he indicated he was concerned about Resident 82's drowsiness and poor appetite. A telephone interview was conducted with the Pharmacist on 2/27/23 at 2:05 p.m. The Pharmacist indicated she reviewed Resident 82 when she admitted and did not make any recommendations. She did not know what her thought process was at the time of the review. On 2/15/23, the Pharmacist indicated on her Pharmacist Observation there were irregularities and to see her report. The Pharmacist did not send the report from 2/15/23 until 2/27/23 due to being on vacation. She indicated Resident 82 received an order to decrease Seroquel and they are doing a gradual dose reduction. An interview was conducted with the NP (Nurse Practitioner) on 2/27/23 at 3:02 p.m. The NP indicated Resident 82 admitted with the discharge plan of going to an assisted living. The plan was to get Resident 82 out of the facility quickly. The NP indicated Resident 82 was diagnosed with COVID-19 upon admission to the facility. The NP indicated that around 2/13/23, Resident 82 was tested for a UTI (Urinary Tract Infection) and was treated for a UTI. The NP indicated Resident 82's sedation and poor food and fluid intake was likely due to the diagnoses of COVID-19 and UTI, not adverse drug reactions to olanzapine and Seroquel usage. A comprehensive record review was completed on 2/23/23 at 3:50 p.m. Resident 82 had the following diagnoses, but not limited to encounter for other orthopedic aftercare, unspecified fracture of right femur, unspecified fall, generalized osteo arthritis, essential hypertension, hyperlipidemia, unspecified dementia, unspecified severity with other behavioral disturbance, Alzheimer's disease with early onset, peripheral vascular disease, hypothyroidism, unspecified anxiety, and pain in the right hip. Resident 82 had orders for Zyprexa Zydis (olanzapine) 10mg daily for unspecified dementia, unspecified severity, with other behavioral disturbance. She received Seroquel 50 mg two times daily for unspecified dementia with unspecified severity, with other behavioral disturbance. It was reduced to Seroquel 25 mg two times daily on 2/23/23. An observation was completed by the Pharmacist on 1/23/23 at 2:53 p.m. It indicated, based on the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgement that as such time, the resident's medication regimen contained no new irregularities. An observation was completed by the Pharmacist on 2/15/23 at 1:45 p.m. It indicated, see report for any noted irregularities. On 2/28/23 at 10:00 a.m., the ED (Executive Director) provide a consultation report from the pharmacist. The report indicated Resident 82 received two or more antipsychotics. The report indicated, Antipsychotics have a BOXED WARNING for increased mortality in older adults with psychosis related dementia. Additionally, they are associated with other potentially serious adverse effects including movement disorders, metabolic abnormalities, and orthostatic hypotension. The pharmacist recommended a gradual dose reduction to decrease olanzapine to 5mg daily, with then goal of discontinuation. Resident 82's care plan, dated 1/31/23, indicated she was at risk for side effects related to use of psychotropic medication, antipsychotic. The goal of the care plan was resident 82 would have no adverse side effects. Interventions included to administer medications as ordered, observed for effectiveness, document side effects as observed and notify MD (medical doctor), observe for side effects: antipsychotic medications: dizziness, dry mouth, indigestion, drowsiness, constipation, impaired balance, weight gain, tremors, abnormal involuntary movements, and pharmacist to review medications routinely. Resident 82's record revealed her weight on 1/23/23 was 122.4 pounds. Her weight on 2/20/23 was 116.0 pounds. Her food and fluid records indicated she refused to accept supplements and meals on several occasions. On 2/16/23, she refused dinner due to her condition and refused to accept any fluids. Her nutrition care plan, dated 1/23/23, indicated she was not motivated to feed herself. The goal indicated she would increase her intake to 75-100 percent of her meals and would not experience weight loss. A policy was provided by the ED on 2/24/23 at 9:30 a.m., titled Nursing Admission/Return Admission Policy and Procedure, with a date of 3/2010. The policy indicated, .Physician Orders, transcribe the routine medication orders to include dosage, route, frequency, and the diagnosis to support the use, ask if the resident/representative understands the medication names, reason for use and why they should be continued after discharge from the facility. Explain the importance of managing medications to avoid adverse drug events or re-hospitalization , admission medication regimen review completed upon admission or as close to admission as possible, per policy 3.1-48(b)(1)

Based on observation and interview, the facility failed to ensure medications were properly secured, and also failed to waste or destroy unused medications, according to federal guidelines, when a nurse threw medications into the trash can and then poured medication down a sink drain for 3 of 5 random medication administration observations. Findings include: On 2/27/23 at 8:47 a.m., during a random observation, a medication cart was observed outside room [ROOM NUMBER], unattended. The cart was unlocked. There were no staff members observed in the hall. The nurse was not within eyesight of the medication cart. A plastic medication cup was on the cart with applesauce and a spoon in it. Medications, several pills of different colors were mixed in the applesauce. There were 6 medication cards, containing medications, turned upside down on cart for Resident 97. On 2/27/23 at 8:50 a.m., Registered Nurse (RN) 18 came out of Resident 20's room. During an interview, she indicated she had prepared Resident 20's medications in applesauce, but she did not want to take them that way. RN 18 then indicated I'm just going to start over. She threw the cup of applesauce and medications into the trash can on the side of the medication cart. She then pushed the medication cart to the front hallway, next to the nurses' station. She put all the medication cards in the drawer and locked it. She threw the trash bag in the soiled utility room trash. A review of Resident 20's morning administered medications, from the MAR (Medication Administration Record) indicated RN 18 had given the following morning medications: Tylenol 500 mg 2 tabs , Allegra (for allergies) 180 mg, amlodipine (for blood pressure) 5 mg, Eliquis(blood thinner) 5 mg, I-caps (supplement for vision) 180 10-2 mg, losartin (for blood pressure) 50 mg, potassium chloride 20 meq, sodium chloride 1,000 mg, sotalol (for a heart irregular rhythm) 120 mg, and torsemide (diuretic) 10 mg. On 2/27/23 at 8:58 a.m., during a random medication observation, RN 18 was observed as she prepared medications for Resident 204. She took a bottle of Miralax from the medication drawer and poured into a plastic medication cup. The powder heaped up over the cup. She then shook the cup over the trash can, to level it off at the top edge of the cup, which was above the 30 ml mark. She then poured the powder into a cup of water, and carried it, with other medications to the resident's room. Resident 204 indicated he did not want the Miralax because his bowels were OK. RN 18 took the MiraLAX which she had mixed in a cup of water and poured it down the sink in the resident's bathroom. On 2/27/23 at 9:15 a.m., during an interview, RN 18 indicated, when they waste narcotics they use a drug buster system, and 2 nurses have to witness. Non-narcotics they usually just throw into the red box, but she could not put a cup of applesauce in there. On 2/28/23 at 9:10 a.m., the Administrator provided a current policy, dated revised 1/1/13, titled, General Dose Preparation and Medication Administration. This policy indicated, .Dispose of unused medication portions in accordance with facility policy .Discard used medication supplies .in accordance with facility policy On 2/28/23 at 10:25 a.m., upon request for The Facility Policy, during an interview, the Director of Nursing Services (DNS) indicated the facility policy said to make medications inaccessible. If the nurse put them into the trash and took trash to the soiled utility they were then inaccessible. It was ok to put medications in the trash if they are not accessible. 3.1-25(m) 3.1-25(o)

Based on interview, observation, and record review, the facility failed to ensure personal protective equipment (PPE) was worn by visitors when in a resident's room who required droplet isolation (special precautions to prevent the spread of germs that are spread in tiny droplets caused by coughing and sneezing) precautions during a COVID-19 pandemic for 1 of 3 residents reviewed for infection control (Resident B). Findings include: During an interview, on 10/9/20 at 11:27 a.m., Licensed Practical Nurse (LPN) 4 indicated Resident B had visitors in her room. Resident B required droplet isolation (special precautions to prevent the spread of germs that are spread in tiny droplets caused by coughing and sneezing) precautions. The visitors had masks on, but no gowns, gloves, or eye protection. She probably should have asked them to put on gowns, gloves, and eye protection before they entered Resident B's room. On 10/9/20 at 11:29 a.m., Resident B's room was observed with two visitors and Resident B inside the room. Both visitors wore masks, but no gowns, gloves, or eye protection. A sign on Resident B's door indicated, .DROPLET + PRECAUTIONS: EVERYONE MUST: .Put on mask, eye protection, gown and gloves before room entry Resident B's record was reviewed on 10/9/20 at 1:27 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 9/16/20, indicated the resident had a moderate cognitive impairment. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. On 10/9/20 at 11:30 a.m., the Director of Nursing Services (DNS) indicated Resident B required droplet isolation precautions, and anyone who entered the room, including visitors, should have worn a gown, mask, eye protection, and gloves. A staff member normally accompanied visitors to the room and made sure they donned personal protective equipment (PPE). During an interview, on 10/9/20 at 11:58 a.m., the Executive Director (ED) indicated Resident B required droplet isolation precautions because she was exposed to an employee who tested positive for COVID-19. Resident B was previously infection with COVID-19, and was considered recovered. On 10/9/20 at 1:46 p.m., the ED provided a document titled, Policy Title: Visitation during COVID 19 Public Health Emergency, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: It is the policy .to allow and encourage visitation when advisable per the procedure below while maintaining safety and core infection control processes .Visitation: .If resident is in droplet plus isolation .visitors must wear droplet plus PPE 3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to ensure treatment and services were provided to prevent further declines in range of motion (ROM) (the full movement potential of a joint, usually its range of flexion and extension) for 3 of 3 residents reviewed for ROM (Resident B, Resident F, Resident C, and Resident E). Findings include: 1. On [DATE] at 10:22 a.m., Resident B was observed lying in bed. The resident's left hand was clinched and the resident was unable to open her hand at this time. There was no brace observed to the resident's left hand. At this time, the resident indicated she had not worn a brace to the left hand or been offered ROM exercises to the left hand for several months. She would have worn the brace and participated in ROM to her left hand if she had been offered. During an interview, on [DATE] at 10:25 a.m., Resident F indicated Resident B was his wife and he had not observed the staff perform ROM exercises with his wife for a long time and he had not observed a brace applied to her left hand daily. Resident B's record was reviewed on [DATE] at 10:48 a.m. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact and had a functional limitation in ROM to an upper extremity. The resident required extensive assist of two plus staff for bed mobility, transfer, and toilet use, and required extensive assist of one staff for dressing, and personal hygiene. A point of care history, dated [DATE] to [DATE], indicated the number of minutes for splint or brace assistance. The record lacked documentation this service had been provided on [DATE], [DATE], [DATE], [DATE], and [DATE]. A point of care history, dated [DATE] to [DATE], indicated number of minutes for passive range of motion (PROM) (therapist or equipment moves the joint through the range of motion with no effort from the patient). The record lacked documentation this service had been provided on [DATE], [DATE], and [DATE]. A care plan, initiated on [DATE] and reviewed on [DATE], indicated the resident required a splint/brace program related to a [DIAGNOSES REDACTED]. The long term goal, dated [DATE], indicated the resident would tolerate wearing the left hand splint for up to four hours per day. Interventions included, but were not limited to, splint/brace program: place left hand splint for up to four hours per day, one time a day. An evaluation note, dated [DATE], indicated the resident was able to tolerate wearing left hand splint for up to four hours per day. No redness or skin irritation to skin under splint, no complaints of pain, and would continue to monitor current program. A care plan, initiated on [DATE] and reviewed on [DATE], indicated the resident required PROM related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The long term goal, dated [DATE], indicated the resident would tolerate 30 repetitions (number of times you perform a specific exercise) of PROM to the left hand/wrist, and fingers one time a day. An evaluation note, dated [DATE], indicated the resident was able to tolerate 30 repetitions of PROM to the left/hand wrist, and fingers one time a day with no breaks or complaints of pain, and would continue to monitor. [DIAGNOSES REDACTED]. During an interview, on [DATE] at 1:16 p.m., Certified Nursing Assistant (CNA) 5 indicated the resident received active range of motion (AROM) and PROM. The resident was supposed to wear a brace to the left hand for up to four hours a day, but would refused to wear it most days. She had spent 15 minutes cleaning the resident's hand this morning, but the resident refused to wear the splint and that was why it had been documented on the point of care history because of the time she had spent cleaning the resident's hand. During an interview, on [DATE] at 1:34 p.m., Licensed Practical Nurse (LPN) 3 indicated she typically worked the hall the resident was on and the resident had not worn a brace to the left hand for a long time. She was unsure if she if the resident was supposed to wear the brace and only knew therapy had been the one's whom applied it months ago when she had worn it. 2. On [DATE] at 11:58 a.m., Resident C was observed in her room in a motorized wheel chair. At this time, the resident indicated she had a stroke years ago and was not able to use her left arm and had limited mobility with her left leg. The staff had not performed ROM exercises with her to her left side seven days a week, and she was unaware of the goals in place for ROM exercises to her left side. Resident C's record was reviewed on [DATE] at 11:30 a.m. An annual Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact and had a functional limitation in ROM to upper and lower extremities on one side. The resident required extensive assist of two plus staff for bed mobility, transfer, and toilet use, and required extensive assist of one staff for dressing, and personal hygiene. A point of care history, dated [DATE] to [DATE], indicated the number of minutes for active range of motion (AROM) (patient performs the exercise to move the joint without any assistance to the muscles surrounding the joint). The record lacked documentation this service had been provided on [DATE], [DATE], [DATE], [DATE], and [DATE]. A point of care history, dated [DATE] to [DATE], indicated the number of minutes for PROM. The record lacked documentation this service had been provided on [DATE], [DATE], [DATE], [DATE], and [DATE]. A care plan, initiated on [DATE] and reviewed on [DATE], indicated the resident required AROM. The long term goal, dated [DATE], indicated the resident would perform 8 repetitions of AROM to neck one time a day. Interventions included, but were not limited to, AROM: resident would perform 8 repetitions of AROM to neck and hold at end points times five seconds, one time a day. An evaluation note, dated [DATE], indicated the resident was able to perform the AROM to her neck with no complaints of pain or rest breaks, would continue with current program. A care plan, initiated on [DATE] and reviewed on [DATE], indicated the resident required PROM related to [MEDICAL CONDITION] (muscle weakness or [DIAGNOSES REDACTED] on one side of the body that can affect the arms, legs, and facial muscles). The long term goal, dated [DATE], indicated the resident would tolerate 20 repetitions of PROM to the left arm and leg two times per day. Interventions included, but were not limited to, gently stretch left side, PROM program seven days a week, one time a day that included 20 repetitions times 2 sets to the left arm and leg with prolonged stretch. An evaluation note, dated [DATE], indicated the resident was able to tolerate 20 repetitions of PROM to the left one time a day with no complaints pain or rest break, and would continue with current program. [DIAGNOSES REDACTED]. During an interview, on [DATE] at 1:11 p.m., Certified Nursing Assistant (CNA) indicated the resident received AROM and PROM exercises. 3. On [DATE] at 1:46 p.m , Resident [NAME] was observed lying in bed with his eyes closed. Resident E's record was reviewed on [DATE] at 10:20 a.m. [DIAGNOSES REDACTED].), generalized muscle weakness, abnormal posture. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had a severe cognitive impairment and used a wheelchair. The resident required extensive assist of two plus staff for bed mobility, transfer, and toilet use, and required extensive assist of one staff for dressing, and personal hygiene. A point of care history, dated [DATE] to [DATE], indicated the number of minutes for walking. The record lacked documentation this service had been provided on [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] A point of care history, dated [DATE] to [DATE], indicated the number of minutes for AROM. The record lacked documentation this service had been provided on [DATE], and [DATE]. A care plan, initiated on [DATE] and reviewed [DATE], indicated the resident required AROM related to rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein in the blood). The long term goal, dated [DATE], indicated the resident would perform 20 repetitions of AROM to bilateral upper and lower extremities. Interventions included, but were not limited to, AROM: the resident would perform 20 times 2 sets of repetitions of AROM to bilateral upper and lower extremities, or omni cycle (therapy exercise equipment) times 15 minutes one time day. Give demonstration, or use cones to reach across the body 15 times to each side, one time daily. A care plan, initiated on [DATE] and reviewed on [DATE], indicated the resident required a transfer program related to rhabdomyolysis. The long term goal, dated [DATE], indicated the resident would stand times four minutes, with 4 repetitions, one time daily. A care plan, initiated on [DATE] and revived on [DATE], indicated the resident required a walking program. The long term goal, dated [DATE], indicated the resident would walk from room [ROOM NUMBER] to cottage nurses station once a day. An evaluation note, dated [DATE], indicated the resident was able to walk from his room to the nurse's station once daily with the assist of one and wheeled walker. No rests breaks or complaints of pain, and would continue with current program. During an interview, on [DATE] at 10:47 a.m., Certified Nursing Assistant (CNA) 8 indicated he provided restorative services to residents on his daily list. Resident B, and Resident C were not currently on his list and the CNA's would provide restorative services to them. Resident [NAME] was on his list for walking, and when he was not there the CNA's were responsible for walking the resident. During an interview, on [DATE] at 11:45 a.m., the Director of Health Services (DHS) indicated if a ROM service was on a resident's point of care profile the staff should complete the service and document it had been completed. She was unsure why there days that lacked documentation. On [DATE] at 10:06 a.m., the Executive Director (ED) provided a document, undated, and titled, Splints, Braces, Orthotics, and indicated it was the policy currently being used by the facility. The policy indicated, Splints, braces and orthotics will be applied according to manufacturer instructions and/or interventions from physical and occupational therapy. Purposes: .to maintain and improve mobility and ROM .Procedure: 1. Follow the recommended wearing time or the time tolerated for wearing the splint, brace On [DATE] at 10:33 a.m., the DHS provided a document, revised ,[DATE], and titled, Restorative Nursing Program, and indicated it was the policy currently being used by the facility. The policy indicated, Purpose: To provide a nursing program for residents who no longer need skilled therapy, but still have functional goals to be met or maintained through practice and repetition. The resident can also be placed on a program to maintain the ability to function at his or her optimal level within the given environment Process: The program is coordinated, supervised and carried out by nursing staff preferable the MDS coordinator or MDS assistant .Program documentation .CNA will document in Point of Care, or a monthly flowsheet, the number of minutes the program was provided .and their initials .The resident and/or representative will be included, to the extent possible, in the development of the restorative care plan and informed of the risks and benefits of the program. Restorative nursing programs include: Active or passive range of motion, splint or brace assistance, walking or bed mobility This Federal tag relates to Complaint IN 782. 3XXX,[DATE](a)(2)

Based on interview, and record review, the facility failed to update physician orders [REDACTED]. Findings include: On [DATE] at 2:44 p.m , Resident 21's medical record was reviewed. Resident 21 had active [DIAGNOSES REDACTED]. Resident 21 had an advance directive physician order [REDACTED]. Resident 21's most recent comprehensive care plan as of [DATE] indicated she had an advance directive care plan to be a DNR, (Do Not Resuscitate, written instructions from a physician telling health care providers not to perform CPR). During an interview on [DATE] at 8:45 a.m., the Director of Nursing Services, (DNS) indicated, Resident 21 had a POST (Physician order [REDACTED]. On [DATE] at 9:30 a.m., the DNS provided a copy of current facility policy titled, Advance Directives, revised ,[DATE]. The policy indicated, .executed Advance Directives will be documented in the medical record. Code status directives (both full and no code) will be documented via a physician's orders [REDACTED]. 3XXX,[DATE](f)(4)(B)

