Every finding on record at Dyer Nursing and Rehabilitation Center

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to assistance with shaving, hair washing, checking for incontinence, oral care, nail care and providing assistance with eating for 14 of 16 residents reviewed for ADLs. (Residents F, G, B, P, Q, R, S, T, N, J, K, H, L, and M) Findings include:1. On 5/27/26 at 9:46 a.m., Resident F was observed with a growth of facial hair. During an interview at that time, the resident indicated he wanted to be shaved. On 5/27/26 at 2:56 p.m., the resident's facial hair remained. On 5/28/26 at 9:06 a.m., 11:14 a.m., and 1:45 p.m., the resident's facial hair remained. During an interview on 5/28/26 at 1:45 p.m., the resident indicated he was still waiting to be shaved. The record for Resident F was reviewed on 5/28/26 at 2:57 p.m. Diagnoses included, but were not limited to, stroke and lack of coordination. A Care Plan, dated 8/8/25 and reviewed on 5/1/26, indicated the resident required assistance with ADLs (activities of daily living) including bed mobility, eating, transfers, toileting, and bathing related to the diagnoses of right above the knee amputation, left below the knee amputation, history of stroke, and incontinence. Interventions included, but were not limited to, assist with personal hygiene including dressing and grooming as needed. Encourage self participation as able. The Quarterly Minimum Data Set (MDS) assessment, dated 5/5/26, indicated the resident was moderately impaired for daily decision making and he was dependent on staff for bathing and personal hygiene. The May 2026 Bath and Skin Reports provided by the facility indicated the resident was shaved on 5/7, 5/21, 5/25, and 5/28/26. During an interview on 5/28/26 at 4:30 p.m., the Administrator and Nursing Consultant 1 indicated the resident would be shaved. 2. On 5/26/26 at 11:00 a.m., Resident G was observed in her room in bed. Her hair was greasy in appearance. On 5/27/26 at 10:38 a.m., the resident's hair remained greasy. During an interview at that time, the resident indicated she needed her hair washed. At 3:04 p.m., the resident's hair remained greasy. On 5/28/26 at 9:10 a.m. and 2:40 p.m., the resident's hair remained greasy. On 5/31/26 at 7:45 a.m. and 9:15 a.m., the resident's hair remained greasy. On 6/1/26 at 9:15 a.m., the resident was observed with greasy hair. The record for Resident G was reviewed on 6/1/26 at 1:22 p.m. Diagnoses included, but were not limited to, stroke and hemiplegia/hemiparesis (muscle weakness and paralysis) following a stroke affecting the left non-dominant side. The Quarterly Minimum Data Set (MDS) assessment, dated 4/24/26, indicated the resident was cognitively intact and dependent on staff for bathing and personal hygiene. A Care Plan, dated 5/1/26, indicated the resident required assistance with ADLs (activities of daily living) including bed mobility, transfers, toileting and bathing related to diagnoses of hemiplegia, metabolic encephalopathy (altered brain function), weakness, incontinence, and impaired mobility. Interventions included, but were not limited to, assist with personal hygiene including dressing and grooming as needed. Encourage self participation as able. The May 2026 Bath and Skin Report provided by the facility indicated there was no documentation of the resident's hair being washed on 5/4, 5/7, 5/11, 5/14, 5/18, 5/21, 5/25, and 5/28/26. On 6/2/26 at 8:55 a.m., the resident was observed in her room in bed. Her hair had been washed and was clean in appearance. During an interview on 6/2/26 at 4:04 p.m., the Administrator indicated the resident's hair should have been washed in a more timely manner. 3. During a confidential interview on 5/29/26 at 1:29 p.m., it was indicated the resident was always wet and never changed every two hours. When visiting, for example from 9:00 a.m. to 2:00 p.m., the resident was not changed. During a return visit at 4:00 p.m. the same day, the resident was soaked and had still not been changed. During a continuous observation on 6/1/26 beginning at 9:25 a.m., Resident B was seated in a broda chair in the East Unit dining room. At 11:10 a.m., the resident was moved from the dining room and positioned across from the nurse's station. At 11:45 a.m., the resident was taken back into the East Unit dining room for lunch. At 11:58 a.m., the resident was being fed lunch. During this time frame, the resident was not taken back to his room and checked for incontinence. During a continuous observation on 6/2/26 beginning at 8:57 a.m., the resident was again seated in his broda chair in the East Unit dining room. At 12:15 p.m., the resident was being served lunch. During this time frame, the resident remained in the unit dining room and was not taken back to his room and checked for incontinence. The record for Resident B was reviewed on 6/1/26 at 2:57 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), stroke, and dementia without behavior disturbance. A Care Plan, dated 12/15/23 and reviewed on 4/3/26, indicated the resident required assistance with ADLs (activities of daily living) including bed mobility, eating, transfers, toileting and bathing related to hemiplegia and hemiparesis (muscle weakness and paralysis). Interventions included, but were not limited to, assist with toileting as needed. The Significant Change Minimum Data Set (MDS) assessment, dated 4/13/26, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. The resident was incontinent of bowel and bladder and was dependent on staff for toileting. During an interview on 6/3/26 at 8:43 a.m., CNA 7 indicated the residents were to be checked and/or changed every two hours and as needed. During an interview on 6/3/26 at 10:00 a.m., Nurse Consultant 1 indicated the residents should be checked for incontinence at least every two hours and as needed. 4. During random observations on 5/26/26 at 10:55 a.m. and 5/27/26 at 10:15 a.m., Resident P was observed sitting in a wheelchair in the memory care dining room. At those times, the resident was unshaven and had long fingernails. During random observations on 5/28/26 at 8:55 a.m., 10:50 a.m., 1:25 p.m., and 2:10 p.m., on 5/29/26 at 7:39 a.m., 8:03 a.m., and 10:25 a.m., and on 5/31/26 at 7:35 a.m., Resident P was observed with a large amount of facial hair. During an interview on 5/28/26 at 1:25 p.m., the resident indicated he liked to be clean-shaven. On 5/31/26 at 9:04 a.m., CNA 1 was observed shaving the resident in the shower room. The record for Resident P was reviewed on 5/28/26 at 2:05 p.m. Diagnoses included, but were not limited to, type two diabetes, dementia, major depressive disorder, bipolar disorder, and anxiety disorder. The 2/23/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and needed substantial to maximal assistance with personal hygiene. A Care Plan, revised on 1/7/26, indicated the resident required assistance with ADLs including bathing. The approaches were to assist with personal hygiene including grooming as needed. The resident was scheduled for a shower every Wednesday and Saturday on the evening shift. The shower sheets indicated the resident was not shaved on 5/2, 5/13, 5/16, 5/18, and 5/20/26. There was nothing documented on 5/6 and 5/27/26. During an interview on 6/1/26 at 11:00 a.m., the Director of Nursing had no additional information to provide. 5. During an interview on 5/27/26 at 11:50 a.m., Resident Q indicated he had very bad tremors in both hands and it was very difficult to eat sometimes. He indicated that on 5/26/26, he did not eat lunch or dinner because his tremors were too bad and no staff offered to help him. During a meal observation on 5/29/26 at 12:00 p.m., the resident was observed eating lunch. Both hands were observed with mild to moderate tremors and he had to lean all the way forward by the plate to eat so the food would not fall off of the silverware. He was served mashed potatoes, a piece of meat, vegetables, and pink lemonade. The meat was not cut up for him and the lid was still on the lemonade. He did not have his Kennedy cup (a specialized, spill-proof adaptive drinking cup designed for individuals with mobility challenges, arthritis, or Parkinson's) for his drink. During a meal observation on 5/31/26 at 8:14 a.m., the resident was observed sitting straight up in the bed. He was eating his food with regular silverware and the built up silverware was not on the tray. He had a cup of orange juice and the Kennedy cup was not observed. He was observed to eat his food with mild to moderate tremors in both hands. The record for Resident Q was reviewed on 5/28/26 at 9:34 a.m. Diagnoses included, but were not limited to, stroke, type two diabetes, major depressive disorder, and anxiety disorder. The 4/24/26 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making, and needed partial to moderate assistance with eating. The resident weighed 145 pounds and has had a significant weight loss. The Care Plan, revised on 7/18/25, indicated the resident required assistance with ADLs including eating. The approaches were to assist with meal consumption, eating and drinking as needed. The Care Plan, revised on 5/26/26, indicated the resident was at risk for impaired nutritional status due to dialysis. The approaches were to provide a Kennedy cup and built up silverware at each meal and provide assistance with meal intake as needed. Provide diet/supplements as ordered by the physician. A Physician's Order, dated 4/24/26, indicated the resident was to receive a liberal renal diet, regular texture, regular thin consistency with a plate guard, a Kennedy cup and built up utensils at meals. During an interview on 6/1/26 at 11:00 a.m., Nurse Consultant 1 was unaware the resident needed help with eating and that he needed a special cup for drinking. She had no additional information to provide. 6. During random observations on 5/26/26 at 10:24 a.m. and 5/27/26 at 11:30 a.m., Resident R was observed in bed with long dirty fingernails. During random observations on 5/28/26 at 8:40 a.m., 10:50 a.m. and 3:15 p.m., the resident was observed in bed with long dirty fingernails and a large amount of food debris in her teeth. On 5/28/26 at 1:26 p.m., Resident R was observed in bed, with long dirty fingernails and food debris in her teeth. Her lunch tray was observed on the over bed table, completely untouched. On 5/29/26 at 8:15 a.m. CNA 3 delivered two breakfast trays to the room, one for Resident R and one for her roommate. The CNA placed Resident R's tray on the over bed table, and moved to the other side of the privacy curtain with the roommate's tray. She then sat down to feed the roommate. At 8:25 a.m., Resident R's tray was still untouched and on the over bed table. At 8:27 a.m., the CNA left the room with the roommate's tray and placed it on the cart. She walked back into the room and prepared Resident R's tray and at 8:28 a.m. began feeding the resident. At that time, the resident's fingernails were still dirty and long and there was a large amount of food in her teeth. On 5/29/26 at 12:00 p.m., Resident R was observed in bed. Her nails were long and dirty and her teeth were full of food debris. At 12:13 p.m. CNA 3 brought the roommate's tray and sat down to feed her. During an interview at 12:16 p.m., CNA 3 indicated Resident R was going to eat after she was finished feeding her roommate. She had left it on the cart so it would stay warm. At 12:18 p.m., the fire alarm went off and the CNA left the room and closed the door. At 12:22 p.m., the Code Red was all clear. The CNA went back into the room to finish feeding the roommate. She finished feeding the roommate at 12:24 p.m., and removed her tray out of the room. At 12:28 p.m., the CNA started to feed Resident R and she was receptive of the food. On 5/29/26 at 2:20 p.m., CNA 3 was asked if she had completed oral care for the resident that morning. She indicated No she had not. She also indicated she had not performed nail care or trimmed her nails. The record for Resident R was reviewed on 5/27/26 at 3:01 p.m. Diagnoses included, but were not limited to, stroke, major depressive disorder, vascular dementia, anxiety disorder, and aphasia (difficulty speaking). The 5/5/26 Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and was dependent on staff for bathing, oral care, eating, and personal hygiene. A Care Plan, revised on 5/12/26, indicated the resident required assistance with ADLs including eating and bathing. The approaches were to assist with with meal consumption, eating and drinking as needed, assist with oral care as needed and assist with personal hygiene as needed. During an interview on 5/29/26 at 2:30 p.m., the Administrator indicated she was going to address the issues with staff and had no additional information to provide. 7. During random observations on 5/26/26 at 10:55 a.m. and 5/27/26 at 10:17 a.m., Resident S was observed seated in a wheelchair dressed in street clothes. At those times, he had a large amount of facial hair observed to his face, chin and neck areas. The record for Resident S was reviewed on 5/28/26 at 3:40 p.m. Diagnoses included, but were not limited to, type two diabetes, dementia, and depression. The 3/3/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and was dependent on staff for personal hygiene. A Care Plan, revised on 3/8/26, indicated the resident had an ADL self care performance deficit related to dementia. The approaches were to assist with care as needed. The resident received a shower on Tuesday and Friday mornings. The shower sheets indicated the resident was shaved on 5/1 and 5/12/26. The resident was not shaved on 5/5, 5/7, 5/15, 5/19, and 5/21/26. There was no documentation on 5/26/26. During an interview on 6/1/26 at 11:00 a.m., the Director of Nursing had no additional information to provide. 8. During random observations on 5/26/26 at 10:50 a.m. and 12:05 p.m., on 5/27/26 at 10:59 a.m., on 5/28/26 at 8:55 a.m., 10:50 a.m., 1:30 p.m. and 3:00 p.m., on 5/29/26 at 7:38 a.m., 10:30 a.m. and 11:50 a.m., Resident T was observed in bed. At those times, his fingernails were long and dirty with a brown like substance underneath them. The record for Resident T was reviewed on 5/29/26 at 2:40 p.m. Diagnoses included, but were not limited to, dementia with behaviors, major depressive disorder, and anxiety disorder. The 3/18/26 admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and needed partial to moderate assistance with personal hygiene. A Care Plan, dated 3/27/26, indicated the resident had an ADL self care performance deficit related to dementia. The approaches were to assist as needed. The shower sheets indicated the resident's nails were last trimmed on 5/14/26. Nail care was not completed on 5/5, 5/7, 5/12, 5/19, and 5/21/26. During an interview on 6/1/26 at 11:00 a.m., the Director of Nursing had no additional information to provide. 9. During an interview on 5/27/26 at 9:41 a.m., Resident N indicated her nails were dirty and long and in need of trimming. During random observations on 5/28/26 at 8:50 a.m., 10:50 a.m., on 5/29/26 at 10:30 a.m., and on 5/31/26 at 8:17 a.m., the resident's fingernails were long and dirty. The record for Resident N was reviewed on 6/1/26 at 9:05 a.m. Diagnoses included, but were not limited to, type two diabetes, morbid obesity, and major depressive disorder. The admission Minimum Data Set (MDS) assessment, dated 4/10/26, indicated the resident was cognitively intact for daily decision making and had a functional limitation of range of motion on one side to the upper extremity. The resident needed substantial to max assist with personal hygiene. The Care Plan, revised on 5/19/26, indicated the resident required assistance with ADLs including bathing. The approaches were to assist with personal hygiene as needed. During an interview on 6/1/26 at 10:50 a.m., Nurse Consultant 1 indicated the resident's nails were cleaned and cut on 5/31/26 and she had no additional information to provide. 10. During observations on 5/26/26 at 10:16 a.m., 5/27/26 at 2:38 p.m., 5/28/26 at 8:58 and 4:17 p.m., and 5/29/26 at 10:21 a.m., Resident J's face was unshaven, hair greasy and uncombed, and his shirt dirty with food debris. The resident was wearing the same shirt each day of the observations. The resident's record was reviewed on 5/28/26 at 11:00 a.m. Diagnoses included, but were not limited to, respiratory failure and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 5/7/26, indicated the resident had moderate cognitive impairment and required moderate assistance with ADLs. There was no documentation of refusal of care since 5/12/26. A Care Plan, revised on 5/18/26, indicated the resident required assistance with ADLs. Interventions included assisting with personal hygiene including dressing/grooming as needed. During an interview on 5/28/26 at 4:33 p.m., the Director of Nursing (DON) and the Administrator were informed of the findings. No additional information was received. 11. During observations on 5/26/26 at 10:29 a.m., 5/27/26 at 3:52 p.m., and 5/28/26 at 10:44 a.m., Resident K's face was unshaven, fingernails were long and dirty, and hair greasy and uncombed. The resident's record was reviewed on 6/1/26 at 1:31 p.m. Diagnoses included, but were not limited to, hemiplegia (weakness on one side of the body) following a stroke, and Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 3/16/26, indicated the resident had moderate cognitive impairment, and was dependent for ADLs (activities of daily living). There was no documentation of refusal of care since 5/2/26. A Care Plan, revised 7/14/25, indicated the resident required assistance with ADLs, including bathing. During an interview on 5/28/26 at 4:33 p.m., the Director of Nursing (DON) was informed of the findings. No additional information was received. 12. During random observations on 5/26/26 at 10:52 a.m., 5/27/26 at 3:41 p.m. and 5/28/26 at 10:19 a.m., Resident H's face was unshaven, and his hair was greasy and uncombed. The resident's record was reviewed on 5/29/26 at 11:49 a.m. Diagnoses included, but were not limited to, diabetes, unstageable pressure ulcer of right heel, and foot drop (inability to lift the front part of the foot). The Quarterly Minimum Data Set (MDS) assessment, dated 3/9/26, indicated the resident had moderate cognitive impairment and required substantial/maximal assistance with activities of daily living (ADLs). A Care Plan, revised on 3/15/26, indicated the resident had an ADL self-care performance deficit. There was no documentation of resident refusal of ADL care. During an interview on 5/28/26 at 4:33 p.m., the Director of Nursing (DON) was informed of the findings. No additional information was received. 13. On 5/26/26 at 10:55 a.m., Resident L was observed in his wheelchair, he was unshaven. On 5/27/26 at 10:20 a.m., and 11:22 a.m., the resident was observed in the dining room and was unshaven. The record for Resident L was reviewed on 5/29/26 at 10:22 a.m. Diagnoses included, but were not limited to, heart failure, weakness, dysphagia (difficulty swallowing) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 3/2/26, indicated the resident was severely impaired for daily decision making and was dependent with all activities of daily living (ADLs). A Care Plan, dated 7/10/25, indicated the resident had impaired cognitive function related to dementia. A Care Plan, dated 3/6/26, indicated the resident required assistance with ADLs. Interventions were to assist with personal hygiene, which included dressing/grooming as needed. During an interview on 6/1/26 at 2:00 p.m., the Administrator indicated she understood the ADLs concern and had no additional information to provide. 14. On 5/26/26 at 3:21 p.m., Resident M was observed asleep in bed. The resident was unshaven and his hair had not been cut. During an interview at the time, the resident's spouse/roommate and emergency contact indicated the staff does not offer to trim the resident's hair or beard and he was in need of both. On 5/29/26 at 10:25 a.m., and 12:11 p.m., the resident was observed asleep in bed, and he was unshaven and his hair was not cut. The record was reviewed for Resident M on 5/26/26 at 3:30 p.m. Diagnoses included, but were not limited to, dementia, diabetes, anxiety, and heart failure. The Annual Minimum Data Set (MDS) assessment, dated 4/1/26, indicated the resident was severely impaired for daily decision making and was impaired on both sides of the upper and lower extremities. Shower/bathing and personal hygiene required dependent care. A Care Plan, dated 1/3/25, indicated the resident had impaired cognitive function related to dementia. A Care Plan, dated 3/6/26, indicated the resident required assistance with ADLs. Interventions were to assist with personal hygiene, which included dressing/grooming as needed. During an interview on 6/1/26 at 2:00 p.m., the Administrator indicated she understood the ADLs concern and had no additional information to provide. This citation relates to Intakes 2984104, 3010389, and 3026073. 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(2)(A) 410 IAC 16.2-3.1-38(a)(3)(B) 410 IAC 16.2-3.1-38(a)(3)(C) 410 IAC 16.2-3.1-38(a)(3)(D) 410 IAC 16.2-3.1-38(a)(3)(E)

Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided related to dining and diet orders for 6 of 6 residents reviewed for accident hazards. (Residents V, D, C, T, U, and E) Findings include:1. On 5/31/26 at 8:11 a.m., Resident V was observed in the East dining room eating her breakfast in front of two other residents. There were no staff members in the dining room while the resident ate her breakfast. The resident ate all of her meal with no staff supervision. The record for Resident V was reviewed on 6/3/26 at 3:45 p.m. Diagnoses included, but were not limited to, Alzheimer's, schizophrenia, and dementia with behavior disturbance. The 4/22/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired for daily decision making and required set up or clean up assist with eating. The resident was also identified as having a weight loss. A Care Plan, reviewed on 4/22/26, indicated the resident was at risk for malnutrition. Interventions included, but were not limited to, provide supervision during meals. During an interview on 6/2/26 at 4:04 p.m., the Administrator indicated the resident should have been supervised while eating her breakfast. 2. On 6/1/26 at 11:55 a.m., Resident D was overheard coughing in the East dining room. The resident was holding a cookie in her left hand after taking a bite and she indicated she couldn't eat the cookie. The resident was served mashed potatoes, creamed corn, and ground meat with gravy. Observation of the resident's tray card at the time indicated the resident was to receive a mechanical soft diet with nectar thick liquids. The record for Resident D was reviewed on 6/1/26 at 9:58 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance and protein-calorie malnutrition. The 3/4/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired for daily decision making and required supervision or touching assistance with eating. The resident received a mechanically altered diet and had episodes of loss of liquids or solids from her mouth when eating or drinking and holding food in her mouth/cheeks or residual food in her mouth after meals. A Care Plan, reviewed on 2/25/26, indicated the resident required assistance with activities of daily living (ADLs) related to eating. Interventions included, but were not limited to, assist with meal consumption, eating, and drinking as needed. A Physician's Order, dated 5/22/26, indicated the resident was to receive mechanical soft texture pleasure feeds with nectar consistency liquids with a Magic Cup (a nutritional supplement) at lunch. During an interview on 6/2/26 at 4:04 p.m., the Administrator and Nurse Consultant 1 indicated the resident should not have received the cookie. 3. On 6/2/26 at 12:04 p.m., Resident C was observed in the East dining room. The resident received lemonade on his lunch tray which was not thickened. The resident's caregiver brought this to the Social Service Director's attention and asked for a glass of thickened lemonade. The record for Resident C was reviewed on 6/2/26 at 11:05 a.m. Diagnoses included, but were not limited to, Parkinson's and dysphagia (difficulty swallowing). The Annual Minimum Data Set (MDS) assessment, dated 3/17/26, indicated the resident was cognitively impaired for daily decision making and he was dependent on staff for eating. A current Care Plan indicated the resident required assistance with activities of daily living (ADLs) related to eating. Interventions included, but were not limited to, assist with meal consumption, eating and drinking as needed. A Care Plan, dated 5/27/26, indicated the resident was at risk for malnutrition. Interventions included, but were not limited to, provide diet as ordered and one to one feed assist. A Physician's Order, dated 5/18/26, indicated the resident was to receive a pureed diet with honey thickened liquids. During an interview on 6/2/26 at 4:04 p.m., the Administrator and Nursing Consultant 1 indicated the resident's lemonade should have been thickened when he received it. 4. During a breakfast meal observation on 5/31/26 at 7:54 a.m., the meal trays arrived to the [NAME] Memory Care Unit dining room. At that time, Resident T and Resident U were observed sitting at the assistance feeding table. Resident U received her tray first and was assisted with set up and she started to feed herself. Resident T was one of the last resident's to be served as he had to be fed. The CNA sat down and started to assist Resident T to eat. At 9:04 a.m., both Residents T and U were still eating their food. CNA 1 and CNA 2 both left the room to take residents out and the nurse was passing medication on the unit, so that left no staff in the room while the resident's were still eating At 9:06 a.m., another staff member brought another resident a bowl of [NAME] Krispie's, but left because she accidentally put sugar on the cereal and the resident did not want it. CNA 2 came back into the room at 9:06 a.m. and gave Resident T another bite of food and walked away from him and out of the room. He proceeded to chew the food in his mouth over some time. CNA 2 came back into the room at 9:08 a.m. and started to ask other residents if they needed to use the bathroom, however, Resident T was still chewing his food and Resident U was picking at her food and drinking her milk. At 9:10 a.m., she gave Resident T another bite of food and left the room while he was still chewing his food. CNA 2 came back into the room at 9:12 a.m. and looked around and left right away, then came back in again at 9:14 a.m. and left again. Resident T was still chewing his food in his mouth and Resident U was drinking her milk. a. The record for Resident T was reviewed on 5/29/26 at 2:40 p.m. Diagnoses included, but were not limited to, dementia with behaviors, major depressive disorder, and anxiety disorder. The 3/18/26 admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. During an interview on 5/31/26 at 9:06 a.m., CNA 2 indicated the resident has had several falls in the last month and has declined in walking and eating, because staff have to assist him to eat now. b. The record for Resident U was reviewed on 6/2/26 at 9:00 a.m. Diagnoses included, but were not limited to, Alzheimer's disease and protein calorie malnutrition. The 2/23/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and needed supervision and cueing for eating. During an interview on 6/1/26 at 11:00 a.m., Nurse Consultant 1 indicated staff should be in the room while the residents were eating. 5. During an observation of the lunch meal in the North Memory Care Dining Room on 5/26/26 at 12:00 p.m., CNA 6 was feeding Resident E. After CNA 6 had fed Resident E approximately half of the regular diet tray, LPN 3 told her it was the wrong tray, and Resident E was supposed to be on a mechanical soft diet. During an interview on 5/26/26 at 12:14 p.m., CNA 6 indicated she was told to feed the resident from that tray. She did not normally work on that unit, and did not know the residents. She fed the resident small pieces of the meatballs and the resident did fine with it. The resident's record was reviewed on 5/29/26 at 9:47 a.m. Diagnoses included, but were not limited to, dementia, diabetes, and heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 3/4/26, indicated the resident had severe cognitive impairment, and was dependent in activities of daily living (ADLs). A Physician's Order, dated 3/5/26, indicated mechanical soft textured diet. The Special Instructions in the resident's electronic medical record indicated, MECHANICAL SOFT TEXTURED DIET. 1 to 1 feed assist. A Care Plan, revised on 3/2/26, indicated the resident had a nutritional problem or potential for nutritional problem. Interventions included providing and serving the diet as ordered. During an interview on 5/29/26 at 2:32 p.m., the Administrator and Nurse Consultant 1 were informed of the findings. No additional information was received. This citation relates to Intakes 2984104 and 3010389. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(1) 410 IAC 16.2-3.1-45(a)(2)

Based on observation, record review, and interview the facility failed to ensure residents who were admitted with or re-admitted with pressure ulcers received a timely assessment and treatment orders for 2 of 6 residents reviewed for pressure ulcers. (Residents C and N) Findings include: 1. On 6/3/26 at 10:29 a.m., the Interim Wound Care Nurse was observed completing treatments to Resident C's right foot, right heel, and sacrum. There was an area of dark skin to the resident's right heel. During an interview at the time, the Interim Wound Nurse indicated the resident's foot and heel were getting better and that the resident was seen weekly by the Wound Physician. The record for Resident C was reviewed on 6/2/26 at 11:05 a.m. Diagnoses included, but were not limited to, Parkinson's, type two diabetes, stroke, and hemiparesis/hemiplegia (muscle weakness and paralysis) following a stroke affecting the left non-dominant side. The 3/17/26 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired for daily decision making and he was dependent on staff for bed mobility. The resident had no pressure ulcers at the time of the assessment. The 5/11/26 Discharge Return Anticipated MDS assessment indicated the resident had no open areas. A Care Plan, dated 5/22/26, indicated the resident had a pressure ulcer or potential for pressure ulcer development related to immobility. The resident had actual impairment to his right heel, right medial foot, coccyx, left ear, and right plantar foot. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness and follow the the facility policies/protocols for the prevention/treatment of skin breakdown and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. A Nurse's Note, dated 4/28/26 at 2:12 p.m., indicated staff had informed the writer (Interim Wound Nurse) that the resident had an open area to his right heel. Upon assessment, the right heel was noted with purple and yellow discoloration, no drainage noted, and the peri wound (area of skin surrounding wound) was pink. The right heel was tender to touch. The physician and the resident's Power of Attorney (POA) were notified and a new treatment was put in place. A Physician's Order, dated 4/28/26, indicated the resident's medial heel was to be cleansed with normal saline, pat dry, apply skin prep and leave open to air. The April 2026 Treatment Administration Record (TAR) indicated the treatment was signed out on 4/29/26 and then it was discontinued on 4/29/26. A Nurse's Note, dated 4/29/26 at 1:43 p.m., was completed by the previous Wound Care Nurse. The entry indicated the writer was notified of possible skin breakdown. Upon assessment, the writer did not observe any skin breakdown. The resident's right heel was intact and no discoloration noted. The writer implemented prevalon boots to bilateral heels. No complaints of pain were voiced and no signs or symptoms of distress noted. Resident's POA notified of boots. A Physician's Order, dated 5/3/26, indicated the resident's right medial heel was to be cleansed with normal saline, pat dry, apply skin prep and leave open to air (LOTA) daily. The treatment was discontinued on 5/5/26. There was no skin assessment and measurements of the resident's heel wound on 5/3/26. A Physician's Order, dated 5/5/26, indicated the resident's right medial heel and right medial ankle were to be cleansed with normal saline/wound cleanser, paint with betadine (a topical antiseptic), allow to dry. Cover with one 4 x 4 and secure with a thin layer of rolled gauze daily. The May 2026 TAR indicated the treatments to the right medial heel and right medial ankle were signed out as being completed 5/5-5/11/26. There was no skin assessment and measurements of the resident's heel and ankle wounds on 5/5/26. There was also no documentation indicating the resident's POA was notified of the treatment orders. The resident was sent to the emergency room for evaluation of altered mental status on 5/11/26 and he returned to the facility on 5/18/26. A Nurse's Note, dated 5/18/26 at 7:20 p.m., indicated the resident arrived to the facility via ambulance accompanied by two paramedics and family at the bedside. The resident was alert to person, and place. The resident was able to make needs known. Respirations were even and unlabored. Abdomen soft and non-tender. Skin warm, and dry. The resident had multiple pressure injuries with treatments in place. All orders received and verified with hospice nurse and physician. Per the hospice nurse, a low air loss mattress and frame had been ordered. Documentation in the Wound Rounds section of the resident's record indicated no assessment of the resident's wounds had been completed by facility staff on the resident's readmission on [DATE]. Wound Rounds documentation, completed on 5/22/26, indicated the resident was admitted with a unstageable (a pressure ulcer where the true depth and severity can't be assessed because the wound bed is obscured by dead tissue) pressure ulcer to to the right heel that measured 4 centimeters (cm) in length by 4 cm in width by undetermined depth. A Physician's Order, dated 5/23/26, indicated the resident's right heel and right medial foot were to be cleansed with normal saline or wound cleanser. Apply a thin layer of betadine and LOTA daily. These were the first documented treatment orders since the resident was readmitted on [DATE]. Physician's Orders, dated 5/27/26, indicated the resident's right distal medial foot, right medial foot, right medial heel, and right medial ankle were to be cleansed with normal saline or wound cleanser, pat dry. Apply thin layer of betadine and LOTA every day shift for wound care. The areas were assessed in Wound Rounds on 5/27/26 and identified as being present on admission. This was the first documented assessment of the areas except for the right heel since being readmitted on [DATE]. During an interview on 6/1/26 at 10:10 a.m., the Director of Nursing (DON) indicated they parted ways with the wound nurse due to not documenting wound treatments and not completing assessments. They identified there was a problem with pressure ulcers and developed a Performance Improvement Plan (PIP), however, the facility was not specifically monitoring new admissions or readmissions for wounds. The DON indicated they would just be caught on the random audits they would be doing weekly. The PIP was initiated on 5/7/26 and wounds were to be monitored through 6/4/26. During an interview on 6/3/26 at 2:45 p.m., Nurse Consultant 1 indicated the resident's wounds were assessed by the hospice nurse during his readmission assessment on 5/18/26 and treatments were ordered. Review of the hospice documentation, dated 5/18/26 and provided by the Nurse Consultant, indicated the wounds were staged but not measured. Treatment orders were also given, but not addressed by facility staff. The treatment orders were not listed on the May 2026 TAR on 5/18/26. During a interview on 6/3/26 at 2:50 p.m., Nurse Consultant 1 indicated there was no documentation of the hospice treatment orders on the TAR starting 5/18/26. All of the resident's wounds were assessed by the Wound Physician on 5/27/26 and new orders received. 2. During an interview on 5/27/26 at 10:11 a.m., Resident N indicated she had pressure ulcers but had not seen. The resident was observed lying in bed and wearing heel boots to both feet. During a wound treatment observation on 6/1/26 at 11:25 a.m., the Interim Wound Nurse and LPN 1 donned the appropriate personal protective equipment and entered the resident's room. The right heel boot was removed from the resident's foot. At that time, there was a deep tissue injury (a severe form of pressure ulcer) observed. The area was intact and dark purple in color. The resident's skin to both of her feet was very dry and scaly with skin peeling away. During an interview at that time, the Interim Wound Nurse indicated the wound physician would be seeing the resident on 6/2/26 and would stage the ulcer. The record for Resident N was reviewed on 6/1/26 at 9:05 a.m. Diagnoses included, but were not limited to, chronic respiratory failure, cervical cancer, type two diabetes, morbid obesity, anemia, dyspnea (difficulty breathing), heart disease, high blood pressure, and, major depressive disorder. The resident was admitted to the hospital on [DATE] and returned to the facility on 5/16/26. The admission Minimum Data Set (MDS) assessment, dated 4/10/26, indicated the resident was cognitively intact for daily decision making and had a functional limitation of range of motion on one side to the upper extremity. The resident was at risk for pressure ulcers and currently had none. The Care Plan, revised on 4/15/26, indicated the resident had the potential for pressure ulcer development related to impaired mobility. The approaches were to monitor, document, and report any changes in skin status. The Care Plan, revised on 5/27/26, indicated the resident had a pressure ulcer to the right heel. A Hospital Note, dated 5/15/26, indicated the resident had a deep tissue injury to the right heel that was clean and intact and was purple and red in color. A Nurse's Note, dated 5/15/26 at 10:49 p.m., indicated the resident returned from the hospital. A complete head to toe assessment was completed and she had wounds that had dressings that were clean, dry, and intact. The admission Assessment, dated 5/16/26, indicated, DTI (deep tissue injury) bilateral heels. There were no measurements and no assessment of the wounds. A Nurse's Note, dated 5/26/26 at 11:09 a.m., indicated the nurse was notified of the resident having potential skin breakdown. Upon assessment, there was discoloration to her right heel. The physician was notified of the new open area and new orders were received. A Physician's Order, dated 5/27/26, indicated cleanse the right heel with normal saline and apply skin prep every morning. There were no physician's orders for any type of wound treatments prior to 5/26/26 for the right heel. The Weekly Wound Round Assessment indicated the right heel DTI measured 3 centimeters (cm) in length, by 3 cm in width, by unknown. The pressure ulcer was 100% maroon and intact. During an interview on 6/1/26 at 10:10 a.m., the Director of Nursing (DON) indicated they parted ways with the wound nurse due to not documenting wound treatments and not completing assessments. They identified there was a problem with pressure ulcers and developed a Performance Improvement Plan (PIP), however, the facility was not specifically monitoring new admissions or readmissions for wounds. The DON indicated they would be just caught on the random audits they would be doing weekly. The PIP was initiated on 5/7/26 and wounds were to be monitored through 6/4/26. During an interview on 6/1/26 at 11:00 a.m., Nurse Consultant 1 indicated they were getting a new wound nurse and she would look to see if there was any information that a treatment was obtained at the time of admission for the right heel. During an interview on 6/2/26 at 9:30 a.m., the Interim Wound Nurse indicated the wound physician saw the resident on 6/2/26 and assessed the right heel pressure ulcer. The Wound Physician Note, dated 6/2/26, indicated the resident had a DTI to the right heel that measured 1.5 cm in length by 2 cm in width by unknown, was intact, and dark purple and maroon in color. The treatment of skin prep remained the same. This citation relates to Intake 3026073. 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(2)

Based on record review and interview, the facility failed to complete post dialysis vital signs and had no documented assessments of dialysis access site for 1 of 3 residents reviewed for dialysis. (Resident C)Finding Included:Resident C's record was reviewed on 3/2/26 at 2:00 p.m. Diagnoses included, but were not limited to, heart failure, end stage renal disease (renal failure), diabetes, and dependent on renal dialysis.The 1/22/26 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident had impairment on both sides of the lower extremities and was on dialysis.A Care Plan, dated 6/4/24 and revised on 2/25/26, indicated the resident required dialysis related to renal failure. Interventions included, but were not limited to, assess dialysis access site for redness, swelling, pain, or drainage, and encourage resident to attend scheduled dialysis appointments. A Physician's Order, dated 12/19/25, indicated to record vital signs pre-dialysis and post-dialysis.A Physician's Order, dated 3/2/26, indicated to assess dialysis access site for redness, swelling, pain, and drainage.The record lacked an order to assess the dialysis access site until 3/2/26.The Medication Administration Record (MAR) for January and February 2026 lacked documentation for assessment of the access site.January 2026 MAR showed documented post-dialysis vitals with a code nine, which indicated to see progress notes. There was no progress note documentation for the following post-dialysis vital signs:1/7/261/14/261/19/261/21/261/23/261/26/26The February 2026 MAR lacked post-dialysis vital signs on 2/11/26.A policy titled, Dialysis Monitoring and Communication Policy, provided by the Director of Nursing on 3/2/26, indicated .2. Observe the dialysis access site for any increased redness, swelling, bleeding, pain and drainage and notify the physician and dialysis center if any present. Document any abnormal findings in the medical records .During an interview on 3/2/26 at 3:47 p.m., the Nurse Consultant indicated there were no post-dialysis vitals on 2/11/2026. She understood the concern with January's lack of post-dialysis progress notes and the access site not being assessed.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed ensure residents who were dependent on staff for activities of daily living (ADL's) received bathing at least twice a week and failed to ensure a resident received incontinence care timely, for 3 of 3 residents reviewed for ADL assistance. (Residents C, B, and D)Findings include:1. During an observation on 1/21/26 at 10:12 a.m., Resident C was lying in bed, the bed sheet was not covering the resident, and the incontinence brief was visible and was observed to be saturated with urine. She indicated she was waiting to be cleaned up. The resident's call light had not been activated and when asked, she indicated she thought it was on. The call light was then activated by the resident at 10:13 a.m. RN 1 entered the room at 10:15 a.m. and the resident indicated she needed her incontinence brief changed. RN 1 turned the call light off and indicated the CNA assigned to her would be notified and then left the room. The resident was interviewed while she waited for staff to return and indicated she received bathing, sometimes once in two weeks. and then it just depends. She indicated she had gone six weeks without being bathed. When she had asked the staff in the past to change her brief, they would tell her they would change her after lunch and then they never return to provide care. She indicated the last time she had her brief changed was before the day shift came in around 6:00 a.m. She drank a lot of water due to her kidneys and she had to urinate a lot. At 10:46 a.m., CNA 2 and RN 1 entered the room. CNA 2 indicated she was assigned to care for the resident and had just been informed the resident needed incontinence care. CNA 2 indicated she started her shift at 7:00 a.m. and this was the first time she checked the resident for incontinence. Incontinence care was then provided by CNA 2 and RN 1.The Director of Nursing (DON), Corporate Nurse, and the Administrator were notified of the observation on 1/21/26 at 11:17 a.m. No further information was received.During an interview on 1/21/26 at 11:04 a.m., RN 1 indicated he could not recall who he had informed the resident needed incontinence care when he had turned the call light off and left the room at 10:15 a.m. Resident C's record was reviewed on 1/21/26 at 3:06 p.m. The diagnoses included, but not limited to, chronic kidney disease, history of urinary tract infections, and diabetes mellitus.A Quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, indicated an intact cognitive status, was dependent on staff for bathing and toileting, required maximum assistance with bed mobility, and was always incontinent of bowel and bladder.A Care Plan, last reviewed on 12/15/25, indicated assistance with ADL's was required. The interventions indicated assistance with bathing would be offered at least two times daily and a bed bath would be offered on non-shower days or with shower refusals, assistance would be given with incontinence care.The shower schedule indicated a shower/bathing was to be completed on Tuesday and Friday mornings. The bathing input forms for 11/2025, 12/2025, and 1/2026, received from the DON, indicated the resident received only four of eight scheduled bathing for November 2025, four of nine scheduled bathing for December 2025, and four of six scheduled bathing in January 2026.The DON was informed of the missed bathing days on 1/21/26 at 3:45 p.m., no further information was received.2. Resident B's closed record was reviewed on 1/21/26 at 1:07 p.m. The diagnoses included, but were not limited to, dementia and bipolar disorder.A Care Plan, dated 9/2/25, indicated assistance was required for ADL care. The interventions included assistance would be provided for hygiene care.The Quarterly MDS assessment, dated 12/22/25, indicated an intact cognitive status, no behaviors, was dependent on staff for toileting, bathing, and hygiene, and was always incontinent of bowel and bladder.A Care Plan, dated 1/8/26, indicated the resident was resistive to care. The interventions indicated the resident would be allowed to make decisions about treatment and would be educated of the possible outcome of not complying with the treatment or care.The shower schedule indicated a shower/bathing was to be completed on Monday and Thursday days. The bathing input forms for 11/2025, 12/2025, and 1/2026, received from the DON indicated she received three of the eight scheduled bathing in November 2025. November 3, 17, 27, 2025 were left blank and November 13 and 20 were marked non-applicable. She received one bed bath in December on 12/25/25. December 1, 4, 7, 11, 15, 18, 22, and 29, 2025 were marked with non-applicable. There were no showers or bathing provided in January prior to the resident being discharged from the facility on 1/23/26.There was no documentation that indicated the resident resisted or refused the bathing.During an interview on 1/21/26 at 2:00 p.m., the DON indicated she was unable to locate any documentation the resident refused the bathing. She acknowledged the care plan indicated she resisted care, not refused care, and there was a lack of bathing at least twice a week for the resident.3. During an interview on 1/21/26 at 9:56 a.m., Resident D indicated she only gets bathed if she asked the staff to bathe her.Resident D's record was reviewed on 1/22/26 at 8:39 a.m. The diagnoses included, but were not limited to, diabetes mellitus and schizophrenia.A Care Plan, dated 8/2/25, indicated assistance was required for ADL's. The interventions included assistance would be provided for hygiene.A Quarterly MDS assessment, dated 12/10/25, indicated an intact cognitive status, no behaviors, and dependent for toileting and bathing. The bathing schedule indicated bathing was to be completed on Tuesday and Friday evenings. The bathing input forms for 11/2025, 12/2025, and 1/2026, received from the DON indicated she received four of eight scheduled bathing in November 2025. November 4, 14, 28, and 25, 2025 was marked with non-applicable. She received five of nine scheduled bathing in December 2025. December 2, 5, 16, and 30, 2025 was marked with non-applicable.During an interview with the DON on 1/21/26 at 3:45 p.m., she had no further information about the bathing.During an interview on 1/22/26 at 9:45 a.m., the DON indicated she had not found any other information about the missed bathing.A facility ADL policy, dated 2/26/21 and received from the Administrator as current, indicated a resident who was unable to carry out ADL's would receive the necessary services to maintain personal hygiene.A facility bowel and bladder incontinence policy, dated 2/12/21 and received from the Administrator as current, indicated the staff would provide assistance with incontinence care for residents who were incontinent routinely, including but not limited to brief changes, peri care, clothing and linen changes.This citation relates to Intake 2687036.3.1-38(a)(3)

Based on record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, related to blood sugars not completed and medications not administered as ordered by a physician, for 1 of 3 residents reviewed for quality of care and receiving medications as ordered. (Resident G)Finding includes:Resident G's record was reviewed on 1/22/26 at 10:01 a.m. The diagnoses included, but were not limited to, dementia and diabetes mellitus.A Care Plan, dated 2/4/25, indicated the resident had diabetes mellitus. The interventions indicated medication would be administered as ordered.A Care Plan, dated 10/29/25, indicated the resident refused medication. the interventions indicated medications would be crushed as needed and/or when she expresses unable to swallow the medication. The reason for the medication would be explained to the resident.An Annual Minimum Data Set assessment, dated 11/5/25, indicated a severely impaired cognitive status and received insulin and an antipsychotic medications.A Physician's Order, dated 5/25/25, indicated humalog insulin was to be administered at 9:00 a.m. and 5:00 p.m. daily after a blood glucose test was completed. The amount of insulin to be administered was dependent on the results of the blood glucose results (sliding scale).The Medication Administration Record (MAR), dated 12/2025, indicated the blood glucose testing had not been completed on 12/16/25 at 5:00 p.m., 12/17/25 at 9:00 a.m. and 12/26/25 at 9:00 a.m. There were no blood sugar results or documentation the insulin was or was not administered.There were no glucose results documented in the Progress Notes or on the blood glucose listings in the record.A Physician's Order, dated 5/24/25, indicated olanzapine (antipsychotic) 2.5 milligrams (mg), one tablet was to be given three time a day for psychosis. The medication was scheduled for 6:00 a.m., 2:00 p.m., and 6:00 p.m.The MAR, dated 12/2025, indicated the olanzapine was refused at 6:00 a.m. on December 1, 2, 5, 6, 8, 9, 10, 12, 13, 15, 18, 19, 21, 23, 24, 25, and 26, 2025.The MAR, dated 1/2026, indicated the olanzapine was refused at 6:00 a.m. on January 1, 2, 3, 5, 11, and 19, 2026.There was no documentation that indicated the Physician had been notified of the medication not received. There was no documentation that indicated the care plan intervention had been followed of crushing the medication or the reason the olanzapine had been refused.During an interview on 1/22/26 at 12:06 p.m., the Director of Nursing indicated she had spoken to the nurse scheduled for the refusal days and he indicated the resident was agitated in the morning. No other interventions had been attempted.A medication administration policy, dated 10/25/14 and identified as current from the Administrator, indicated medications were to be administered in a safe, accurate, and effective manner.This citation relates to Intake 2706590.3.1-37