Based on observation, interview, and record review, the facility failed to ensure privacy for a gastric tube ([DEVICE]) medication administration for 1 of 2 residents with [DEVICE]s (Resident 56). Findings include: On 11/17/19 at 9:35 a.m., Licensed Practical Nurse (LPN) 9 prepared Resident 56's [DEVICE] medications. She entered his room, did not close his door, asked him to lift his shirt, and administered the following medications in his [DEVICE]: a. 5 mL's (milliliters) of [MEDICATION NAME] solution (nerve pain and anticonvulsant), totaling 250 mg (milligram). b. 2.5 mL's of [MEDICATION NAME] suspension (antacid), totaling 20 mg. c. 5 mL's of [MEDICATION NAME] (anticonvulsant), totaling 100 mg. d. 15 mL's of potassium chloride liquid (treats and prevents low blood pressure), totaling 20 mEq (milliequivalent). e. 6.25 mg crushed carvedilol (treats high blood pressure and heart failure) in 40 ml of water. f. 81 mg crushed aspirin (blood thinner) in 40 ml of water. g. 75 mg crushed [MEDICATION NAME] (antidepressant) in 40 mL of water. h. 50 mg crushed losartan (antihypertensive) in 40 mL of water. An observation of two unidentified residents passed by Resident 56's room during the [DEVICE] medication administration. On 11/21/19 at 10:26 a.m., Resident 56's record was reviewed. Resident 56's [DIAGNOSES REDACTED]. (sudden onset of severe oxygen deprivation). On 11/20/19 at 11:23 a.m., the Director of Nursing Services (DNS) indicated the door should have been closed for the resident's privacy during a [DEVICE] medication administration. A current policy, titled, Enteral Tube - Medication Administration, dated 01/2018, was provided by the DNS on 11/20/19 at 9:30 a.m. A review of the policy indicated, .Procedure Steps: .Provide privacy and explain procedure 3.1-3(p)(4)

Based on observation, interview, and record review, the facility failed to ensure individualized interventions were implemented and pressure reducing devices were placed effectively to reduce pressure and prevent an increase from a stage 3 pressure ulcer (full thickness skin loss) to a stage 4 pressure ulcer (full thickness tissue loss) for 1 of 2 residents reviewed for pressure ulcers that had developed within the facility (Resident F), and failed to prevent an increase from a stage 2 pressure ulcer (partial thickness) to a stage 3 pressure ulcer for 1 of 2 residents reviewed for pressure ulcers (Resident G). Findings include: 1. During an interview on 8/13/2015 at 9:24 a.m., Licensed Practical Nurse (LPN) #31 indicated Resident F had a stage 3 pressure ulcer (full thickness skin loss) to her 5th metatarsal (toe) on the right foot. During an observation on 8/13/15 at 1:48 p.m., Resident F was observed to wear bilateral foam boots to both feet, with her right leg contracted, bent outward toward the right. The right side of her foot was observed laying flat against a heel lift device device on the bed beneath her foot. During an observation on 8/17/2015 at 11:12 a.m., with Wound Nurse #35 present, Resident F's right leg was observed to be contracted, bent outward toward the right, with a foam boot on her right foot. The right side of Resident F's foot was observed laying flat against a heel lift device that had been in place under her foot. Resident F's pressure ulcer was observed. Wound Nurse #35 measured the pressure ulcer and indicated the pressure ulcer measured 2.2 centimeters by 1.5 centimeters with a depth of 1.9 centimeters with 0.2 centimeters of bone exposed on the distal edge. She indicated the pressure ulcer had changed from a stage 3 pressure ulcer to a stage 4 pressure ulcer (full thickness tissue loss). During an observation on 8/17/2015 at 2:35 p.m., with Registered Nurse (RN) #36 present, Resident F's right foot was observed in a foam boot, with the right side of her foot laying flat against the heel lift device under her foot. During an observation on 8/19/2015 at 10:32 a.m., with Certified Nursing Assistant (CNA) #34 present, Resident F was observed positioned on her left side, with her right leg contracted outward toward the right. Her right foot was observed in a foam boot, with the right side of her foot laying flat against the heel lift device under her foot. Resident F's record was reviewed on 8/17/2015 at 11:40 a.m., Resident F's [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #18 was at risk for development of pressure ulcers by clinical assessment. Skin treatments included turning and repositioning. A Significant Change MDS, dated [DATE], indicated Resident F had a Stage 3 pressure ulcer with measurements of 1.8 centimeters by 2.4 centimeters with a depth of 0.8 centimeters. Skin and ulcer treatment included a pressure reducing device for her bed. Resident F was totally dependent upon the assistance of at least two employees for bed mobility, which included turning side to side and positioning body while in bed. Resident F had functional limitation in range of motion, with impairment on both sides of her lower extremities, which included her hip, knee, ankle and foot. Skin Grids for Resident F's pressure ulcer to her right 5th metatarsal included the following measurements: 3/23/2015: unstageable pressure ulcer (suspected deep tissue injury) with measurements of 1 centimeter by 0.8 centimeters with no depth. 3/30/2015: unstageable pressure ulcer with measurements of 1.5 centimeters by 1 centimeters with no depth. 4/6/2015: unstageable pressure ulcer with measurements of 1.2 centimeters by 0.6 centimeters with no depth. 4/14/2015: unstageable pressure ulcer with measurements of 1.5 centimeters by 1 centimeter with no depth. 4/21/2015: unstageable pressure ulcer with measurements of 1 centimeter by 0.5 centimeters with no depth. 4/27/2015: unstageable pressure ulcer with measurements of 0.5 centimeters by 0.5 centimeters with no depth. 5/4/2015: unstageable pressure ulcer with measurements of 0.8 centimeters by 0.5 centimeters with no depth. 5/11/2015: unstageable pressure ulcer with measurements of 2.5 centimeters by 3 centimeters with no depth. 5/18/2015: unstageable pressure ulcer with measurements of 3 centimeters by 3 centimeters with no depth. 5/25/2015: unstageable pressure ulcer with measurements of 3 centimeters by 1.5 centimeters with no depth. 6/1/2015: unstageable pressure ulcer with measurements of 1.5 centimeters by 1.7 centimeters with no depth 6/8/2015: unstageable pressure ulcer with measurements of 2 centimeters by 2 centimeters with 0.3 centimeters of depth. 6/15/2015: stage 2 pressure ulcer (partial thickness loss of dermis) with measurements of 3.5 centimeters by 2 centimeters with 0.7 centimeters of depth. 6/22/2015: stage 3 pressure ulcer with measurements of 1.8 centimeters by 2.4 centimeters with 0.5 centimeters of depth. 6/29/2015: stage 3 pressure ulcer with measurements of 2.2 centimeters by 2.5 centimeters with 0.6 centimeters of depth. 7/6/2015: stage 3 pressure ulcer with measurements of 2 centimeters by 2.2 centimeters with 0.3 centimeters of depth. 7/13/2015: stage 3 pressure ulcer with measurements of 2 centimeters by 2 centimeters with 0.2 centimeters of depth. 8/3/2015: stage 3 pressure ulcer with measurements of 2.5 centimeters by 2 centimeters with 0.1 centimeters of depth. 8/10/2015: stage 3 pressure ulcer with measurements of 1.5 centimeters by 1.5 centimeters with 0.1 centimeters of depth. 8/17/2015: stage 4 pressure ulcer with measurements of 2.2 centimeters by 1.5 centimeters with 0.1 centimeters of depth. A Braden Risk Assessment scale, dated 6/2/2015, indicated Resident F had a high risk score of 11 for skin breakdown. A skin integrity care plan, dated 6/22/2015, indicated Resident F was at high risk for skin breakdown and required increased frequency of turning and a pressure reduction support surface. Interventions included implementing an individualized turning schedule if applicable and protect heels if exposed to friction. A CNA assignment sheet, dated 8/10/2015, indicated Resident F required her heels to be elevated. A Physical Therapy treatment note, dated 7/6/2015 at 12:32 p.m., indicated it was discussed with Resident F's caregivers how important continued pressure relief was to improve wound healing. A Physical Therapy progress note, dated 7/8/2015, indicated Resident F's caregiver training on the importance of pressure relief to hasten wound healing remained ongoing. A Physical Therapy progress note, dated 7/17/2015 at 12:00 p.m., indicated Resident F exhibited continued hyptertonicity (extreme muscle tension) and muscle shortening while lying in bed but was able to tolerate heel lift and accomodate pressure relief. Resident F's caregivers were trained to continue with pressure relief. A physician's telephone order, dated 8/4/2015, indicated an order to cleanse Resident F's stage 3 pressure ulcer to right 5th metatarsal with normal saline. Apply foam nonadhesive wrap Kerlix and [MEDICATION NAME] every other day for 21 days. A physician's telephone order, dated 8/13/2015, indicated an order for [REDACTED]. A nurse's progress note, dated 8/14/2015 at 6:45 a.m., indicated Resident F's right 5th metatarsal had increased from a stage 3 pressure ulcer to a stage 4 pressure ulcer with measurements of 1.5 centimeters by 1.5 centimeters with a depth of 0.1 centimeters and 0.1 cm of bone exposed on the distal edge. A physician's telephone order, dated 8/17/2015, indicated an order to cleanse Resident F's right 5th metatarsal stage 4 ulcer with normal saline and apply a foam dressing wrap with kerlix daily for 21 days. Pressure is to be kept off of Resident F's right foot. During an interview on 8/17/2015 at 11:19 a.m., Wound Nurse #35 indicated a heel lift device was placed under Resident F's legs to off-load her heels. She indicated Resident F was not capable of staying in this position for long due to her leg contractures. She indicated her pressure ulcer had received pressure from improper positioning of her right foot laying flat on the heel lift when she moved her leg and staff are unable to continually watch her to ensure she had not caused pressure to her right 5th metatarsal by moving her legs. During an interview on 8/17/2015 at 2:35 p.m., RN #36 indicated Resident F's right foot had not been properly positioned with the right side of her foot laying flat against the heel lift device. She indicated Resident F should have been repositioned. During a telephone interview on 8/17/2015 at 3:22 p.m., Resident F's Physician indicated her heels were to remain off-loaded and pressure was to be kept off of the area of her right 5th metatarsal in order to promote healing. During an interview on 8/17/2015 at 3:36 p.m., Wound Nurse #35 indicated a specialized turning schedule had been recommended for Resident F but she had been put on an every 2 hour turn and reposition program. She indicated turning and repositioning Resident F every 2 hours had been too long of a time lapse if the Resident would pull her contracted right leg out of position and cause pressure to her right 5th metatarsal pressure ulcer. She indicated resident should not have any pressure on that area. 2. During an interview on 8/12/15 at 2:03 p.m., Licensed Practical Nurse (LPN) #24 indicated Resident G had a stage 3 pressure ulcer on his left heel. On 8/19/15 from 10:24 a.m. to 10:54 a.m., a dressing change and Foley catheter care was observed for Resident G. Licensed Practical Nurse (LPN) #24 used hand sanitizer prior to the entry of Resident G's room and put on disposable gloves. LPN #24 removed the old pressure ulcer dressing from his heel ulcer, cleansed the pressure ulcer with wound cleaner, and then removed her gloves. LPN #24 washed her hands with soap and water for 20 seconds, turned the water faucet off with her bare hand, and dried her hands with paper towels. Soap suds were observed on LPN #24's left forearm as she put on new gloves and completed the dressing change. After the new pressure ulcer dressing was secured, LPN #24 washed her hands with soap and water for 20 seconds, turned the water off with her bare hand, and dried her hands with a paper towel. During an interview on 8/19/2015 at 10:54 a.m., LPN #24 indicated she washed her hands before and after providing care to residents, when her hands were contaminated with bodily fluids, and after disposing of gloves. She indicated she used a paper towel to turn off the water faucet after she washed her hands and dried her hands. Resident G's record was reviewed on 8/18/15 at 10:07 a.m. The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident G was an extensive assistant of 2 or more people for bed mobility and transfer. The MDS indicated the resident had one stage 3 pressure ulcer. The form titled,Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other form, dated 2/8/15, indicated Resident G had a new stage 2 pressure ulcer on his left heel. The form titled,Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other form, dated The Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other form, dated 5/18/15, indicated the stage 2 pressure ulcer on the resident's left heel had become a full thickness stage 3 pressure ulcer. The physician telephone orders, dated 8/5/15, ordered a Podus boot to be wore when Resident G was out of bed and was to have his heel up in bed due to his left heel stage 3 pressure ulcer. The physician order [REDACTED]. The Skin Integrity Assessment: Prevention and Treatment Plan of Care, 7/14/15, indicated Resident G was at moderate risk for skin integrity issues, the resident was to be on a turn schedule, the resident's heels were to be protected, was to wear a Podus boot on the his left foot, and use a Trapeze when indicated. The care plan did not indicate how often the resident was to be turned, when the Podus boot was to be wore, or to bridge the resident's heels up in bed. The Certified Nursing Assistant (CNA) assignment sheet provided on 8/18/15 at 2:15 p.m. ,by LPN #24, indicated the resident used a trapeze to assist with bed mobility, and the resident's heels were to be floated. The assignment sheet did not indicate resident needed to be turned. During an interview on 8/18/15 at 11:36 a.m., Licensed Practical Nurse (LPN) #24 indicated she needed to get clarification on the Resident G's boot order. She indicated she believed the boot was ordered for day and night but was not sure why. She indicated she believed he should only have it during the day. On 8/19/2015 at 10:31 a.m., Resident G was observed in bed with a bridge pillow under his legs, his heels laying against the mattress, and no boots were observed on his feet. During an interview on 8/19/15 at 10:33 a.m., Certified Nursing Assistant (CNA) # 25 indicated Resident G's bridge pillow was in it's normal position and his heels would occasionally lay against the mattress. LPN #24 indicated sometimes they place pillows under his lower legs to help off load the pressure off of the resident's heels. During an interview on 8/19/15 at 3:01 p.m., the Wound Nurse #35 indicated Resident G indicated the resident had an order for [REDACTED]. She indicated she was unsure how the CNAs were supposed to know the resident required turning because the facility had removed the yellow dots from the doors and she was unaware the turning schedule was not listed on the CNA assignment sheet. During an interview on 8/19/15 at 3:48 p.m., the Wound Nurse #35 indicated Resident G was supposed to have boots on in bed and in up in chair until new sleeping boots came. She indicated the resident was supposed to have his heels floated off the mattress. She indicated she was unaware the resident did not have boots on in bed and was unaware the CNA assignment sheet indicated boots were to be wore when out of bed only. During an interview on 8/20/15 at 9:46 a.m., CNA #25 indicated Resident G was to be turned and repositioned every 2 hours. She indicated the resident turning schedule was not on the CNA assignment sheet, but there used to be dots on the doors next to the residents' names which indicated who was on a turn every 2 hours schedule. On 8/19/15 at 10:00 a.m., the Administrator provided the current pressure ulcer policy. The policy indicated care plans should include interventions for residents at risk of skin impairment may include but were not limited to: frequent turning and repositioning, and off loading pressure to heels. The policy indicated residents at moderate risk should have a turning schedule with foam wedges for lateral positioning. The policy indicated residents at high risk should have an increased turning schedule, use foam wedges for lateral positioning, and reduce pressure to heels. The policy indicated very high risk residents should have all treatments. The policy indicated the interventions should be communicated to the staff. This Federal tag relates to Complaint IN 593. 3.1-40(a)(2)

Based on record review and interview, the facility failed to prevent a resident's significant weight loss of 20 percent in 30 days, and failed to provide nursing, dietary, or physician's assessments after the 20 percent weight loss for 1 of 3 residents reviewed for nutrition (Resident #79). Findings include: Resident #79's record was reviewed on 8/18/15 at 2:00 p.m. The vitals report indicated Resident #79 weighed 161 pounds on 5/5/15, 169 pounds on 6/5/15, 135 pounds on 7/5/15, and 137 pounds on 8/2/15. The Nutritional Risk Data Collection and Assessment, dated 11/26/14, indicated Resident #79 had decreased intake and averaged less than 50 percentage intake at meals for five days. The assessment indicated the Registered Dietician (RD) recommended a regular diet to liberalize the resident's diet. The Nutritional Risk Data Collection and Assessment, dated 12/5/14, indicated the physician had discontinued Resident #79's regular diet and resumed the limited high fat food diet. The nursing progress notes, dated 11/14/14 to 8/5/15, were reviewed on 8/20/15 at 2 p.m. The nursing progress note dated 12/12/14 at 2:30 p.m., was the last progress note that addressed Resident #79's decreased meal intake. The nursing progress notes, dated 6/1/15 at 2:35 p.m., to 8/5/15 at 2:00 p.m., did not indicate the physician or family was notified of the Resident #79's June-July weight loss. The nursing progress notes, dated 6/1/15 at 2:35 p.m., to 8/5/15 at 2:00 p.m., did not indicate Resident #79 had been assessed by nursing or dietary for his significant weight loss. The CORP-Meal Intake Detail Report for June 2015 indicated Resident #79 consumed 50 percent or less of meals on the following dates: 6/2/15 - ate less than half of dinner (26%-49%) 6/5/15 - refused breakfast and ate less than half of dinner (26%-49%) 6/6/15 - refused most of lunch (1%-25%), and ate less than half of dinner (26%-49%) 6/8/15 - refused breakfast and refused most of dinner (1%-25%) 6/9/15 - ate less than half of breakfast and dinner(26% -49%) 6/11/15 - ate less than half of lunch (26%-49%) 6/12/15 - refused most of breakfast and lunch (1% -25%) 6/13/15 - refused most of lunch (1%-25%) 6/14/15 - refused most of dinner (1%-25%) 6/15/15 - refused most of breakfast, lunch, and dinner (1%-25%) 6/19/15 - refused most of breakfast (1%-25%) and ate less than half of dinner (26%-49%) 6/21/15 - ate less than half of dinner (26%-49%) 6/24/15 - refused most of dinner (1%-25%) 6/26/15 - refused most of breakfast and lunch (1%-25%) 6/29/15 - ate less than half of breakfast (26%-49%), refused most of lunch (1%-25%) The Nutrition Risk Care Plan, dated 6/25/15, indicated Resident #79 was at risk for weight loss due to decreased intake of less than 75 percent. The goals were for the resident to consume at least 70% of meals, and his weight would remain within 3% of current weight. The care plans interventions indicated staff was to monitor the Resident's weight per protocol, monitor intake of meals, and notify the physician and family of significant weight changes. The Food/Fluid Intake Record for July 2015 indicated Resident #79 consumed 50 percent or less of meals on the following dates: 7/2/15 - breakfast of 50% 7/4/15 - breakfast of 50% 7/5/15 - dinner of 50% 7/6/15 - breakfast of 25% 7/715 - refused breakfast 7/8/15 - breakfast of 25% 7/9/15 - breakfast of 25% 7/16/15 - breakfast and lunch of 50% 7/19/15 - dinner of 50% 7/2015 - dinner of 50% 7/24/15 - breakfast of 50% 7/25/15 - dinner of 50% 7/26/15 - lunch of 50% 7/27/15 - breakfast and lunch of 50% 7/28/15 - dinner of 50% The physician telephone order, dated 7/20/15, ordered a diet change to a regular diet. The physician order [REDACTED].#79 was on a diet of limited high fat foods and was allowed two free meals every month. Resident #79 was observed and interviewed in the dining room on the following dates and times: 8/12/15 at 12:04 p.m.-- Resident observed in dining room. Indicated the food was good and he was excited to have a hot dog for lunch. 8/18/15 at 11:51 a.m.-- Resident in dining room. Alert and indicated he was ready to eat. 8/20/15 at 11:58 a.m.-- Resident observed in dining room. Indicated excited for lunch at 12:05 p.m., received food. 12:15 p.m., offered alternative meal 12:20 p.m., received substitute. CNAs observed to encourage eating throughout meal. Resident observed to feed self without limitation. During an interview on 8/19/2015 at 4:07 p.m., the Registered Dietician indicated he was unfamiliar with Resident #79 and his weight loss. He indicated he would look into his weight loss. During an interview on 8/20/2015 at 3:10 p.m., the Director of Nursing (DON) indicated she did not find documentation that the physician was notified of Resident #79's weight loss from June to July. She indicated documentation of physician and family notification would be in the nursing progress notes. She indicated the diet order in July came from the Dietary Manager's recommendation. During an interview on 8/21/2015 at 10:10 a.m., Licensed Practical Nurse (LPN) #22 indicated if a resident had weight loss during the month she told the Unit Manager and the Unit Manager contacted the physician and family. During an interview on 8/21/2015 at 10:38 a.m.,Unit Manager (UM) #23 indicated she notified the physician and family the same day a resident's weight loss was discovered. Unit Manager (UM) #23 indicated when a resident consumed 50 percent or less of a meal the Certified Nursing Assistant (CNA) notified the charge nurse and the charge nurse notified the physician. She indicated she had recently became the UM for the unit so she did not handle Resident #79's decreased intakes for June or July, and she was unsure what the former UM had done about his reduced intake. On 8/21/15 at 12:00 p.m., the Nurse Consultant indicated the facility did not have a nutrition policy. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to evaluate the effectiveness of pain management interventions which resulted in uncontrolled pain that interfered with daily care and prevented participation in previously enjoyed activities. This deficient practice affected 1 of 35 residents reviewed for pain management (Resident #7). Findings include: Resident #7's record was reviewed on 6/10/2013 at 11:18 A.M. Resident #7 had [DIAGNOSES REDACTED]. An un-timed, physician's note, dated 1/18/2013, indicated Resident #7 had been combative during care. The physician indicated in this note the behavior was most likely due to pain. The physician changed Resident #7's pain medication from as needed to scheduled. During an interview on 6/11/2013 at 10:44 A.M., Resident #7 stated, "I don't hurt when I am in bed. Just when I get up, I hurt all over." During an observation on 6/11/2013 at 11:02 A.M., CNA's #11 and #12 were observed transferring Resident #7 from her bed to her chair for lunch. Prior to being transferred to the chair, Resident #7 did not exhibit verbal or non-verbal expressions of pain. CNA #11 and #12 put Resident #7's shoes on her feet and began to transfer her. At this time Resident #7 stated, "They hurt my feet. Oh, Oh, Oh, please don't do that. Please don't do that. Please don't do that. Oh, Oh that's awful. I can't do it. I'm sorry. No, I can't. I'm sorry. Make them leave me alone, please. Don't. It hurts. I'm trying to. Oh, Oh, my goodness gracious." Once Resident #7 was up and in the chair she no longer complained of pain. During an interview at this time, CNA #11 and #12 indicated they had told nursing about her pain during care. They further indicated they felt pain very much affected Resident #7's quality of life. A care plan, dated 4/25/2013, indicated Resident #7 had acute pain. A goal listed for Resident #7 was "Amelioration" of immediate pain. Interventions listed to meet this goal included administer pain medication as ordered, monitor and record effectiveness of medication, assess for verbal and not-verbal signs and symptoms of distress or pain unrelieved by ordered treatments/medication, and report to provider signs and symptoms of distress or pain unrelieved by ordered treatments/medications. A care plan, dated 5/17/2013, indicated Resident #7 had cognitive impairment, her orientation had severe impairment, she was oriented to person and place, and had long term and short term memory problems. An intervention listed included staff were to anticipate her needs. A care plan, dated 6/3/2013, indicated Resident #7 yelled obscenities during oral care related to pain and was physically abusive during ADL (activity of daily living) care with staff. Goals listed for Resident #7 included: Resident #7 would not harm herself or others, she would accept care, and the frequency of her behaviors would decrease. Interventions to meet these goals included assess for pain. The May 2013 and June 2013, Medication Administration Records (MAR) indicated, nurses were to provide a rating if Resident #7's pain program was not effective. The MARs lacked documentation of a pain rating. An un-timed quarterly nursing data collection and assessment note, dated 5/24/2013, indicated Resident #7 currently had pain, the pain had been present in the past several months, and she effectively used a Pain Rating Scale. This form further indicated Resident #7 was totally dependent on staff for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene, and bathing. An un-timed pain data collection and assessment document, dated 5/24/2013, indicated Resident #7 vocalized crying/whining and stated"ouch" during care and transfers. Resident #7 was unable to rate her pain on a zero to ten scale so the Wong-Baker Face pain Scale Number was utilized. Staff rated Resident #7's pain as a 4 (hurts little more) on the pain scale. Documentation was lacking of an assessment of the effectiveness of the current pain interventions provided to Resident #7. An un-timed pain data collection and assessment note, dated 6/7/2013, indicated Resident #7 cried and whined and was agitated. A score of 4 (hurts little more) was documented as staff's rating of her pain. The record lacked documentation of an assessment of the effectiveness of the current pain medication/interventions. An un-timed nursing assessment update note, dated 6/10/2013, indicated Resident #7 was awake, alert to person, combative with care, demeanor was peaceful other than became anxious and agitated with care. This assessment contained a nursing narrative which indicated, "...Patient gets extremely upset, cursing, hitting and anxious with any type of care...." This narrative lacked documentation of an assessment of the effectiveness of current pain control interventions. A care plan, dated 5/17/2013, indicated it was very important or somewhat important for Resident #7 to choose between a bath or shower and she preferred a shower. During an interview on 6/10/2013 at 1:00 P.M., the DON (Director of Nursing) and RN (Registered Nurse) #2 both indicated Resident #7 got very agitated during showers. They indicated she did not get as agitated for bed baths. The DON indicated the family wanted Resident #7 to have showers. At this time, the DON was queried about interventions addressing Resident #7's pain prior to showers. She indicated she was not for sure. Documentation of all pain management interventions, assessments, and evaluations of the effectiveness of her current pain management regimen was requested. A 6/10/2013-4:00 P.M., verbal/telephone order, indicated, "DC (discontinue) showers, change to bed baths due to patient's anxious behaviors in showers." The record lacked documentation of a pain assessment to determine if current pain interventions were effective prior to having Resident #7's preferred form of bathing discontinued. A care plan, dated 5/17/2013, indicated Resident #7 enjoyed all kinds of music and doing things with groups of people. Goals for Resident #7 included going to morning groups, music, showers, A.M. groups, and attending special events 2-5 times a week. Interventions to meet these goals included to provide her with her preferred choices of group activities and to provide transportation to group activities. On 6/10/2013 at 10:00 A.M., an activity called "Chronicle Review" was provided for the residents. Resident #7 had been assessed to enjoy this activity. During this activity, Resident #7 was observed sitting in her room with her eyes open. At 10:30 A.M., an activity called "Fit and Fun" was provided for the residents. Resident #7 had been assessed to enjoy this activity. During this activity, Resident #7 was observed sitting in her room with her eyes open. On 6/10/2013 at 10:00 A.M., an activity called "Chronicle Review" was provided for the residents. Resident #7 had been assessed to enjoy this activity. During this activity, Resident #7 was observed in her bed with her eyes open. At 10:30 A.M., an activity called "Fit and Fun" was provided for the residents. Resident #7 had been assessed to enjoy this activity. During this activity, Resident #7 was observed in her bed with her eyes open. During an interview on 6/11/2013 at 2:25 P.M.., the Activity Director indicated she brought Resident #7 to activities when she was up. She included her in group activities but she usually had to leave because she hurt. She wasn't able to tell staff where she hurt. Her mood fluctuated a lot because of her pain. The Activity Director further indicated Resident #7 would apologize for having to leave because she hurt. The Activity Director clarified the activity listed as "Mix and Mingle" occurs at lunch when she goes around and talks to the residents at lunch. The Activity Director indicated she did not provide 1:1 activities to Resident #7. At this time documentation of Resident #7's activity attendance for May and June 2013, was requested. Resident #7's activity attendance for May 1-31, 2013, indicated activities that met her assessed preferences were available thrifty-one of the thrifty-one days in May. Other than the activity called "Mix and Mingle" provided during lunch, Resident #7 was not taken to activities twenty-six out of the thirty-one days in May. Resident #7's activity attendance for June 1-11, 2013, indicated activities that met her assessed preferences were available on eleven of the eleven days. Other than the activity called "Mix and Mingle" provided during lunch, Resident #7 was not taken to activities on nine of the eleven days reviewed. During an interview on 6/12/2013 at 9:24 A.M., the Administrator indicated he felt the facility had identified Resident #7's pain but because of the lack of coordination between staff they had not put the pieces together to evaluate the effectiveness of the current pain control interventions. He further indicated even though the nurses were documenting on the MAR indicated [REDACTED]. 3.1-37(a)

Based on observation, record review and interview, the facility failed to follow their policies and procedures to ensure the prevention of neglect in treatment and services related to basic bowel care and assessment and monitoring of opioid pain medication for 1 of 4 residents reviewed for neglect of care and services. The resident required medical intervention at the emergency room twice in two weeks. (Resident Y) Findings include: 1. Resident Y's clinical record was reviewed on 6/15/12 at 10:55 a.m. It indicated he was admitted [DATE] for surgical wound care. His [DIAGNOSES REDACTED]. The 9/9/2011 admission MDS (Minimum Data Set) assessment and the 6/1/2012 readmission MDS assessment both indicated he was nonverbal and totally dependent on staff for all aspects of his care. The MDS assessment indicated Resident Y was not able to take himself to the bathroom independently or to verbally express feelings of discomfort and/or pain. A careplan entry, dated 10/25/2011, indicated Resident Y had a history of [REDACTED]. Review of the computerized bowel care sheets indicated Resident Y had no recorded bowel movements from May 15 through May 22, 2012, i.e. seven days. Further, he'd had a small BM on May 12th, none on the 13th, and two small BMs on May 14th. This indicated he had not had an adequate bowel evacuation since May 11th. On May 22, 2012, Resident Y's family alerted staff that the resident was "not acting right." The note of 5/22/2012 at 2:20 p.m., indicated "approached by mother, requested to eval resident. Mom states something is not right with (resident)...eyes open, pupils reactive yet sluggish. resident is still, not moving limbs or body...very still, reactive to tactile stimuli..." The physician was notified and authorized transfer to the emergency room per the family's request. The "Emergency Department Discharge Instructions" form, dated 5/22/12, was reviewed on 6/15/12 at 10:55 a.m. At the emergency room (E.R.) on 5/22/12, Resident Y was diagnosed with [REDACTED]." An abdominal CT (computed tomography) taken at that time indicated "There is a large amount of formed stool noted throughout the colon...Impression: 1. large stool burden." The E.R. nursing note indicated the resident returned to the facility 5/23/12 at 12:15 a.m. Family interview on 6/19/12 at 12:48 p.m., indicated she had not changed a BM brief during her visits in the facility nor when she took Resident Y out of the facility. She stated she'd seen "scratch marks on his abdomen and behind his legs" which she believed Resident Y had self inflicted pulling and tearing at his abdomen and legs due to abdominal discomfort. She indicated that as soon as the bowel impaction was manually removed in the emergency room , Resident Y had visibly relaxed. Observations on 6/14/12 at 12 noon, 1:00 p.m., 2:22 p.m. and 4:10 p.m.; 6/15/12 at 11:05 am, 1:35 p.m., 2:55 p.m.; 6/18/12 at 10:35 a.m., 12:52 p.m., 2:10 p.m. and 4:15 p.m., indicated Resident Y spent most of his time in bed and was up only for meals. The privacy curtain was kept closed enough to be unable to visualize the resident without going into the room past the curtain. Staff were noted in the room only when direct care was necessary. The facility protocol for bowel care indicated their "standard bowel care to relieve constipation with a provider order may include the following: ? Milk of Magnesia 30 cc (cubic centimeters) PO (orally) every third day without BM ? [MEDICATION NAME] Suppository rectally if no results from Milk of Magnesia ? Fleets Enema rectally if no results from [MEDICATION NAME] Suppository" Review of the nursing notes from May 11 through May 22, 2012 indicated there was no documentation