Based on record review and interview, the facility failed to ensure a urinalysis (UA) with culture and sensitivity (C&S) laboratory test was completed as ordered for 1 of 1 resident reviewed for laboratory testing. (Resident C) Finding includes:During an interview on 1/21/26 at 10:15 a.m., Resident C indicated she has had urinary tract infections and that she has burning with voiding for a while. She indicated they had tried different medications and they could not get rid of the infection.Resident C's record was reviewed on 1/21/26 at 3:06 p.m. The diagnoses included, but were not limited to, chronic kidney disease, history of urinary tract infections, and diabetes mellitus.A Quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, indicated an intact cognitive status, was dependent on staff for bathing and toileting, required maximum assistance with bed mobility, and was always incontinent of bowel and bladder.A Care Plan, last reviewed on 12/15/25, indicated enhanced barrier precautions were required related to a multi-drug resistant organism urinary tract infection. A Nurse's Progress Note, dated 12/29/25 at 1:41 p.m., indicated the resident had complaints of burning with urination. The Nurse Practitioner was notified and an order for a UA with C&S was obtained.A Nurse Practitioner's order, dated 12/30/25, indicated a UA with C&S was to be collected.There was no documentation in the record that indicated the laboratory test had been completed.During an interview on 1/21/26 at 3:45 p.m., the Director of Nursing indicated the UA C&S had not been completed.This citation relates to Intake 2687036.3.1-49(f)(1)

Based on record review and interview, the facility failed to establish and/or maintain a system that accounted for, periodically reconciled, and ensured the disposition of all controlled drugs, related to lack of documentation of narcotic medication administration for 1 of 1 resident reviewed for misappropriation of property. (Resident M) Finding includes: A Facility Reported Incident (FRI), dated 8/8/25 at 5:01 p.m., indicated an employee was unable to locate scheduled analgesic medication for Resident M. The search was initiated, and the facility was unable to locate the medication. The facility administrator, Director of Nursing (DON), Medical Director, and the resident's responsible party were notified. The resident was assessed and as needed Tylenol was given for pain management. The follow-up indicated that the employee was unable to locate the scheduled analgesic medication for Resident M. A search of all medication carts and medication rooms was initiated. The facility was unable to locate Resident M's medication. A full house narcotic count was conducted at this time. The pharmacy was contacted, and Resident M's medication was re-ordered and the cost was billed to the facility. The drug delivery manifests were reviewed, and staff were working from the date of receipt of medication until current date were interviewed. As a result of staff interviews conducted, the discrepancy with the medication was determined to have occurred between the day shift and evening shift on 8/6/25. Staff working during that timeframe were immediately sent for drug testing and suspended pending test results. One staff member's test result was still in a pending status with the lab. That staff member remains suspended until the results were available. Resident M had been receiving her medications as prescribed. Other residents were interviewed and reported no issues with receiving their medications. The facility's investigation report indicated LPN 8 was interviewed on 8/8/25. LPN 8 reported that she took care of Resident M on 7/30/25 from 12:00 p.m. until 11:00 p.m. The employee reported that she remembered the resident having two cards of Norco (narcotic pain medication) on that day. One card was untouched, and the other had approximately 12-16 pills left. The employee indicated that she worked again on 8/6/25 and received the keys from the unit manager LPN 9. LPN 8 and LPN 9 were about to count the cart and LPN 9 indicated there were only two medication cards in the narcotic box. LPN 8 thought that was odd because when she last worked there were four cards in total in the narcotic box. There were no cards of Norco for Resident M at the time, so she assumed the orders had been changed. When it was time to pass medications, LPN 8 realized Resident M still had active orders for Norco. LPN 8 attempted to get the medication out of the emergency drug kit (EDK), but she was told by the pharmacy that she could not pull a dose from the emergency box. The employee reported that she gave the resident Tylenol for pain at that time. LPN 9 was interviewed by facility staff on 8/8/25. The employee reported that she took care of Resident M on 8/6/25. The employee reported that when she received the medication cart, Resident M had two medication cards of Norco, one of which was full, and the other had about 8 pills left. She reported that she gave Resident M one dose of Norco during her shift. LPN 9 reported off to LPN 8, who was the nurse for the day. LPN 9 initially reported there were two medication cards for another resident in the narcotic box when she handed over the keys to LPN 8. When asked what happened to the cards for Resident M, LPN 9 responded that there were four medication cards left in the cart. LPN 10 was interviewed by facility staff on 8/8/25. The employee reported that she worked from 3:00 p.m. until 11:00 p.m. on 8/3/25. During the shift she recalled there being two cards of Norco for Resident M. She indicated that one card was full and the other was the card they were pulling medications from. Resident M's medications were all available and given during her shift. RN 7 was interviewed by facility staff on 8/9/25. The employee reported that she remembered receiving Resident M's Norco from pharmacy. She recalled that there were still a few pills left in the current card, and she received 2 more cards from pharmacy. She had placed them in the narcotic box. A Packing Slip Proof of Delivery, dated 7/29/25, indicated two hydrocodone-acetaminophen (Norco) tablets 7.5-325 milligram medication cards containing 21 pills each were delivered on 7/29/25. RN 7 signed on the signature page. Resident M's record was reviewed on 11/25/25 at 12:56 p.m. A Physician's Order, dated 7/16/25, indicated hydrocodone-acetaminophen tablet 7.5-325 milligrams (mg) give 1 tablet by mouth three times a day for pain.The August 2025 Medication Administration Record (MAR) indicated the hydrocodone-acetaminophen 7.5-325 mg was not administered on 8/6/25 at 10:00 p.m., 8/7/25 at 10:00 p.m., and 8/8/25 at 2:00 p.m. Each dose was marked 9 - other/see progress notes. On 8/7/25 at 2:00 p.m., the MAR was left blank. There were no narcotic count sheets available for Resident M. During an interview on 11/25/25 at 12:37 p.m., the Nurse Consultant indicated LPN 8 had worked and realized a medication card was missing since the last shift she worked. The medication was not available in the narcotic box, so she went to pull the medication from the EDK, however the pharmacy told her that the medication had just been filled, and she was unable to pull the medication. Once they were notified of the missing medication cards, they started to interview staff that had taken care of Resident M. There were no identified problems with narcotics until the interviews occurred with LPN 8 and LPN 9. LPN 8 indicated when she arrived for her shift, there were no Norco medication cards in the cart. When LPN 9 was interviewed she had said there were two medication cards in total in the narcotic box, and they belonged to another resident. When LPN 9 was asked where Resident M's Norco pills were, she then changed her story and said there was a total of four medication cards in the box. There was a full house sweep to determine if any other resident's medications were missing which included reviewing all of the narcotic count sheets. The medication cards for Resident M were not in the narcotic box and the narcotic count sheet was also missing. Both LPN 8 and LPN 9 were sent for drug testing. It appeared that LPN 9 had tampered with the urine test completed on 8/8/25 and had a rescheduled test again on 8/14/25. Based off the inconsistency with LPN 9's interview and the appearance of her tampering with the drug test, she was then immediately terminated. After this occurred, a new procedure was put into place. During change of shift hand-off, the nursing staff must fill out a count sheet that now includes how many total cards are in the narcotic box as well as an actual count of the medication pills. During a follow-up interview on 11/25/25 at 1:50 p.m., the Nurse Consultant indicated it was standard of care for the nursing staff to do a change of shift narcotic count and fill out the narcotic count sheet. They did not have any policies related to narcotic counts. The staff did not have a formal in-service for their nursing staff related to the new procedure of the narcotic count. This citation relates to Intake 2593183. 3.1-25(b)(3)

Based on record review and interview, the facility failed to ensure a resident's blood pressure was monitored per Physician's Orders, for a resident who was receiving multiple medications for hypertension. (Resident B)Finding includes:Resident B's record was reviewed on 11/24/25 at 9:56 a.m. The diagnoses included, but were not limited to, hypertensive heart disease and chronic kidney disease.The following Physician's Orders indicated medications that affect the blood pressure:8/20/25, spironolactone (anti-hypertensive/heart failure medication) 50 milligrams (mg) daily.8/29/25, midodrine (treatment of orthostatic hypotension) 5 mg three times a day for major side effect systolic supine hypertension.8/29/25, a Physician's Order indicated vital signs were to be checked every shift.9/2/25, metoprolol tartrate (beta-blocker to treat hypertension) 25 mg twice a day.9/4/25, bumetanide (diuretic) 1 mg twice a day.The Medication Administration Record, dated 11/2025, indicated the vital signs had not been ochecked every shift as ordered by the physician.During an interview, on 11/25/25 at 12:18 p.m., the Director of Nursing indicated the order had not been transcribed to the Medication Administration Record.A facility medication administration policy, dated 10/2014 and received as current from the RN Nurse Consultant, indicated, .Monitoring of side effects or medication-related problems occurs continually.This citation relates to Intake 2617694.3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to residents who were in Enhanced Barrier Precautions (EBP) and Contact Isolation, for 2 random observations. (Residents E and L) Findings include: 1. During an observation on 11/24/25 at 4:52 a.m., CNA 1 responded to Resident E's call light and the resident indicated she needed her incontinence brief changed. There was a sign on the outside of the entry door that indicated Contact Isolation and EBP precautions were required. CNA 1 completed hand hygiene, applied gloves and prepared the supplies for the care. She indicated she was ready to start the care and was stopped prior to the administration of care. CNA 1 walked to the entry door and observed the sign on the door and then donned a gown. Resident E's record was reviewed on 11/25/25 at 10:32 a.m. The diagnoses included, but were not limited to, diabetes mellitus, urinary tract infection (UTI), and Klebsiella Pneumoniae (bacteria). An admission Minimum Data Set (MDS) assessment, dated 10/24/25, indicated maximum assistance was required for toileting and bathing and she was occasionally incontinent of bowel and bladder. A Care Plan, dated 11/3/25, indicated EBP for Klebsiella Pneumoniae was required. The interventions indicated the facility protocol for EBP would be followed. A Physician's Order, dated 11/3/25, indicated EBP was required due to Klebsiella Pneumoniae in the urine. A gown and gloves were to be used for high contact resident care activities. 2. During an observation on 11/24/25 at 5:09 a.m., CNA 2 was in Resident's L room. The resident was lying in bed and the covers were off the resident. CNA 2 indicated she had just completed incontinence care and there was a soiled brief in the waste basket. CNA 2 was wearing gloves but no gown. The entry door had a sign that indicated both residents of the room required EBP. CNA 2 indicated she was unsure of the facility's EBP policy and then read the EBP sign on the door.Resident L's record was reviewed on 11/25/25 at 11:59 a.m. The diagnoses included, but were not limited to, spinal stenosis and urinary tract infection.An Annual MDS assessment, dated 10/3/25, indicated maximum assistance was required for toileting and bed mobility, was dependent on staff for bathing, and moderate assistance was required for hygiene. The resident was frequently incontinent of bowel and bladder.A Physician's Order, dated 11/12/25, indicated EBP was required related to multidrug-resistance organisms (MDROs)in the urine. Gown and gloves were required for high contact resident care activities.During an interview on 11/25/25 at 2:18 p.m., the RN Nurse Consultant indicated CNA 2 was a new employee and was still in orientation.A facility EBP policy (Centers for Clinical Standards and Quality, Safety & Oversight Group Memorandum. Reference: QSP-24-08-NH), dated 3/2024 and received from the RN Nurse Consultant as current, indicated EBP was required for residents with any MDROs. EBP was to be for, but not limited to, dressing, bathing, hygiene, changing briefs.3.1-18(b)

Based on record review, and interview, the facility failed to report Doppler ultrasound results to the physician in a timely manner resulting in delayed treatment for 1 of 3 residents reviewed for notification. (Resident D)Finding includes:Resident D's record was reviewed on 8/11/25 at 1:51 p.m. The diagnoses included, but were not limited to, stroke, aphasia (difficulty speaking), hemiparesis (paralysis on one side of the body, dysphagia (difficulty swallowing) and weakness.The Quarterly Minimum Data Set (MDS) assessment, dated 5/12/25, indicated the Resident was severely impaired for daily decision making. The resident required substantial/maximum assistance with shower/bathing, upper body dressing and personal hygiene. The resident required dependent care with lower body dressing and toileting. A Physician's Order, dated 7/29/25, indicated for a Doppler ultrasound (non-invasive imaging technique used to assess blood flow in various parts of the body) to be completed on the right lower extremity due to new onset edema with pain.A Nurse's Note, dated 7/29/25 at 10:35 a.m., indicated the resident had new onset edema (swelling) to the right lower extremity and foot and had complaints of pain. The Nurse Practitioner (NP) was aware and had ordered a Doppler. The paperwork was ready and a tech would arrive at the facility within 24 hours.A Nurse's Note, dated 7/30/25 at 10:30 a.m., indicated the resident continued to have edema on the right lower extremity. The Doppler tech was in the facility and indicated the report would be ready in an hour. The NP was made aware.The Doppler report indicated results were interpreted on 7/30/25 at 12:25 p.m. The impression indicated there was partial clotting in the proximal to distal superficial femoral vein causing luminal stenosis (a blood clot partially impeding blood flow through the vein).There was no documentation indicating the facility had communicated the abnormal Doppler results upon receipt to the physician or NP. There was no follow up on the Doppler procedure from 7/30-8/5/25.A Nurses Note, dated 8/5/25 at 10:16 a.m., indicated a new order was received for Eliquis (blood thinner) 5 milligrams twice a day.A Physician's Order dated 8/5/25, indicated to administer Eliquis (blood thinner) 5 milligrams by mouth twice a day.During an interview on 8/11/25 at 3:35p.m., the Director of Nursing indicated a Doppler had been ordered on 7/29/25 and it was completed on 7/30/25. She had called the company who interpreted the results, and they indicated they reported the results on 7/30/25. She could not determine when the results were reported to the physician and understood the concern that there was a delay in treatment.This citation relates to Complaint 2584012.3.1- 49(j)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to food spillage on the clothing and a shirt raised up exposing the resident's back for 1 of 3 residents reviewed for dignity. (Resident E) Finding includes: During a random observation on 6/18/25 at 9:42 a.m., Resident E was observed sitting in a wheelchair at a table. The resident's shirt was raised up exposing his abdomen, the incontinent brief, and his back and side. There was a wet red stain on the front of the shirt and scrambled eggs were observed on his shorts and lower abdomen. During a random observation on 6/18/25 at 1:15 p.m., the resident was observed sitting in his wheelchair in the main lobby after eating ice cream. There was a white towel over the front of the white shirt. The white shirt was the same one as above and it was still raised up in the back, exposing the resident's sides and back. The red stain was now dried. On 6/18/25 at 1:27 p.m., the resident was observed sitting in his wheelchair in the east unit dining room. The white towel was still in place over the front of him and the white shirt was still lifted up, exposing his side and back. On 6/18/25 at 1:45 p.m., CNA 1 pushed the resident back to his room and was going to lay him down and provide incontinence care. During an interview at that time, the resident indicated he was able to feed himself. During an interview on 6/18/25 at 2:00 p.m., CNA 1 indicated after he was showered and before breakfast, he had a blow out so he was changed. She was aware that his white shirt had a dried red stain on it and saw the dried scrambled eggs in his brief. The record for Resident E was reviewed on 6/18/25 at 3:12 p.m. Diagnoses included, but were not limited to, stroke, left side hemiplegia, Parkinson's disease, major depressive disorder, high blood pressure, anxiety disorder, and need for assistance with personal care. The 4/3/25 Annual Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had a limited range of motion impairment on one side for both upper and lower extremities. The resident was dependent on staff for toileting, bathing, and dressing and needed substantial to maximum assist with eating. A Care Plan, revised on 4/14/25, indicated the resident required assistance with ADLs including eating, and toileting. The approaches were assist with toileting, personal hygiene, and dressing as needed. During an interview on 6/18/25 at 4:15 p.m., the Director of Nursing indicated the resident's shirt should have been pulled down and at least changed. This citation relates to Complaint IN00459057. 3.1-3(t)

Based on record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to incontinence care for 1 of 3 residents reviewed for ADLs. (Resident E) Finding includes: During a random observation on 6/18/25 at 9:42 a.m., Resident E was observed sitting in a wheelchair at a table. The resident's shirt was raised up exposing his abdomen, the incontinent brief, and his back and side. There was a wet red stain on the front of the shirt and scrambled eggs were observed on his shorts and lower abdomen. On 6/18/25 at 1:45 p.m., CNA 1 pushed the resident back to his room and was going to lay him down and provide incontinence care. CNA 2 entered the room with the hoyer lift and assisted CNA 1 with the resident as they put him in the bed. CNA 1 indicated at that time, that she had given the resident a shower before breakfast that morning. She then proceeded to remove the resident's shorts and incontinent brief. The brief was heavily soiled with urine and bowel movement and had the remnants of dried scrambled eggs near his pubic area. During an interview on 6/18/25 at 2:00 p.m., CNA 1 indicated after he was showered and before breakfast, he had a blow out so he was changed, but he had not been changed since then. She was aware and saw the dried scrambled eggs in his brief. The record for Resident E was reviewed on 6/18/25 at 3:12 p.m. Diagnoses included, but were not limited to, stroke, left side hemiplegia, Parkinson's disease, major depressive disorder, high blood pressure, anxiety disorder, and need for assistance with personal care The 4/3/25 Annual Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had a limited range of motion impairment on one side for both upper and lower extremities. The resident was dependent on staff for toileting, bathing, and dressing and needed substantial to maximum assist with eating. A Care Plan, revised on 4/14/25, indicated the resident was at risk for complications related to bowel and bladder incontinence. The approaches were to check and change as required for incontinence. A Care Plan, revised on 4/14/25, indicated the resident required assistance with ADLs including eating, and toileting. The approaches were assist with toileting, personal hygiene, and dressing as needed. The Bladder Incontinence section in the CNA task section indicated the resident was incontinent of bladder as follows: - 5/23/25: documented at 9:56 a.m. and 9:59 p.m. - 5/25/25: documented at 9:32 a.m. and 9:59 p.m. - 5/26/25: documented at 4:14 a.m. as not applicable and 10:37 a.m. - 5/31/25: documented at 1:15 a.m. and 11:07 a.m. - 6/1/25: documented at 10:18 a.m. - 6/2/25: documented at 10:48 a.m. and 8:23 p.m. - 6/6/25: documented at 9:23 a.m. and 9:59 p.m. - 6/10/25: documented at 12:41 p.m. and 9:59 p.m. - 6/11/25: documented at 12:40 a.m. and 1:59 p.m. - 6/14/25: documented at 9:39 a.m. and 9:59 p.m. - 6/16/25: documented at 12:06 a.m. and 1:26 p.m. During an interview on 6/18/25 at 4:15 p.m., the Director of Nursing (DON) indicated the CNAs should have provided incontinence care in a more timely manner. The 2/12/21 Incontinence Bowel/Bladder policy, provided by the DON as current on 6/19/25 at 12:14 p.m., indicated a resident who was incontinent of bladder should receive appropriate treatment and services to maintain bladder function. Clinical staff would provide assistance with incontinence care for residents who were incontinent of bladder routinely, including but not limited to brief changes, peri care, clothing changes, and bed linen changes. This citation relates to Complaint IN00459314. 3.1-38(a)(2)(C)

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to assistance with meals, shaving, oral care, and providing showers and nail care for 12 of 14 residents reviewed for ADLs. (Residents E, K, O, B, M, G, F, H, L, N, P, and J) Findings include: 1. On 2/5/25 at 8:05 a.m., Resident E received her breakfast tray. The resident was seated at a table with two other residents. At 8:11 a.m., the resident was asked by a staff member if she was going to eat. The resident picked up her milk and put it back down. At 8:18 a.m., no staff had offered to sit down and feed the resident or assist her with her meal. Staff were observed to be passing coffee and the trays. At 8:25 a.m., a CNA walked over to the resident and handed her a spoon and told her where her fork was. The resident then proceeded to start eating her oatmeal. On 2/6/25 at 11:59 a.m., Resident E was seated at a table in the unit dining room. She had been served her lunch tray and she was making no attempts to feed herself. The resident's eyes were open and she was looking around the room. At 12:15 p.m., a CNA told the resident to wake up and that it was time to eat. The CNA approached the resident and gave her something to drink and she also gave her a few bites of food. The resident started feeding herself after that. This was the first time the resident was provided assistance since 11:59 a.m. The record for Resident E was reviewed on 2/5/25 at 2:02 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavior disturbance, nonpsychotic mental disorder, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 12/7/24, indicated the resident was cognitively impaired for daily decision making and she needed set up assistance with eating. A current Care Plan indicated the resident required assistance with ADLs including bed mobility, eating, transfers, toileting and bathing related to dementia. Interventions included, but were not limited to, assist with meal consumption, eating and drinking as needed. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing indicated the resident should have been assisted with her meals in a more timely manner. 10770 2. During random observations on 2/4/25 at 9:10 a.m. and 11:10 a.m., Resident K was observed with dry cracked lips with flakes of skin hanging from the top lip. During random observations on 2/5/25 at 7:21 a.m., on 2/6/25 at 9:27 a.m., 9:54 a.m., and 3:20 p.m., and on 2/7/25 at 11:16 a.m., the resident's lips were dry, and cracked. There was a scabbed area noted on his bottom lip. The record for Resident K was reviewed on 2/5/25 at 10:35 a.m. Diagnoses included, but were not limited to, cerebral palsy, quadriplegia, epilepsy, autistic disorder, severe protein malnutrition, peg tube, and dysphagia (difficulty swallowing). The 1/22/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and was dependent on staff for oral hygiene and bathing. A Care Plan, revised on 8/29/24, indicated the resident needed assistance with ADLs including bathing. The approaches were to assist with oral care as needed and provide a shower or a complete bed bath at least two times a week. A Care Plan, revised on 9/25/24, indicated the resident was at risk for oral/dental health problems. The approaches were to provide mouth care as per ADL personal hygiene. There was no documentation of oral care in the CNA task section. The CNA task section of the electronic record indicated the resident was scheduled to receive showers every Monday and Thursday evenings. For December 2024 and January 2025, the resident was missing showers on 12/9/24, 12/19/24, 1/2/25, 1/13/25, 1/20/2, and 1/23/25. During an interview on 2/7/25 at 11:51 a.m., the resident's mother indicated there were many times she had come in and his lips were very dry, cracked or flakes of skin hanging off of them. During an interview on 2/8/25 at 3:15 p.m., the Director of Nursing indicated oral care was to be completed daily and showers were to be done two times a week. 3. During an observation on 2/3/25 at 2:52 p.m., Resident O was observed sitting in his wheelchair in his room. At that time, his left hand was flaccid and closed and he could not open his hand without assistance. His fingernails on the left hand were very long and digging into his skin. During random observations on 2/4/25 at 11:02 a.m. and 2/5/25 at 7:25 a.m., the resident's fingernails on the left hand were long and digging into his skin. During an interview on 2/5/25 at 1:56 p.m., the resident indicated the nurse had cut his fingernails for him so they would not dig into his skin. The record for Resident O was reviewed on 2/5/25 at 3:06 p.m. Diagnoses included, but were not limited to, stroke and hemiplegia affecting the left side. The 11/27/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and needed substantial to maximum assist for bathing and personal hygiene. A Care Plan, revised on 6/14/23, indicated the resident required assistance with ADLs including bathing. The approaches were to provide a shower or complete bed bath at least two times a week. The documentation in the CNA task section indicated nail care had not been provided from 1/7/25 through 2/2/25. The CNA task section of the electronic record indicated the resident was to receive a shower on Monday and Thursday evenings. There were no showers documented on 12/19/24, 1/6/25, 1/13/25, 1/20/25, 1/23/25, and 1/30/25. There were no showers documented for the resident for 2/2025. During an interview on 2/7/25 at 3:15 p.m., the Director of Nursing had no further information to provide. 4. During an interview on 2/3/25 at 11:55 a.m., Resident B indicated he liked to be clean shaven. At that time, the resident had a large amount of facial hair on his face and his fingernails were very long and dirty, and had a black like substance underneath them. The resident indicated he did not always get a shower two times a week. On 2/5/25 at 7:20 a.m. and 9:22 a.m., the resident's fingernails were still long and dirty. The record for Resident B was reviewed on 2/7/25 at 11:57 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, periprosthetic fracture of the internal prosthetic left hip joint and right hip joint, end stage renal disease, dependence on renal dialysis, and a skin infection. The 12/10/24 Admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and needed partial to moderate assist with bathing and substantial to max assist with personal hygiene. A Care Plan, dated 1/30/25, indicated the resident required assistance with ADLs including bathing. The approaches were to assist with person hygiene including dressing/grooming as needed. There was no documentation the resident was assisted with shaving. The CNA task section of the electronic record indicated the resident was to receive a shower every Monday and Thursday evening. The resident refused a shower on 1/2/25 and there were no other complete bed baths or showers documented. There was no documentation of any other refusals. Nail care had been completed last on 1/20/25. During an interview on 2/7/25 at 3:15 p.m., the Director of Nursing indicated she had no additional information to provide. 5. During an observation on 2/6/25 at 11:44 a.m., the lunch trays arrived to the memory care unit. The first trays passed to the residents who were seated in the dining room was at 11:52 a.m. Resident M was seated at a table with 3 other residents. Two of the four residents seated at the table were served immediately. At 12:09 p.m., Resident M still had not received her lunch tray. Finally at 12:16 p.m., the resident received her meal tray. It was left front of her and not set up, so she could not eat it. At 12:23 p.m., the resident still had not been assisted with eating. At 12:30 p.m., the resident picked up her juice and removed the lid and drank from it by herself. All other residents were eating and one other resident was being assisted by CNA 1. At 12:34 p.m., QMA 1 was asked why no one was assisting Resident M, and she stated Oh she is a feed. Finally at 12:35 p.m., Assistant Director of Nursing (ADON) 1 moved Resident M to a different table and started to feed her. The record for Resident M was reviewed on 2/10/25 at 2:00 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, dementia, anxiety, heart disease, and protein calorie malnutrition. The 12/16/24 Admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and she needed substantial to maximal assistance with eating. A Care Plan, dated 12/20/24, indicated the resident required assistance with ADLs including eating. The approaches were to assist with meal consumption and eating/drinking as needed. During an interview on 2/7/25 at 3:15 p.m., the Director of Nursing indicated the resident should have been assisted to eat in a timely manner. 6. During an interview on 2/3/25 at 3:00 p.m., Resident G indicated she had not received a shower since been being admitted . The record for Resident G was reviewed on 2/5/25 at 8:25 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cellulitis of the limb, chronic obstructive pulmonary disease (COPD), heart failure, bipolar disorder, anxiety, and depression. The Admission Minimum Data Set (MDS) assessment, dated 1/29/25, indicated the resident was cognitively intact for daily decision making, and was dependent on staff for bathing. A Care Plan, dated 1/25/25, indicated the resident required assistance with ADLs including bathing. The approaches were to provide a shower or complete bed bath at least two times a week. The CNA task section of the electronic record indicated the resident was to receive a shower on Tuesday and Friday evenings. The resident received 1 complete bed bath on 1/28/25 and there was no other documentation the resident refused or had another shower or completed bed bath since admission. During an interview on 2/7/25 at 3:15 p.m., the Director of Nursing had no additional information to provide. 43293 7. During random observations on 2/3/25 at 1:06 p.m., 3:15 p.m., 3:30 p.m. and 3:55 p.m., Resident F was observed lying in bed, curled up on his left side. On 2/5/25 at 10:38 a.m., the resident was observed lying on his right side. At 1:49 p.m. he was observed lying on his right side, and a melted, unopened sherbet was on the bedside table. He was observed again at 3:08 p.m., lying on his right side. On 2/6/25 at 11:11 a.m., the resident was observed lying on his right side. Two full styrofoam cups were on the bedside table. At 11:13 a.m., the CNA repositioned the resident on his left side, but did not offer him any fluids. At 1:22 p.m., he was observed lying on his left side. On 2/7/25 at 9:04 a.m., the resident was observed lying on his right side. An unopened dietary supplement carton and full juice cup were on the bedside table. At 10:54 a.m., he was observed lying on his right side. At 1:30 p.m., he was lying on his right side. A full juice and unopened applesauce were both warm and on the nightstand. The record for Resident F was reviewed on 2/5/25 at 8:33 a.m. Diagnoses included, but were not limited to, congestive heart failure, dementia, depression, and emphysema. The 11/3/24 Annual Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, was dependent in activities of daily living (ADLs), and was receiving hospice services. A Care Plan, revised on 2/12/24, indicated the resident was dependent with ADLs including bed mobility and eating. The approaches included assisting with bed mobility and eating and drinking as needed. During an interview on 2/7/24 at 4:08 p.m., ADON (Assistant Director of Nursing) 2 indicated the resident should be turned and repositioned every two hours and the CNAs should assist/feed the resident for between meal drinks and snacks. 8. During a Resident Council meeting on 2/6/25 at 2:17 p.m., Resident H indicated he was supposed to be getting showers on Tuesdays and Fridays, but had not been receiving them. The record for Resident H was reviewed on 2/6/25 at 2:53 p.m. Diagnoses included but were not limited to, Alzheimer's disease, unspecified intellectual disabilities, and depression. The 11/16/24 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and required one-person physical assistance with activities of daily living (ADLs) and transfers. A Care Plan, revised on 11/22/23, indicated the resident required assistance with ADLs. Approaches included assist with bathing as needed. The CNA task section of the electronic record indicated there was no shower or bath documented for 12/3/24, 12/10/24, 1/7/25, 1/14/25, and 2/5/25. There were no documented resident refusals. During an interview on 2/7/25 at 9:34 a.m., ADON (Assistant Director of Nursing) 2 indicated the resident should have been getting showers every Tuesday and Friday. 9. During random observations on 2/4/25 at 9:16 a.m. and 2/5/25 at 8:06 a.m., Resident L's fingernails were long, jagged, and dirty. During an interview on 2/6/25 at 11:04 a.m., the resident indicated he wanted his fingernails cut and wanted a shower. At that time, his fingernails remained long, jagged, and dirty. The record for Resident L was reviewed on 2/5/25 at 1:23 p.m. Diagnoses included, but were not limited to pneumonia, type 2 diabetes, and dementia. The 12/31/24 Medicare-5 day Minimum Data Set (MDS) assessment indicated, the resident had severe cognitive impairment, and required moderate assistance with ADLs. A Care Plan, updated 3/24/25, indicated the resident had the potential for impaired skin integrity. Approaches included keeping the resident's fingernails short. The CNA task section of the electronic record indicated only one shower, on 1/29/25, was documented since the resident was admitted on [DATE]. Resident refusal of showers were documented on 1/11/25, 1/15/25, and 1/18/25. The record lacked documentation of attempting to re-schedule missed showers. During an interview on 2/7/25 at 3:56 p.m., ADON (Assistant Director of Nursing) 1 indicated all showers should be documented in the electronic record, refused showers should be re-attempted, and that she would have a nurse cut the resident's fingernails. 10. During a dining room observation on 2/3/25 at 12:03 p.m., Resident N was observed in a broda chair (a positioning chair for individuals with complex needs) without a meal tray. The three other residents in the room had meal trays. There was no staff in the room. At 12:17 p.m., there still was no staff in the room and Resident N had no lunch tray. At 12:24 p.m., a CNA started to feed the resident. During a dining room observation on 2/6/25, the meal trays arrived at 11:44 a.m. At 12:22 p.m., CNA 1 started feeding Resident N. At 12:23 p.m., CNA 1 left the dining room. No other staff were present. At 12:29 p.m., CNA 1 returned and resumed feeding the resident. The record for Resident N was reviewed on 2/6/25 at 10:48 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, and hypertension. The 1/5/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, was dependent with ADLs and required maximum assist with eating. The Task List, updated 2/3/25, indicated the resident was totally dependent for feeding, and the staff must complete the task for the resident. During an interview on 2/7/25 at 4:00 p.m., the Director of Nursing (DON) indicated the resident should not have had to wait to be fed. 11. During an interview on 2/3/25 at 3:37 p.m., Resident P indicated he was supposed to be getting showers on Tuesdays and Fridays but was not receiving them. The record for Resident P was reviewed on 2/7/25 at 8:44 a.m. Diagnoses included, but were not limited to, ESRD (end-stage renal disease), congestive heart failure, diabetes, and stroke. The 11/27/24 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and required maximum assistance with ADLs. A Care Plan, revised on 7/3/24, indicated the resident required assistance with ADLs related to the amputation of both lower legs. Approaches included assisting with hygiene as needed. The CNA task section of the electronic record indicated there was no shower or bath documented for 12/3/24, 12/6/24, 12/10/24, 12/17/24, 12/24/24, 12/27/24, 12/31/24, 1/10/25, 1/17/25, 1/21/25, and 1/31/25. There were no documented resident refusals. During an interview on 2/7/25 at 9:34 a.m., Assistant Director of Nursing (ADON) 1 indicated the resident should be getting showers on Tuesdays and Fridays. During an interview on 2/7/25 at 9:34 a.m. the Director of Nursing (DON) indicated she had talked to the resident about showers before, and with the schedule they made, he should be getting them. 48055 12. During an interview on 2/4/25 at 9:20 a.m., Resident J indicated he did not get a shower at least two times a week, he only remembered receiving a shower on Saturday. The record for Resident J was reviewed on 2/5/25 at 1:54 p.m. Diagnoses included, but were not limited to, acquired absence of right below knee, type 2 diabetes mellitus with neuropathy, other complications of amputation stump, and dependence on renal dialysis. The Quarterly Minimum Data Set (MDS) assessment, dated 12/9/24, indicated the resident was cognitively intact and needed substantial to maximal assist for showers. The CNA task section of the electronic record indicated the resident was supposed to receive a shower every Tuesday and Friday. Documentation for the month of January 2025 indicated the resident did not receive a shower or bed bath from 1/3/25 - 1/20/25. During an interview on 2/6/25 at 3:15 p.m., Nurse Consultant 1 indicated the resident should have received at least two showers per week. This citation relates to Complaints IN00450533 and IN00451791. 3.1-38(a)(2)(A) 3.1-38(a)2)(D) 3.1-38(a)(3)(C) 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)