related to bowel care/management or constipation. There was no indication the bowel sheets had been reviewed. There was no indication assessment or treatment had been provided. Review of the physician orders [REDACTED]. In addition, the resident had a physician order, dated 11/7/2011, to use [MEDICATION NAME] suppositories every three days as necessary for constipation. Milk of Magnesia was documented as having been given once, 5/10/2012, during the month of May 2012. No doses of [MEDICATION NAME] were documented as given. This issue was discussed during an interview with the Administrator and Director of Nursing Services (DNS) at 5 p.m. on 6/18/2012. The DNS shook her head negatively and insisted this could not have occurred. She indicated the family had taken the resident out of the facility and failed to report a BM had occurred during the outing. Family interview on 6/19/12 at 12:48 p.m., indicated the only time she had taken Resident Y out of the facility in May 2012 was to the dentist on 5/16/12. She indicated she had not changed a BM brief during her visits in the facility nor when she took Resident Y out of the facility. She added, "He's much too big for that now. There are no places we could do that. I'd have to bring him back to the facility and let them do it." 2. Continued record review for Resident Y indicated he had a 1/19/2012 physician's orders [REDACTED]. This was used sparingly until 5/16/2012 when he had two teeth extracted. Until that time, [MEDICATION NAME] was documented on the May 2012 MAR (medication administration record) as having been given once on May 4, May 7 and May 13, 2012. Review of the May 2012 MAR and the [MEDICATION NAME] sign out sheets indicated Resident Y then received [MEDICATION NAME] more often: On May 15th (the day before the extraction) he received 5 doses, none on the 16th or 17th, 5 doses on the 18th, 5 doses on the 19th, 5 doses on the 20th, 3 doses on the 21st, 1 dose on the 22nd, 2 doses on the 23rd. On the 24th he received 4 doses, 5 doses on the 25th, 3 doses on the 26th, and 4 doses on the 27th. A nursing note entry of 5/27/12 at 3:22 p.m., indicated "spent all day sleeping et was unable to be aroused by staff or family to eat lunch. He had 2 doses on the 28th. This was now twelve days after the teeth extractions. The indications documented in the nursing notes for giving the [MEDICATION NAME] were usually related to increased agitation, head banging and thrashing around in bed. However, not all doses of [MEDICATION NAME] were recorded in the nursing notes. Examples not inclusive of all were: 5 doses of [MEDICATION NAME] were documented on the [MEDICATION NAME] tracking sheet as given to Resident Y on 5/19/12, but there were no nursing notes for that date. On 5/20/12, he received 5 doses of [MEDICATION NAME]: 4 am, 8 am, 12 noon, 4 pm and 8 pm. The nursing notes for that day were as follows: "2:20 am, lab results called to physician. no new orders.; 3 am, rested quietly, some moaning & yelling out early in the shift. 0 bleeding noted to his gums around his mouth r/t (related to) teeth being pulled. Pt inc (incontinent) of bladder, staff provides peri care & repositioning...." The system the facility used for tracking controlled drugs was to maintain a booklet for each month with a different page for each drug order. Each page had spaces to be completed by staff each time a new order of controlled medication was received. These spaces were listed as "resident's name, Rx #, date, medication, strength, nurse receiving medication, directions, physician, transferred from page number (if applicable), and quantity." There was no space on this designated tracking page to indicate what indicators were to be followed. The behaviors of head banging, throwing his body to and fro and becoming agitated were common to his diagnoses. Family interviewed on 6/19/12 at 12:45 p.m., indicated these behaviors had been displayed since Resident Y's infancy and seemed to come in "spurts." They indicated Resident Y's usual indicators of pain were biting his clothes and a certain pitched squeal. There were no comprehensive assessments documented regarding whether or not the head banging and throwing his body to and fro were his ways of expressing pain or frustration or behaviors related to his severe autism and [MEDICAL CONDITION]. On 5/28/2012, the 1:55 p.m. nursing note indicated, "T-95.6, O2 (oxygen) 96%, BP 68/42, P 56, R 18. Writer notified by family that approx (approximately) 12 p res stopped breathing. Upon assessment noted res (resident) pale, cool et (and) clammy. Lung fields cl (clear). resp shallow at 18. BP 68/42, O2 sats 96% RA (room air). MD notified and received order to send res out. At 12:15 res resp (respirations) decreased to 14, [MEDICAL CONDITION] noted on auscultation. Res moved to floor c (with) stimulation res open eyes briefly. Crash cart obtained at 12:25 p. 911 arrived at 12:30 p et res transferred out to HRH (hospital). Family followed ambulance out." Review of the hospital discharge summary of 5/29/2012 indicated Resident Y's primary [DIAGNOSES REDACTED]. With the third [DIAGNOSES REDACTED]. He was discharged back to the facility on 5/29/2012 with a change in his pain medication from scheduled [MEDICATION NAME] to [MEDICATION NAME] Elixer on an as needed basis "to avoid over sedation." To be noted, the [MEDICATION NAME] order had also been on an as needed basis. The Administrator and Director of Nursing Services indicated during an interview on 6/18/2012 at 5 p.m., that the behaviors of head banging and throwing his body to and fro were indicators of pain and could not be further evaluated due to his mute autism and mental [MEDICAL CONDITION]. They did not offer an explanation for the lack of assessment of his lethargy. Review of the facility Abuse/Neglect protocol on 6/18/2012 at 11:35 a.m. indicated the facility defined neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. This presumes that instances of abuse/neglect of all residents, even those in a coma, cause physical harm, pain or mental anguish." The most recent abuse/neglect all staff inservice was dated 8/18/2011. This federal tag relates to complaint IN 086. 3.1-28.(a)

Based on record review and interviews, the facility failed to provide adequate bowel care for a mute resident receiving opiate pain medication over an extended period of time by failure to monitor the BM sheets, failure to utilize the existent physician orders [REDACTED]. This affected 1 of 4 residents reviewed for bowel care and resulted in transfer to the emergency room with [DIAGNOSES REDACTED]. (Resident Y) Findings include: 1. Resident Y's clinical record was reviewed on 6/15/12 at 10:55 a.m. It indicated he was admitted [DATE] for surgical wound care. His [DIAGNOSES REDACTED]. The 9/9/2011 admission MDS (Minimum Data Set) assessment and the 6/1/2012 readmission MDS assessment both indicated he was nonverbal and totally dependent on staff for all aspects of his care. The MDS assessment indicated Resident Y was not able to take himself to the bathroom independently or to verbally express feelings of discomfort and/or pain. A careplan entry, dated 10/25/2011, indicated Resident Y had a history of [REDACTED]. Interviews of LPN #3 and #4 and the Director of Nursing Services about facility bowel protocol indicated the following: A. LPN #3 6/18/12 at 4 p.m.: There is a bowel sheet printed out for the nurses every day. We are to monitor it. If a resident goes 3 days without a BM, give PRN dose of Milk of Mag. Repeat it if necessary. B. LPN #4, 6/18/12 at 4:40 p.m.: Day shift monitors and gives PRN Milk of Mag if over 3 days without BM or if they only have small BMs. They tell the 2nd shift nurse and if no results, give another dose Milk of Mag. Said would tell day shift if no results and they would call MD. C. Director of Nursing Services 6/18/12 at 5 p.m.: Daily print outs of CNA computerized bowel care sheets. Nurse is to monitor. Give Milk of Mag if 3 days without BM. Follow up with [MEDICATION NAME] if no results from Milk of Mag. Review of Resident Y's physician orders [REDACTED]. Review of [MEDICATION NAME] in the 2010 Nursing Spectrum Drug Handbook indicated it is classified as an opioid narcotic to be used for moderate or severe pain when continuous around-the-clock [MEDICATION NAME] is needed. Potential adverse reactions included constipation and pruritis (extreme itching). The May 2012 MAR (Medication Administration Record) indicated [MEDICATION NAME] was given once on 5/4/12, 5/7/12 and 5//13/12. On the 15th of May it was given 5 times for suspected oral pain. Two teeth were extracted 5/16/12. He received no doses on the 16th or 17th, 5 doses on the 18th, 5 doses on the 19th, 5 doses on the 20th, 3 doses on the 21st, 1 dose on the 22nd, 2 doses on the 23rd. On the 24th he received 4 doses, 5 doses on the 25th, 3 doses on the 26th, and 4 doses on the 27th. A nursing note entry of 5/27/12 at 3:22 p.m. indicated "spent all day sleeping et was unable to be aroused by staff or family to eat lunch. He had 2 doses on the 28th. It was by then twelve days after the teeth extractions. Review of the computerized bowel care sheets mentioned above indicated Resident Y had no recorded bowel movements from May 15 through May 22, 2012, i.e. seven days. Further, he'd had a small BM on May 12th, none on the 13th, and two small BMs on May 14th. This indicated he had not had an adequate bowel evacuation since May 11th. On May 22, 2012, Resident Y's family alerted staff that the resident was "not acting right." The note of 5/22/2012 at 2:20 p.m., indicated "approached by mother, requested to eval resident. Mom states something is not right with (resident)...eyes open, pupils reactive yet sluggish. resident is still, not moving limbs or body...very still, reactive to tactile stimuli..." The physician was notified and authorized transfer to the emergency room per the family's request. The "Emergency Department Discharge Instructions" form, dated 5/22/12, was reviewed on 6/15/12 at 10:55 a.m. At the emergency room (E.R.) on 5/22/12, Resident Y was diagnosed with [REDACTED]." An abdominal CT (computed tomography) taken at that time indicated "There is a large amount of formed stool noted throughout the colon...Impression: 1. large stool burden." The E.R. discharge document indicated the impaction was removed and the resident returned to the facility 5/23/12 at 12:15 a.m. Review of the nursing notes from May 11 through May 22, 2012 indicated there was no documentation related to bowel care/management or constipation. There was no indication the bowel sheets had been reviewed. There was no indication assessment or treatment had been provided. Review of the physician orders [REDACTED]. Milk of Magnesia was documented as having been given once, 5/10/2012, during the month of May 2012. No doses of [MEDICATION NAME] were documented as given. Family interview on 6/19/12 at 12:48 p.m., indicated she had not changed a BM brief during her visits. She stated she'd seen "scratch marks on his abdomen and behind his legs," which she believed Resident Y had self inflicted by pulling and tearing at his abdomen and legs due to abdominal discomfort. She indicated that as soon as the bowel impaction was removed in the emergency room , Resident Y had visibly relaxed. The facility protocol for bowel care was reviewed on 6/18/12 at 4:50 p.m. and indicated their "standard bowel care to relieve constipation with a provider order may include the following: ? Milk of Magnesia 30 cc (cubic centimeters) PO (orally) every third day without BM ? [MEDICATION NAME] Suppository rectally if no results from Milk of Magnesia ? Fleets Enema rectally if no results from [MEDICATION NAME] Suppository" Review of the nursing notes from May 11 through May 22, 2012 was notable in that nothing was mentioned about bowel care, constipation, etc. Further review of the computerized bowel care sheets for May through June 16, 2012 indicated there was no documented bowel movement from June 1 through June 8, 2012. This was 8 days without a documented bowel movement. Review of the MAR indicated [REDACTED]. A small bowel movement was documented for June 9, 2012 and two extra large bowel movements were documented on 6/10/12. This issue was discussed during an interview with the Administrator and Director of Nursing Services (DNS) at 5 p.m. on 6/18/2012. The DNS shook her head negatively and insisted this could not have occurred. She indicated the family had taken the resident out of the facility and failed to report a BM had occurred during the outing. Family interview on 6/19/12 at 12:48 p.m., indicated the only time she had taken Resident Y out of the facility in May 2012 was to the dentist on 5/16/12. She indicated she had not changed a BM brief during her visits in the facility nor when she took Resident Y out of the facility. She added, "He's much too big for that now. There are no places we could do that. I'd have to bring him back to the facility and let them do it." The 10/25/2012 care plan addressing "alteration in bowel elimination plan of care" indicated Resident Y had a history of constipation. The interventions included "Review Care Tracker BM Reports." This federal tag relates to complaint IN 086. 3.1-37(a)