Based on observation, record review, and interview, the facility failed to ensure insulin was signed out as ordered for 2 of 5 residents reviewed for unnecessary medications. The facility also failed to ensure treatments for skin excoriation, skin tears, and bruises were ordered and the areas were assessed and monitored for 2 of 6 residents reviewed for non-pressure related skin conditions, signs and symptoms of edema were addressed for 1 of 1 resident reviewed for edema, and no assessment of lung sounds were documented and new orders put into place for 1 of 1 resident reviewed for a change in condition. (Residents S, T, R, Q, and F) Findings include: 1. The record for Resident S was reviewed on 2/6/25 at 9:44 a.m. Diagnoses included, but were not limited to, dementia with behavior disturbance and type 2 diabetes. The Annual Minimum Data Set (MDS) assessment, dated 11/22/24, indicated the resident was cognitively impaired for daily decision making and she was receiving insulin injections. A Care Plan, reviewed on 12/30/24, indicated the resident was at risk for complications related to a diagnosis of diabetes mellitus. Interventions included, but were not limited to, administer diabetes medications as ordered. A Physician's Order, dated 5/25/24 and listed as current on the February 2025 Physician's Order Summary (POS), indicated the resident was to receive Humalog insulin based on a sliding scale twice a day. The sliding scale insulin dose was to be administered based on the resident's blood sugar: If 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. If blood sugar was over 400, call the Physician. The December 2024 Medication Administration Record (MAR), indicated there was no documentation of the resident's blood sugar and/or insulin administration at 5:00 p.m. on 12/9/24 and 12/23/24. The January 2025 MAR, indicated there was no documentation of the resident's blood sugar and/or insulin administration on 1/5/25 at 9:00 a.m. and at 5:00 p.m. on 1/4/25, 1/10/25, and 1/29/25. The February 2025 MAR, indicated there was no documentation of the resident's blood sugar and/or insulin administration on 2/2/25 at 5:00 p.m. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing indicated the insulin and/or blood sugar results should have been signed out as given. 2. On 2/3/25 at 11:59 a.m., Resident T was observed in his room in bed. The resident had multiple reddish/purple discolored areas to his bilateral arms and blood stains were observed on the sheet underneath the resident's left arm. On 2/4/25 at 10:31 a.m., the discoloration remained to the resident's bilateral arms and again there were fresh blood stains on the sheet beneath the resident's left arm and on the protective sleeve to the resident's left elbow. On 2/5/25 at 1:53 p.m., the resident was observed in his room in bed. There was dried blood on the sheet beneath the resident's left arm. The discoloration remained to both of his arms. The record for Resident T was reviewed on 2/7/25 at 7:58 a.m. Diagnoses included, but were not limited to, chronic respiratory failure and atherosclerotic heart disease. The Admission Minimum Data Set (MDS) assessment, dated 2/5/25, was in progress. A Care Plan, dated 1/30/25, indicated the resident was at risk for complications related to antiplatelet (a medication that prevents blood clots from forming) therapy use. Interventions included, but were not limited to, daily skin inspection and report abnormalities to the nurse. An Admission Nurse's Note, dated 1/29/25 at 1:20 p.m., indicated the resident was admitted with many purple areas to the bilateral upper and lower extremities. He indicated his skin was very fragile and he had a skin tear to the left wrist area with a Hydrocolloid (a self adhesive water proof dressing for wounds) dressing in place. The Admission Assessment, dated 1/29/25, indicated the resident was admitted with purple discolored areas to the bilateral upper and lower extremities, a wound to the left chin area, and a skin tear to the left wrist. The Weekly Skin Observation sheet, dated 2/6/25, indicated the resident's skin was intact and no new areas were observed. The February 2025 Physician's Order Summary (POS) had no orders related to assessing and monitoring the discolorations and there were no treatment orders for the resident's left arm. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing indicated areas of bruising were to be monitored every shift and orders should have been obtained to do so. 10770 3. The record for Resident R was reviewed on 2/6/25 at 10:13 a.m. Diagnoses included, but were not type 2 diabetes, major depressive disorder, anxiety disorder, dementia, altered mental status, adult failure to thrive, high blood pressure, and heart failure. The 12/7/24 Annual Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and received insulin in the last 7 days. A Care Plan, revised on 2/4/25, indicated the resident had the diagnosis of diabetes and received insulin. The approaches were to provide diabetic medication as ordered by the doctor. A Physician's Order, dated 10/25/24, indicated Humalog KwikPen Subcutaneous Solution Pen-injector 100 units/ml, inject as per sliding scale: if 151 - 200 = 6 units; 201 - 250 = 8 units; 251 - 350 = 10 units; 351 - 400 = 12 units. If the glucose was greater than 400, give 12 units and call the doctor four times a day. A Physician's Order, dated 10/28/24, indicated Insulin Detemir Solution 100 units/milliliter (ml), inject 50 units subcutaneously at bedtime. A Physician's Order, dated 1/31/25, indicated Humalog KwikPen Subcutaneous Solution Pen-injector 100 units/ml, inject as per sliding scale: if 151 - 200 = 6 units; 201 - 250 = 8 units; 251 - 350 = 10 units; 351 - 400 = 12 units. If the glucose was greater than 400, give 12 units and call the doctor four times a day and inject 10 unit subcutaneously three times a day. The 11/2024, 12/2024, and 1/2025 Medication Administration Records (MAR) indicated the Humalog KwikPen was not signed out as being administered at 8:00 a.m. on 11/6/24, 11/20/24, 1/4/25, 1/13/25, and 1/16/25, at 11:30 a.m., on 11/20/24, 12/4/24, 1/4/25, 1/5/25, 1/8/25, 1/16/25, 1/17/25, 1/18/25, and 1/19/25, at 4:30 p.m. on 11/7/24, 11/26/24, 12/22/24, and 1/5/25, and at 9:00 p.m., on 11/7/24, 11/9/24, 11/26/24, 12/22/24, and 12/23/24. The 11/2024 and 12/204 MAR indicated the Insulin Detemir 50 units at 9:00 p.m. was not signed out as being administered on 11/7/24, 11/9/24, 11/26/24, 12/3/24, 12/22/24, and 12/23/24. During an interview on 2/7/25 at 3:15 p.m., the Director of Nursing had no additional information to provide. 4. During a random observation on 2/5/25 at 1:30 p.m., Resident Q was observed sitting in a broda chair in the dining room on the memory care unit. At that time, an audible loose, congested, weak cough could be heard and observed from the resident. The resident's eyes were closed and she did not respond when spoken to. At 2:05 p.m., the resident remained in the same position as above and was still observed with an audible gurgle and a loose and congested cough. No staff were observed in the room at that time. On 2/5/25 at 2:19 p.m., CNA 7 came into the dining room and heard the resident's loose cough with the audible gurgle and indicated she needed to tell the nurse about the resident. At that time, she removed the resident from the dining room and took her back to her room. At 2:25 p.m LPN 1 entered the memory care and assessed the resident in her room and indicated she needed to notify the Nurse Practitioner. The words chest x-ray could be heard from the nurse while she was in the hallway. During an observation on 2/6/25 at 9:33 a.m., the resident was dressed in street clothes lying in a broda chair. Her eyes were closed and an audible wheeze could be heard while she was breathing. There was a clear liquid running down her face, shirt and right arm. Her shirt was visibly wet on the right side. At 10:54 a.m., the Social Service Employee brought in the traveling dentist to assess the resident's mouth. At that time, the dentist donned clean gloves to both hands and performed an assessment of her mouth and teeth right there in the dining room in front of all the other residents. The dentist indicated to CNA 1 the resident was severely dehydrated and possibly needed intravenous fluids as her tissue in her mouth was sticking to her teeth. On 2/6/25 at 11:00 a.m., CNA 1 entered the dining room, removed the resident and took her back to her room where she was placed in bed. The record for Resident Q was reviewed on 2/6/25 at 2:33 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited fracture right pubis, osteoarthritis, heart failure, heart disease, vascular dementia, chronic kidney disease, anxiety, dysphagia (difficulty swallowing), protein calorie malnutrition, and mood disorder. The Admission Minimum Data Set (MDS) assessment, completed on 1/30/25, indicated the resident was not cognitively intact for daily decision making and needed set up or clean up assistance for eating. A Care Plan, dated 1/15/25, indicated the resident required assistance with ADLs (activities of daily living) including eating. The approaches were to assist with meal consumption, eating and drinking as needed. A Care Plan, dated 1/15/25, indicated the resident was at risk for complications secondary to renal insufficiency related to chronic kidney disease and will have no complications of fluid overload. A Nurse's Note, dated 2/5/25 at 2:39 p.m., indicated Resident coughing/congestion noted, Vitals 64, b/p [blood pressure] 128/66. Np [Nurse Practitioner] notified orders received and noted. POA [Power of Attorney] made aware. A Nurse's Note, dated 2/5/25 at 5:04 p.m. and documented on 2/6/25 at 4:10 p.m., indicated the resident was fed and consumed 25% of dinner. The resident had 120 cubic centimeters (cc) of juice and two ounces of the mighty shake supplement. There was no cough or temperature noted and no other issues or concerns. A Nurse's Note, dated 2/5/25 at 8:15 p.m. and documented on 2/6/25 at 4:13 p.m., indicated the resident received her evening medications and took few sips of water. Her vital signs were stable. A Nurse's Note, dated 2/6/25 at 11:15 a.m., indicated the resident was sitting in the dining room up in the broda chair and was seen by the dentist. The CNA informed the nurse of the concerns about resident sounding like she was gurgling. The resident was assessed and her blood pressure was 95/58, pulse was 58, respirations were 16 and the oxygen saturation was 65% on room air. The resident was started on oxygen at two liters and the Nurse Practitioner (NP) was notified and gave orders to send the resident to hospital for an evaluation. An NP Progress Note, dated 2/6/25 at 11:21 a.m., indicated the resident was seen for dehydration, abnormal vital signs and hypoxia (a condition where the body's tissues do not receive enough oxygen) and lethargy. The resident was currently lying in bed, was lethargic and had reports of dry mucous membranes and notable for dehydration with profound hypoxia of 65% on room air. Her respiratory exam indicated diminished lung sounds throughout with equal excursions (when both sides of the chest expand equally when a person inhales deeply). The plan was to send the resident out to the hospital for an evaluation. The resident's temperature, oxygen saturation, and blood pressure were checked on 2/5/25 at 1:04 p.m. (prior to the nurse's assessment when the resident was observed with the loose cough). The next documented temperature, oxygen saturation and blood pressure was documented on 2/5/25 at 4:10 p.m., all of which were within normal limits. There were no vital signs, including an oxygen saturation, checked for the midnight shift on 2/5/24. There was no documented assessment of the resident's lung sounds on 2/5/25 after her change of condition. There was no documentation of any orders obtained from the NP on 2/5/25. During an interview on 2/6/25 at 11:30 a.m., Assistant Director of Nursing (ADON) 1 indicated she had a resident who she needed to send out to the hospital. When queried if the resident was Resident Q, she indicated yes it was. The ADON was unaware the resident was observed with congestion, a loose cough and gurgling the day before. She was not made aware of those details, and was told the resident just needed to see the nurse. ADON 1 indicated she was going to send the resident out immediately. During an interview on 2/6/25 at 3:15 p.m., ADON 1 indicated the resident was assessed by the NP and had an oxygen saturation of 65% and the NP indicated to send the resident to the hospital. During an interview on 2/6/25 at 3:47 p.m., Nurse Consultant 1 indicated she called LPN 1, who did order the chest x-ray, however, it was ordered through the mobile x-ray portal and not in the point click care system. She indicated the Director of Nursing was looking into why the mobile x-ray company had not been out to do the x-ray. There was no physician order documented in the point click care system, therefore ADON 1 would not have known the x-ray had been ordered and there was no assessment for the resident on the midnight shift. During an interview on 2/6/25 at 4:25 p.m., Nurse Consultant 1 indicated the mobile x-ray company indicated a routine order meant they had 24 hours to come out to the facility and get it done. During an interview on 2/7/25 at 11:10 a.m., LPN 1 indicated she notified the NP of the resident's condition and orders were obtained to get a chest x-ray as soon as possible. LPN 1 indicated the x-ray was put in as routine because she did not know when the mobile x-ray company would get there as sometimes they come from all different parts of the state. During an interview on 2/7/25 at 3:15 p.m., the Director of Nursing had no additional information to provide. The resident was admitted to the hospital on 2/6/25 with influenza A, healthcare associated bacterial pneumonia and acute kidney injury. A chest x-ray report, dated 2/6/25 and obtained in the hospital, indicated consider a cat scan to further evaluate the findings to exclude any possibility of pulmonary nodules versus possibility of nodular infiltrates in the right lung base accounting for these opacities. Additionally, the possibility of right lower lobe and right middle lobe pneumonia including possible aspiration pneumonia was considered. The current 10/1/20 Change in Condition/Assessment policy, provided by Nurse Consultant 1 on 2/10/25 at 11:55 a.m., indicated when a change in resident condition was identified, the RN/LPN must complete an assessment including vital signs and any complaints of pain. Any recommendations or new orders related to the change in condition were to be transcribed and carried out per the providers instructions. 43293 5. During an observation on 2/4/25 at 10:00 a.m., Resident F's left hand was very swollen and he had red, excoriated skin patches on the back of his right shoulder area. The hospice aide indicated there was no treatment she knew of for either area. On 2/5/25 at 8:30 a.m., the hospice aide finished bathing the resident and pointed out where the excoriated area remained on the back of the resident's shoulder. The swelling to the resident's hand was unchanged. The record for Resident F was reviewed on 2/5/25 at 8:33 a.m. Diagnoses included, but were not limited to, CHF, dementia, depression, and emphysema. The 11/3/24 Annual Minimum Data Set (MDS) assessment, indicated the resident had severe cognitive impairment, was dependent in activities of daily living (ADLs), and was receiving hospice services. A Care Plan, updated on 11/4/24, indicated the resident had the potential for impaired skin integrity related to fragile skin. Approaches included identifying and documenting potential causative factors, monitoring and documenting location, size and treatment of skin injury, and reporting abnormalities to the physician. A Nurse's Note dated 2/3/25 at 6:44 a.m., indicated the resident's left hand was very puffy, and they would report it to the a.m. nurse. A Nurse's Note dated 2/3/25 at 8:57 a.m., indicated the hospice aide informed LPN 1 the resident had skin excoriation under the right arm, groin, and buttocks. The record lacked follow up assessments and treatments for the swollen hand and skin excoriation. During an interview on 2/7/25 at 10:13 a.m., LPN 1 indicated she would normally inform the hospice nurse and they would get orders for treatment, but she did not call them on 2/3/25, then she was off for a few days. She indicated she would call them immediately. On 2/7/25 at 10:54 a.m., the Director of Nursing and Assistant Director of Nursing (ADON) 2 were informed of the findings and offered no further information. This citation relates to Complaint IN00451791. 3.1-37(a)

Based on observation and interview, the facility failed to ensure residents in the memory care unit were supervised during meals and while eating for 4 of 4 residents reviewed for supervision. (Residents 81, R, L, and 6) Findings include: 1. During a random observation on 2/3/25 at 12:03 p.m., there were 4 residents observed in the memory care unit lounge at the end of the hall. All of them were observed with their lunch meal in front of them and eating by themselves with no staff in the room. Resident 81 and Resident R were observed seated at a table by themselves. Resident R was served pork, broccoli, and a baked potato. The baked potato was cut up, however the pork was still whole and not cut into smaller pieces. Resident 81 was observed sitting in a wheelchair next to Resident R. She was served pureed meat, pureed vegetable, pureed potatoes, and a pureed dessert in a separate bowl. She was also served a red beverage and a carton of lactose free milk. At 12:15 p.m., Resident R picked up the carton of lactose free milk, which was Resident 81's milk, and drank it. Again there was no staff in the room to assist the residents. Resident 6 and Resident L were seated at a table by themselves and eating their food. Resident 6 had a mechanically altered diet and her meat was ground. She also had a cup of thickened liquid in front of her. There was no staff in the room to supervise the residents. At 12:23 p.m., CNA 6 entered the lounge and sat down to feed another resident who was in the room as well. Residents 81, R, L, and 6 were still eating their food without staff supervision. 2. During a random observation on 2/6/25 at 9:33 a.m., Resident 81 was observed sitting in the dining room on the memory care unit. At that time, she was eating a jelly packet. There was no staff in the room. At 11:44 a.m., the lunch trays arrived to the unit and were parked by the dining room. At 11:52 a.m., Assistant Director of Nursing (ADON) 1 started to pass the trays to the residents who were seated in the dining room. Resident 81 received her lunch tray at 11:54 a.m., which consisted of a carton of lactose free milk, double portions of pureed meat, pureed rice, pureed vegetables and applesauce. Resident R received her lunch at 11:59 a.m., which consisted of some type meat, mashed potatoes, vegetables, and green jello. She received one cup of pink lemonade, of which she drank the entire cup in one breath. At 12:01 p.m., CNA 1 left the dining room and proceeded to pass the rest of the lunch trays to those residents who were in their rooms. QMA 1 was observed passing medications by the medication cart in the hallway, therefore there was no staff in the dining room supervising the residents while they ate. At 12:09 p.m., there still was no staff in the dining room to supervise the residents while they ate. During an interview on 2/7/25 at 3:15 p.m., the Director of Nursing indicated the residents were to be supervised while eating. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to disinfect multi-use equipment, perform hand hygiene after glove removal, medications touched with bare hands, hand hygiene not completed after direct resident contact, glucometers not disinfected after use for 1 of 1 glucometer observed, not donning personal protective equipment (PPE) for a resident in enhanced barrier precautions (EBP), not containing soiled linen, and the improper storage of personal care equipment during random infection control observations. (Residents 63, 25, 83, 72, and 10 ) Findings include: 1. On 2/4/25 at 9:13 a.m., CNA 4 and CNA 5 were observed in Resident 63's room preparing to transfer her via a Hoyer lift (a mechanical lift). At 9:25 a.m., the CNAs donned gloves without hand sanitizing and transferred the resident via the Hoyer lift. After transferring the resident, the CNAs removed their gloves and CNA 5 placed the Hoyer lift in the hallway outside of the resident's room. The CNA did not disinfect the Hoyer after use and both CNAs did not hand sanitize after removing their gloves. At 9:39 a.m., a different CNA removed the Hoyer from the hallway and took it into another resident's room. At 9:45 a.m., the Hoyer was again taken into another resident's room. The Hoyer was not disinfected until 9:50 a.m. by CNA 4. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing and Assistant Director of Nursing 1 indicated the multi-use equipment was to be wiped down with a germicidal wipe after use. The Hand Hygiene policy was provided by Nurse Consultant 1 on 2/7/25 at 11:05 a.m. and identified as current. The policy indicated an alcohol based hand sanitizer was to be used immediately before touching a patient, after touching a patient or the patient's immediate environment, and immediately after glove removal. 2. On 2/7/25 at 5:30 a.m., RN 4 was observed preparing Resident 25's medication. The RN dispensed the medication into her bare hand and then she placed the medication into the medication cup prior to administer to the resident. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing indicated the RN should not have touched the resident's medication with her bare hand. 3. On 2/7/25 at 5:35 a.m., RN 4 was observed preparing Resident 83's medication. The RN dispensed the medication into her bare hand and then she placed the medication into the medication cup prior to administering to the resident. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing indicated the RN should not have touched the resident's medication with her bare hand. The Oral Medication Administration policy was provided by Nurse Consultant 1 on 2/7/25 at 11:05 a.m. The policy indicated to pour or push the correct number of tablets or capsules into the souffle cup, taking care to avoid touching the tablet or capsule, unless wearing gloves. 4. On 2/7/25 at 5:45 a.m., CNA 3 was observed in Resident 72's room providing morning care. The CNA was wearing gloves but no gown. The resident was in Enhanced Barrier Precautions (EBP) due to having a gastrostomy tube (a tube surgically inserted into the stomach that allows for the delivery of food and medication) and a pressure ulcer. At that time, soiled bed linens and a gown were observed on the floor. An incontinence brief soiled with bowel movement and disposable wash cloths were also observed on the floor next to the resident's bed. There was also two areas of bowel movement observed on the floor next to the resident's bed. None of the linen and personal care items were contained. During an interview at that time, the CNA indicated the resident needed to be changed and she didn't have a bag. The CNA proceeded to pick the items up from the floor and dispose of them in the trash can. The linens were placed in a bag and removed from the room. The CNA left the resident's room wearing her gloves in the hallway and carrying the bag of soiled linen and went to another resident's room in another hallway. The CNA donned a clean pair of gloves over her dirty gloves and placed the soiled bag of linen on the floor outside of another resident's room. After leaving the resident's room, the CNA proceeded down the hallway wearing her gloves and dragging the bag of soiled linen on the floor while she made multiple stops in other resident rooms in the hallway. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing and Assistant Director of Nursing 1 indicated the linen should have been contained in Resident 72's room and gloves were not to be worn in the hallway. They also indicated the bag of soiled linen should not have been dragged down the hallway. The facility Infection Prevention and Control Program was provided by Nurse Consultant 1 on 2/7/25 at 11:05 a.m., and identified as current. The policy indicated soiled linens were to be bagged or otherwise contained at the point of collection in leak-proof containers or bags. 5. On 2/7/25 at 6:40 a.m., RN 3 was observed checking Resident 72's blood pressure. He was not wearing gloves and he did not wash or sanitize his hands prior to entering the resident's room. After obtaining the resident's blood pressure result, the RN left the room. He did not wash or sanitize his hands and the blood pressure cuff was not disinfected. At 6:53 a.m., RN 3 was observed checking the resident's blood sugar with a glucometer. The RN donned gloves but did not sanitize or wash his hands prior. After obtaining the resident's blood sugar result, the RN removed his gloves and did not sanitize or wash his hands. At 6:58 a.m., the RN administered the resident's insulin. Prior to administering the insulin, the RN donned gloves without sanitizing or washing his hands. After administering the insulin, the RN walked back to the medication cart in the hallway. The RN was still wearing his gloves and proceeded to document on the computer while wearing his gloves. The glucometer was placed back inside the medication cart. During an interview on 2/7/25 at 7:05 a.m., RN 3 indicated the glucometer was for the unit and not individual residents. He also indicated he should have disinfected the glucometer prior to putting it back into the medication cart. The RN then proceeded to wipe the glucometer with a germicidal wipe and then placed it back into the cart. RN 3 indicated he should have sanitized his hands in between contact with each resident. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing and Assistant Director of Nursing 1 indicated the multi-use equipment was to be wiped down with a germicidal wipe after use. They also indicated the glucometer was to wiped down and wrapped with a germicidal wipe and then left open to air to dry. Hand sanitizing should be completed after resident contact and after glove removal. The facility Glucometer Cleaning policy was provided by Nurse Consultant 1 on 2/7/25 at 11:05 a.m. and identified as current. The policy indicated the glucometer was to be cleaned and disinfected with a pre-moistened germicidal or antimicrobial wipe. The meter was to be wiped with the wipe/towel until all surfaces of the glucometer were visibly wet, wrap with wipe, leave wet according to manufacturer's instructions and place the glucometer on a clean surface such as a paper towel and allow to air dry. 6. On 2/7/25 at 6:30 a.m., RN 3 was observed administering medications to Resident 10. The RN was not wearing gloves at the time. The RN did not sanitize his hands prior to administering the medications and he did not sanitize his hands after making direct contact with the resident. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing indicated hands were to be sanitized and/or washed after each direct resident contact. The Hand Hygiene policy was provided by Nurse Consultant 1 on 2/7/25 at 11:05 a.m. and identified as current. The policy indicated an alcohol based hand sanitizer was to be used immediately before touching a patient, after touching a patient or the patient's immediate environment, and immediately after glove removal. 48055 7. During the environmental tour with the Maintenance Director on 2/11/25 at 1:16 p.m., the following was observed: a. room [ROOM NUMBER] - A pink wash basin was positioned on the back of the toilet and uncontained. b. room [ROOM NUMBER] - A bed pan was on the floor in the bathroom next to the garbage can. c. room [ROOM NUMBER] - There was a pink bed pan on the night stand that was uncontained. d. room [ROOM NUMBER] - A urinal with yellow fluid was in the sink and open. e. room [ROOM NUMBER] - An uncontained wash basin was on the floor in the resident's room. During an interview on 2/11/25 at 1:45 p.m. the Maintenance Director, indicated the bed pans should not be on the floor. 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown while in bed during the day for 1 of 2 residents reviewed for dignity. (Resident 72) Finding includes: On 2/3/25 at 11:49 a.m. and 2:12 p.m., Resident 72 was observed in her room in bed. The resident was wearing a hospital gown at both times. On 2/4/25 at 10:23 a.m., the resident was again observed in her room in bed wearing a hospital gown. On 2/5/25 at 9:27 a.m., 10:54 a.m., and 1:49 p.m., the resident was observed in her room in bed wearing a hospital gown. On 2/6/25 at 9:25 a.m., 10:25 a.m., 11:40 a.m., and 3:27 p.m., the resident was again observed in her room in bed wearing a hospital gown. On 2/7/25 at 5:45 a.m., AM care was provided to the resident. The resident was dressed in a clean hospital gown. The record for Resident 72 was reviewed on 2/6/25 at 10:54 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, dysphagia (difficulty swallowing) and gastrostomy status (a tube surgically inserted into the stomach that allows for the delivery of food and medication). A Significant Change Minimum Data Set (MDS) assessment, dated 1/18/25, indicated the resident was cognitively impaired for daily decision making and was dependent on staff for upper and lower body dressing. A Care Plan, which was last reviewed on 1/14/25, indicated there was no current care plan related to the resident wanting to wear a gown in bed during the day. During an interview on 2/7/25 at 1:45 p.m., the Director of Nursing indicated a care plan would be initiated related to the resident wearing a gown in bed during the day. 3.1-3(t)