Based on observation, record review and interviews, the facility failed to ensure 1 of 4 residents sampled for medication review did not receive unnecessary medication. This was due to the facility's failure to perform thorough assessments of the resident's condition to determine need for these medications and/or to monitor for adverse reactions. This resulted in the resident being transferred to the emergency room with a resultant [DIAGNOSES REDACTED]. (Resident Y) Findings include: During the orientation tour of 6/14/2012 at 11:15 a.m., Resident Y was observed lying on a mattress on the floor of his room. He was observed to be unable to get out of bed independently unless he rolled out. RN #5 indicated at the time that Resident Y was severely autistic and had behaviors of yelling, thrashing when in a wheelchair, rolling into furniture, biting self and staff and wore a helmet at all times to prevent injuries during these behaviors. Resident Y's clinical record was reviewed on 6/15/12 at 10:55 a.m. It indicated he was admitted [DATE] for surgical wound care. His [DIAGNOSES REDACTED]. The 9/9/2011 admission MDS (Minimum Data Set) assessment and the 6/1/2012 readmission MDS assessment both indicated he was nonverbal and totally dependent on staff for all aspects of his care. The MDS assessment indicated Resident Y was not able to take himself to the bathroom independently or to verbally express feelings of discomfort and/or pain. Interview with LPN #6 on 6/18/12 at 2:20 p.m., indicated Resident Y had been calm and quiet when admitted last year, but as his physical condition improved, he became more and more active and now was uncontrollable at times, requiring staff to stay with him 1:1 just to keep him safe from his potentially self-injurious behaviors. Nursing notes and physician orders [REDACTED]. Because the resident began chewing on his clothing and trying to put things in his mouth at that time, the family suggested he was in pain. Staff began utilizing a PRN (as needed) physician order [REDACTED]. [MEDICATION NAME] is classified as an opioid narcotic. On May 15th, the controlled substance register for the [MEDICATION NAME] indicated 5 doses were administered to Resident Y for oral pain. The teeth were extracted on 5/16/12 and he received 3 doses on the 16th and none on the 17th of May. He received 5 doses on the 18th, 5 doses on the 19th, 5 doses on the 20th, 3 doses on the 21st, 1 dose on the 22nd, 2 doses on the 23rd. On the 24th he received 4 doses, 5 doses on the 25th, 3 doses on the 26th, and 4 doses on the 27th. A nursing note entry of 5/27/12 at 3:22 p.m. indicated "spent all day sleeping et was unable to be aroused by staff or family to eat lunch. He had 2 doses on the 28th. It was by then twelve days after the teeth extractions. Review of the physician orders [REDACTED]. twice daily if needed for anxiety. [MEDICATION NAME] is in the benzodiazepine classification of drugs. Review of [MEDICATION NAME] in the 2010 Nursing Spectrum Drug Handbook indicated the interaction between [MEDICATION NAME] and opioids ([MEDICATION NAME]) included depression of the CNS (central nervous system) which is the control center for breathing, blood pressure, and heart rate, amongst other functions. It advised "watch for excessive CNS depression, i.e. low blood pressure, slow heart rate and respirations." Comparison of the nursing notes and controlled substance registers indicated Resident Y was given both of these medications, sometimes at the very same time. Evidence of staff attempts to determine whether the resident needed a pain pill or an anxiety pill, if any, were lacking. Examples, not inclusive of all: a. 5/18/12: Nursing note, no time stated: "alert, rested quietly in bed most of night. [MEDICATION NAME] 5 mg tab PO (orally) @ 12 am and 4 am per order, crushed in applesauce c thickened water...0 bleeding noted form extraction sites to mouth...." There was no indication Resident Y needed these two doses of an opioid. A nursing note at 2 p.m. indicated, "Res agitated @ breakfast this morning. Res was banging head on back of w/c (wheelchair) et yelling loudly. PRN [MEDICATION NAME] given as ordered by MD. Res laid down p (after) breakfast. Continued to roll around mat et make loud noises. Res fell asleep approximately 10 a.m....remains in bed asleep @ this time. 0 further behaviors noted since breakfast." The controlled substance register indicated he received [MEDICATION NAME] every 4 hours (12 a.m., 4 a.m., 8 a.m., 4 p.m., and 8 pm) and [MEDICATION NAME] 0.5 mg at 8 a.m. and 8 p.m. Both were to be given only if needed. b. 5/19/12: There were no nursing notes for the entire day. Resident Y received 5 doses of [MEDICATION NAME] and 0.5 mg of [MEDICATION NAME] at 7 a.m. and 1.0 mg at 7:40 p.m. c. 5/23/12: Nursing note at 7:30 p.m.: "Has remained quiet most of shift. Resting soundly. 0 symp (symptoms) of agitation, medication x 1 for pain. Oral care provided...." Resident Y received [MEDICATION NAME] at 6 p.m. and 10 p.m. and [MEDICATION NAME] at 2 a.m. and 9 p.m. There were no comprehensive assessments documented regarding whether or not the head banging and throwing his body to and fro were his ways of expressing pain or frustration or behaviors related to his severe autism and [MEDICAL CONDITION]. On 5/28/2012, the 1:55 p.m. nursing note indicated, "T-95.6, O2 (oxygen) 96%, BP 68/42, P 56 R 18. Writer notified by family that approx (approximately) 12 p res stopped breathing. Upon assessment noted res (resident) pale, cool et (and) clammy. Lung fields cl (clear). resp shallow at 18. BP 68/42, O2 sats 96% RA (room air). MD notified and received order to send res out. At 12:15 res resp (respirations) decreased to 14, [MEDICAL CONDITION] noted on auscultation. Res moved to floor c (with) stimulation res open eyes briefly. Crash cart obtained at 12:25 p. 911 arrived at 12:30 p et res transferred out to HRH (hospital). Family followed ambulance out." Review of the emergency room discharge summary of 5/29/2012 indicated Resident Y's primary [DIAGNOSES REDACTED]. The third [DIAGNOSES REDACTED]. He was discharged back to the facility on [DATE] with a change in his pain medication from scheduled [MEDICATION NAME] to [MEDICATION NAME] Elixer on an as needed basis "to avoid over sedation." During interview with the Administrator and the Director of Nursing on 6/18/12 at 5 p.m., they indicated staff were giving the [MEDICATION NAME] for behaviors of head banging, throwing his body to and fro/especially while in a wheelchair, and biting. The Director of Nursing indicated it was hard for them to tell what was bothering him because he is mute and mentally disabled. They indicated the reason the medication was given was to be documented in the nursing notes. This federal tag relates to complaint IN 086. 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(5) 3.1-48(a)(6)

A. Based on record review and interview, the facility failed to prevent an avoidable accident related to improper transfer of a resident (Resident #54) using a Hoyer lift (mechanical lift) causing extensive bruising 1 of 7 residents reviewed for bruising in a sample of 20 residents reviewed. B. Based on record review and interview, the facility failed to monitor the functioning of a personal alarm for a resident (Resident #13) with a history of falls. The deficient practice affected 1 of 2 residents reviewed with self-release alarmed belts. Findings include: A. 1. On 5/14/12 at 10:25 A.M., tour was initiated with Registered Nurse (RN) #4. Resident #54 was identified as non-interviewable and required total assistance with care. At that time, the Certified Nursing Assistant (CNA) Assignment Sheet for Resident #54 was requested from RN #4 and received at 11:00 A.M. In an interview, RN #4 indicated the sheet was the most current. The CNA Assignment Sheet indicated Resident #54 was a total assist with all activities of daily living and required the use of a Hoyer (mechanical) lift with 2 person assist with transfers. On 5/14/12 at 11:00 A.M., the Administrator provided an abuse investigation for Resident #54 for the Abuse Prohibition Protocol. The facility abuse investigation included, but was not limited to the following information: A "Fax/Incident Report," dated with incident date 12/4/11 at 4:00 A.M., included, but was not limited to, "Brief Description of Incident: During ADL (activities of daily living) care Certified Nursing Assistant (CNA) # 1 noted bruise to resident's (Resident #54) right breast and back measuring 19 centimeters by 8 centimeters... Immediate Action Taken: Assessed rest of body no other area identified, pain assessment completed, Director of Nursing (DoN), family, and M.D. notified... ongoing investigation continues... Preventative Measures Taken: In-servicing CNA's and Nursing on the use of the Hoyer lifts and the proper use of slings with a return demonstrations... Nursing will be able to identify improper use of hoyer sling..." A "Incident of Unknown Origin," dated 12/4/11 at 4:00 A.M., included, but was not limited to, "Any environmental factors/resident habits that may have caused injury? Transfers with Hoyer lift and assist of one (should have been 2 staff transferring with the mechanical lift)... Factors that may have caused the incident: Resident (#54) is transferred with a Hoyer lift... Nursing identified staff member (CNA #8) using Hoyer pad incorrectly..." A written statement from RN #3, dated 12/5/11, no time, included, but was not limited to, "Observed (CNA #8) transferring (Resident #54) with the Hoyer lift... did not look appropriate for resident... hand grips appear on bottom instead of top of sling (had sling upside down) sling looked too small... straps cutting into (resident) arms..." On 5/15/12 at 2:05 P.M., Resident #54's record was reviewed. [DIAGNOSES REDACTED]. A quarterly "Minimum Data Set" screening, dated 3/22/12, included, but was not limited to, "Brief Interview Mental Status (BIMS): no score (unable to complete)... Transfer: 4/3 (extensive assist of 2 or more persons..." On 5/15/12 at 4:20 P.M., the policy and procedure on the Hoyer lift and the manufacturer's guide for the Hoyer lift was requested from the Administrator and DoN. On 5/16/12 at 8:45 A.M., the "Mechanical Lift" policy and procedure, dated 1/11, and the manufacturer's guide for the "Manual/Electric Portable Patient Lift," dated 2011, was received from the DoN. The policy and procedure included, but was not limited to, "Verify that staff is aware of the proper procedures and the manufacturer's instructions for equipment use..." The "Manual/Electric Portable Patient Lift" included, but was not limited to, "Warning: Although Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant... The use of one assistant is based on the evaluation of the health care professional for each individual case..." B.1. On 5/14/12 during the initial tour of the facility, Resident #13 was identified as non-interviewable, having mental retardation, history of falls, and utilizing a self-release seat belt while up in wheelchair for fall prevention. At 10:45 A.M., during the initial tour, Resident #13 was observed in his room at the bedside releasing his self-release belt, and standing to retrieve a personal item off his bed. At that time, his personal alarm started sounding and RN #4 immediately checked on the resident without incident. On 5/17/12 at 1:10 P.M., Resident #13's record was reviewed. [DIAGNOSES REDACTED]. A "Nurse's Progress Notes," dated 4/23/12, no time, indicated Resident #13 fell getting out of bed to his wheelchair as the wheelchair brakes were not locked. On 5/17/12 at 1:20 P.M., in an interview, LPN #6 indicated Resident #13 could release his self-release seat belt without any difficulty. At that time, LPN #6 instructed the resident to release his seat belt on command. Resident #13 was observed to move the seat belt without difficulty or cueing. However, upon removal of the seat belt, the alarm did not sound. At that time, in an interview, LPN #6 indicated the resident broke his alarm and had a history of [REDACTED]. She indicated she would replace his alarm. On 5/17/12 at 1:25 P.M., the daily function check for Resident #13's personal alarm was requested. LPN #6 could not find the documentation in the chart and indicated the function was to be checked each shift. On 5/17/12 at 1:30 P.M., in an interview, RN #4 indicated Resident #13's self-release seat belt should be checked and documented each shift. RN #4 was unable to locate the documentation for the personal alarm function check. On 5/18 12 at 3:00 P.M., the documentation of Resident #13's personal alarm function was requested from the Administrator and DoN. On 5/21/12, the Administrator and DoN were unable to provide the requested documentation for Resident #13's personal alarm function checks each shift. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to proactively implement effective and timely interventions to prevent a friction/ shear wound from developing into a Stage 4 pressure ulcer, (Resident #83); and failed to ensure a liquid protein nutritional supplement ordered to enhance the healing of a pressure sore was administered, (Resident #68). This impacted 2 of 4 residents reviewed with pressure ulcers in a sample of 18 residents. Findings include: 1. In an interview during the initial tour on 2/21/11 at 10:55 A.M., the A.D.O.N. (Assistant Director of Nursing) indicated Resident #83 had a Stage 4 pressure sore on the coccyx, which was acquired in-house. The resident currently had a "Roho" pressure-relieving cushion for his wheelchair, and was transferred in and out of bed with a mechanical lift. The clinical record for Resident #83 was reviewed on 2/22/11 at 9:00 A.M. [DIAGNOSES REDACTED].V.A. (stroke) with left arm weakness, depression, and incontinence (loss of control)of bowel and bladder. The resident was hosptalized on [DATE] and returned to the facility on [DATE]. A document titled "Admission Skin Assessment" indicated, by a pictograph, that the resident had a pressure sore measuring 0.4 cm. (centimeters) by 3 cm., and located on the top posterior portion of the left inner thigh, below the buttock. Another area was identified at the top posterior portion of the right inner thigh, below the buttock, measuring 0.3 cm. by 2 cm. No other areas of pressure sores or skin breakdown were identified on the form. A "Braden Risk Assessment Scale" form, dated 12/1/10, indicated the resident was at "... moderate for risk of skin breakdown...." upon return from hospital. On 12/15/10, he was assessed to be at "... high risk for skin breakdown....," and on 12/19/10, 12/22/10, and 1/12/11, he was assessed to be at "...moderate risk for skin breakdown...." A "Physician Notification" form, dated 12/14/10 at 2:50 P.M., indicated the resident had "... new areas (pressure sores) on buttock and coccyx," with a date and time of onset of symptoms 12/14/10. The "Wound Evaluation Progress Notes" from the facility's Wound physician specialist, indicated the following: 12/15/10--the resident had "two areas on the right gluteal and left buttock... friction wounds." An area on the coccyx was not identified. 12/22/10--"... still has areas on right and left buttock, ...friction...." 12/28/10--"... friction wound on coccyx measuring 6.8 x 4.0 and wound base 100% red." 1/5/11--the note indicated the resident had "friction wound on LT (left) coccyx measuring 2.1 x 0.8 cm, 10 % wound base red, 90% yellow, and no black. Right buttock measuring 2.4 x 1.1, 10 % of wound base red, 90% yellow and no black. On mid line coccyx 1.2 x 0.4, 60% wound base red, 40% yellow and no black." 1/12/11-- the note indicated friction wounds to these areas: R (right) buttock 1.8 x 1.2 x < 0.1, with 100 % wound base red . LT coccyx 0.6 x 0.3 and 100% wound base red, and mid line coccyx 1.8 x 0.7 x < 0.1 with 100% wound base red." All areas had a minimal amount of serous (clear fluid) drainage. 1/19/11--"... friction/shear wound on coccyx 5.5 x 4.2.... Hoyer (mechanical) lift only, no slide board...." 1/26/11--"... friction/shear wound on coccyx 7.2 x 3.7 x 0.2." 2/2/11--"... friction/press (pressure), Stage II 5.6 x 4.5 moderate amount of serous drainage and 70% wound base red and 30 % yellow." 2/9/11--"... friction wound sacral/coccyx 7.5 x 4.5 x 1.0.... Pt. (patient) must be on left/right side, not on back. Pt. continues to move into position onto back. In bed only for sleep...." 2/16/11--"... coccyx wound 5.8 x 3 x 0.8, 70 % red wound base and 30% yellow." One Care Plan entry, originally dated 12/14/10 with a most recent revision date of 2/16/11, addressed a problem of " SKIN INTEGRITY ASSESSMENT: PREVENTION AND TREATMENT PLAN." In the section for "Skin Protection," with a start date of 12/14/10, the following interventions checked: "use assistive devices to reduce friction and facilitate resident movement such as: turning sheets, overbed trapeze, resident lift...." In the section for "Manage Friction and Shear," no interventions were checked. The resident was observed to have a trapeze over his bed. On 2/8/11 an intervention was added for a "... Stat 3 air mattress to aid in wound healing...." On 2/23/11 at 11:45 A.M., the resident was observed while the Wound Care specialist physician evaluated his open areas. The physician indicated the area was a friction wound measuring 3.5 x 3.4 x 2.7, noting a color of 10 % red and 96% black superficial with minimal serous exudate. The coccyx wound was observed to have dark gray tissue, and the physician was able to place half of his index finger inside the wound while assessing. The surrounding wound tissue had areas of red and yellow and the outer rim of wound was pink in color. The wound was also noted to have a mild odor. The wound dressing the physician removed from the area was noted to be partially saturated with a light, yellow fluid. In an interview on 2/23/11 at 3 P.M., the Director of Nursing indicated the resident had previously used the facility's standard pressure-reducing mattress prior to the order for the Stat 3 specialty low air loss mattress on 2/8/11. 2. In an interview during the initial orientation tour on 2/21/11 at 10:55 A.M., R.N. #1 indicated Resident #68 had pressure sore open areas of the sacrum and both ischial prominences. In an interview on 2/23/11 at 11:15 A.M., L.P.N. #2, the facility Wound Nurse, indicated Resident #68 was admitted about 1 year ago with multiple massive open areas of both heels and legs, the sacrum, and bilateral ischium. She indicated the resident had been followed weekly since admission by the facility wound care physician/specialist, and that the areas on the heels and legs were now healed. The sacral and ischial areas, while still open, were significantly reduced in size. L.P.N. #2 also indicated part of the difficulty in getting the areas healed was due to the long time periods the resident had to sit during his [MEDICAL TREATMENT]. The clinical record for Resident #68 was reviewed on 2/22/11 at 10:30 A.M. [DIAGNOSES REDACTED]. A "Wound Evaluation Progress Note" from the facility Wound physician specialist, dated 12/1/10, indicated the resident had the following areas: Sacrum--3.8 by 4.3 by 1.2 cm. (centimeters); right ischium--4.3 by 3.0 by 1.8 cm.; and left ischium--5.4 by 2.3 by 1.0 cm. A "Wound Evaluation Progress Note" on 2/16/11 indicated the following measurements: Sacrum--4.3 by 3.4 by 1.7 cm.; right ischium--5 by 2.8 by 0.6 cm.; and left ischium--8 by 3.6 by 2 cm.. The note indicated "Discussed with pt. (patient) need to minimize time sitting up...." The resident's wounds were observed during an evaluation and dressing change by the Wound physician and facility Wound nurse on 2/23/11 at 11:15 A.M. The physician pointed out the healed areas on the resident's heels and legs. The sacrum and right ischium areas were observed to have a clean, beefy red appearance. The Wound physician indicated the left ischial area had just recently developed a small area of necrosis, which he would probably have to debride. The February, 2011 physician order [REDACTED]. (milliliters) twice a day for "wound healing." On 12/8/10, the physician increased the dosage of Prostat to 30 ml. three times a day. The January 2011 M.A.R. (Medication Administration Record) listed the order as "Prostat 30 ml. orally 3 times a day to aid in wound healing." The administration times, however, were listed at 12:00 P.M. and 8:00 P.M. There was no additional listing for a third administration of the supplement. The M.A.R. also indicated the resident received the Prostat twice a day from 1/1 through 1/13/11, then only at 12:00 P.M. from 1/14 through 1/21/11. The 8:00 P.M. dose was circled for these days, indicating the Prostat was not given. The doses at 12:00 P.M. and 8:00 P.M. from 1/22 through 1/31/11 were circled, indicating both doses were not given. The "Nurse's Medication Notes" on the reverse side of the M.A.R. listed 14 entries indicating the Prostat "[MEDICATION NAME]" supplement was "NA" (not available). The February 2011 M.A.R. had all entries from 2/1 through 2/23/11 circled as "not given," with "Nurse's Medication Notes" on the reverse side indicating the Prostat was not available. Notes on 2/4, 2/16, and 2/20/11 also indicated "(name of pharmacy) notified," with no subsequent notes to indicate the results of the notification. In an interview on 2/24/11 at 1:05 P.M., L.P.N. #3 indicated she usually worked on another unit, and had only been on the resident's unit yesterday (2/23) and today. She indicated she became aware that the Prostat was not available and called the pharmacy. A pharmacy staff person told her that the Prostat came in 4 different formulations, and they would need a further order from the physician on which one he wanted. L.P.N. #3 indicated she then called the physician and got a clarification order. She had no information related to why this had not been done previously. In an interview on 2/24/11 at 3:10 P.M., the Director of Nurses indicated she became aware of the problem with the Prostat orders just recently. 3.1-40(a)(2)