Based on observation, record review, and interview, the facility failed to ensure residents were assessed to self-administer medications and oxygen therapy and had physician's orders to self-administer for 3 of 3 residents reviewed for self-administration of medication. (Residents 91, 105 and 30) Findings include: 1. During a random observation on 2/3/25 at 2:15 p.m., there was an Albuterol hand held inhaler observed on Resident 91's over bed table. The resident was not in her room at that time. During random observations on 2/4/25 at 9:39 a.m. and 11:25 a.m., the resident was observed in bed. At those times, the Albuterol inhaler was observed on the over bed table. During an interview on 2/4/25 at 9:40 a.m., the resident indicated she brought the inhaler from home and used it almost every day. The record for Resident 91 was reviewed on 2/4/25 at 10:00 a.m. Diagnoses included, but were not limited to, heart failure, type 2 diabetes, and dyspnea (difficulty breathing) The 12/21/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. There was no care plan indicating the resident could self-administer her own medications. There was no physician's order for the Albuterol inhaler. There was no self-administration of medication completed for the resident. During an interview on 2/5/25 at 9:42 a.m., Assistant Director of Nursing (ADON) 2 indicated she was made aware the resident had an inhaler on her over bed table on 2/4/25 in the afternoon. The resident informed staff that she brought the inhaler from home. She had discontinued the inhaler months ago because it was an as needed medication and the resident was not asking for it. The current 2/15/21 Self-Administration of Medications-Clinically Appropriate policy, provided by Nurse Consultant 1 on 2/10/25 at 11:55 a.m., indicated a resident may only self-administer medications after the interdisciplinary team (IDT) had determined which medications may be self-administered. The IDT will determine at a minimum if the resident had the capacity to follow directions, the resident's cognitive status was evaluated, and the resident's ability to understand and store medication securely. 2. During a random observation on 2/3/25 at 2:20 p.m., Resident 105 was observed in bed and indicated she was not feeling well. At that time, there was a plastic cup filled with an orange substance on the over bed table. The resident was asked what was in the cup, and she indicated it was her potassium medication. She had vomited and had diarrhea earlier, so the nurse waited and brought her medication to her later after lunch. During an observation on 2/3/25 at 2:45 p.m., the resident's call light was on and Assistant Director of Nursing (ADON) 2 got up to answer it. At that time, she observed the orange liquid on the over bed table. She was not aware it was the potassium medication and thought it was an orange drink. During an interview at 2:45 p.m., LPN 1 indicated she had administered the potassium medication after lunch and then heard a code blue, so she ran out of the room to go and help, and left the medication on the resident's over bed table. She did not go back to see if the resident had consumed the medication. The record for Resident 105 was reviewed on 2/5/25 at 10:12 a.m. Diagnoses included, but were not limited to stroke, heart disease, and heart failure. There was no care plan the resident could consume medication without supervision. There was no self-administration of medication assessment completed to indicate the resident could consume medication without staff supervision. A Physician's Order, dated 11/20/24, indicated Effer-K Oral Tablet Effervescent 25 milliequivalents (meq), give 1 tablet by mouth two times a day for supplement. During an interview on 2/7/25 at 3:15 p.m., the Director of Nursing had no additional information. The current 10/25/14 Oral Medication Administration Policy provided by Nurse Consultant 1 on 2/7/25 at 11:25 a.m., indicated staff were to administer medication and remain with the resident while the medication was swallowed. 43293 3. During observations on 2/3/25 at 3:13 p.m., 2/5/25 at 1:53 p.m., and 2/7/25 at 9:15 a.m., an oxygen concentrator with nasal cannula (a pronged tube for dispensing oxygen through the nose) connected was observed in Resident 30's room. During an interview on 2/3/25 at 3:13 p.m., the resident indicated he used the oxygen whenever he felt like he needed it, and usually at night. He demonstrated how to turn the concentrator on, which he learned from watching staff do it. The record for Resident 30 was reviewed on 2/5/25 at 10:09 a.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), dementia, schizophrenia, and sleep apnea. The 12/1/24 Annual Minimum Data Set (MDS) Assessment indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 1/27/25, indicated oxygen at two lpm (liters per minute) every eight hours as needed for shortness of breath. There was no order or an assessment for self-administration. During an interview on 2/7/25 at 9:20 a.m., Respiratory Therapist (RT) 1 indicated the resident put his oxygen on and off independently, and she did not know she needed to assess his ability to use the oxygen correctly. During an interview on 2/7/25 at 9:23 a.m. the Director of Nursing (DON) indicated they should determine if a resident could use oxygen correctly before allowing them to self-administer. 3.1-11(a)

Based on record review and interview, the facility failed to ensure a PASARR (preadmission screening and resident review) was completed when a new mental health diagnoses was added for 1 of 1 resident reviewed for PASARR. (Resident 124) Finding includes: The record for Resident 124 was reviewed on 2/7/25 at 10:32 a.m. Diagnoses included but were not limited to, metabolic encephalopathy, dementia, and unspecified psychosis not due to a substance or known physiological condition. A PASARR level I, dated 1/10/25, indicated further screening was not needed unless the resident had a serious mental illness or intellectual development disability. The diagnosis of unspecified psychosis not due to a substance or known physiological condition was added to the resident's record on 1/13/25. There was no PASARR level 2 performed. During an interview on 2/4/25 at 1:44 p.m., the Social Services Director indicated they did not do a level 2 PASARR, but she would re-do the level 1. She thought the resident had the diagnosis of psychosis since a prior hospitalization , but she was not sure. The PASARR level I, completed on 2/5/25, indicated a face-to-face level 2 was needed. During an interview on 2/6/25 at 4:45 p.m., the Social Services Director indicated she was making arrangements for the level 2 to be done. 3.1-16(d)(1)(A)

Based on record review and interview, the facility failed to ensure effective services were provided to a dependent resident at risk to develop pressure injuries, and Resident C developed a facility-acquired pressure injury on the sacrum that deteriorated and exhibited signs and symptoms of infection for 1 of 3 residents reviewed for pressure ulcers. This deficient practice resulted in Resident C experiencing a significant change in condition that required hospitalization for wound-related septic shock and surgical debridement of the wound. The immediate jeopardy began on 3/9/24, when the sacral area was found and not thoroughly assessed. Treatment and further interventions for prevention and healing of the DTI were not initiated. The Administrator, Director of Nursing, and the Nurse Consultant were notified of the immediate jeopardy at 4/5/24 at 9:34. The immediate jeopardy was removed on 4/5/24, and the deficient practice corrected on 3/18/24, prior to the start of the survey, and was therefore Past Noncompliance Finding includes: Resident C's record was reviewed on 4/3/24 at 11:48 a.m. The diagnoses included, but were not limited to, stroke, subarachnoid hemorrhage, non-traumatic, respiratory failure, bipolar, aphasia, vascular implants and grafts, spina-bifida with shunts, and history of breast cancer (9/23/22). An Admission Clinical Observation, dated 3/2/24 at 3:09 p.m., indicated the resident was oriented to person and situation, was incontinent of bowel and bladder, bedfast, had a very limited ability to respond meaningfully to pressure related discomfort, the skin was constantly exposed to moisture, was completely immobile, and required maximum assistance with moving. There were no pressure ulcers present. The special instructions and risk factors included, a potential/actual impairment to the skin integrity. The interventions were to educate the resident/family caregivers of causative factors and measures to prevent skin injury, avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, and follow facility protocols for treatment of injury. Effective interventions to provide complete pressure relief to the bilateral buttocks were not included on the Admission Clinical Observation. A Care Plan, dated 3/4/24, indicated a potential for skin impairment. The interventions were to avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Provide peri care to keep clean and dry as possible. Keep HOB (head of bed) as low as possible when in bed with knee [NAME] (bed adjustment to achieve elevation and bend) raised to prevent shearing injury. Heel boots/elevate heels off mattress with pillows under calves in bed. Assist with repositioning as needed. Barrier cream to buttock/peri area after each incontinent care every shift. A Physician's Order, dated 3/4/24, indicated house barrier cream was to be used after each incontinence episode, every shift, for prevention and could be kept at bedside for the CNAs to apply. The plan of care for potential skin impairment and the Physician Orders, dated 3/4/24, did not include documentation to show the facility implemented effective interventions for pressure relief to prevent the development of pressure injuries. An Admission Minimum Data Set (MDS) assessment, dated 3/9/24, indicated a moderately impaired cognitive status, limited impairment of the bilateral upper extremities, and one side of the lower extremities, a wheelchair was used, eating had not been attempted, had a feeding tube for nutrition and hydration, and received a mechanical altered diet. The resident was dependent for toileting, showers, hygiene, and transfers. She required maximum assistance with bed mobility, was incontinent of bowel and bladder, was a risk for pressure ulcers, and had one unstageable pressure ulcer that was not present on admission. There was an application of dressings and ointments/medications, pressure reducing devices for the chair and bed, and nutrition or hydration interventions, and pressure ulcer care. The March 2024 CNA Task Form indicated the staff were to remind or assist the dependent resident to change positions every two hours. The form indicated staff had not reminded nor assisted with repositioning on 26 of 39 shifts between 3/5/24 and 3/17/24. The form had not included specific documentation that determined whether staff reminded or assisted the dependent resident with repositioning during the remaining 13 shifts. The CNA Skin Condition Task form, dated 3/6/24 at 5:59 p.m., indicated a discolored area was found, was not a new area, and the Nurse was notified. The task form did not include sufficient documentation to determine location of the skin impairment, the specific nurse notified, or when the nurse was notified. The Nurses' Progress Notes, Nursing Assessments, and IDT (Interdisciplinary Team) Progress Notes, dated from 3/6/24 at 6 p.m. through 3/9/24 at 12:25 p.m., had no documentation that indicated an area of skin discoloration had been identified or assessed. A Registered Dietician's (RD) Admission Evaluation, dated 3/7/24, indicated Resident C had no skin impairments. The note indicated the RD recommended to the physician to decrease the resident's calorie intake by 120 calories and protein intake by 25 grams daily. A Physician's Order, dated 3/9/24, indicated a new order was received to decrease the resident's parenteral feeding of Jevity 1.5 (calorically dense, fiber-fortified therapeutic nutrition) to be administered at 70 cc an hour for 16 hours. A Weekly Skin Observation report, dated 3/9/24 at 12:08 p.m., indicated the facility-acquired discoloration on the sacrum area was identified by LPN 5 as a Deep Tissue Injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm mushy, boggy, warmer, or cooler than adjacent tissue). There were no measurements or description of the specific wound characteristics. The report did not include documentation to show interventions were implemented to provide complete pressure relief to the sacrum. A Risk Management Form, offered by the DON (Director of Nursing), dated 3/9/24 at 11:31 a.m., indicated, a nursing description of a DTI to the sacrum. The description of action taken was repositioned and notified the Physician and family. The actions taken did not include interventions implemented to provide complete pressure relief and treatment to the facility-acquired DTI on the sacrum. A Communication Progress Note, dated 3/9/24 at 1:39 p.m., indicated the family and Physician were notified of the newly acquired DTI to the sacral area. A Physician's Order, dated 3/14/24, and back-dated to start on 3/9/24, indicated the sacrum area was to be cleansed with normal saline or wound cleanser and skin barrier cream was to be applied to the peri-wound and the facility- acquired DTI was to be covered with a border gauze every Monday, Wednesday, Friday, and as needed. The Treatment Administration Record (TAR), dated 3/2024, indicated the treatment was not provided in accordance with the Physician's order of 3/9/24 for two days, and there were no interventions that provided complete pressure relief to the facility-acquired DTI implemented. A Family Communication Progress Note, dated 3/14/24 at 4:41 p.m., indicated the resident's family was updated on the sacrum area, current treatment, and gave consent for the resident to see the Wound Specialist weekly. There were no Nursing Progress Notes, Wound Progress Notes, nor IDT Progress Notes, dated 3/9/24 through 3/14/24, that included sufficient documentation to show the facility-acquired DTI on the sacrum was effectively assessed or monitored by the staff. There were no interventions initiated that provided complete pressure relief to the facility-acquired DTI. A Care Plan, dated 3/14/24, indicated an impaired skin breakdown on the sacrum. The interventions were, administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing as per facility policy, measure length, width and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements and declines to the nurse and physician, monitor the nutritional status, serve the diet as ordered, monitor intake and record, monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X (by) width X depth), and stage. The plan of care had not included documentation to show interventions were implemented to provide complete pressure relief to the facility-acquired DTI on the sacrum. The initial facility Wound Nurse assessment, dated 3/15/24 at 10:15 a.m., indicated the facility-acquired DTI on the sacrum had deteriorated to an unstageable (pressure ulcer known but not stageable due to coverage of the wound bed by slough and/or eschar) pressure injury that measured 6.0 cm (centimeters) in length by 6.0 cm in width by an unknown depth. The wound bed contained 90% necrotic and 10% red tissue with a scant amount of serosanguinous drainage and distinct wound edges. The assessment had not included documentation that indicated interventions to provide complete pressure relief to the facility-acquired DTI that deteriorated to an unstageable sacral wound. The first assessment of the sacral wound was completed on 3/15/24 at 10:15 a.m. and indicated the wound was acquired on 3/9/24. It was now unstageable, with 90% necrotic soft tissue and 10% red non-granulating tissue. There was scant serosanguinous (blood tinged) drainage. The wound edge was distinct and attached. The measurement of the wound was 6.00 centimeters (cm) by 6.00 cm by unknown (length by width by depth). A Skin and Wound Progress Note, dated 3/15/24 at 12:58 p.m., indicated the resident was seen for a wound evaluation with a family member present in the room. The family member was aware of the wound decline. A low air loss mattress would be placed. Supplements were in place to help promote wound healing. The Physician and Registered Dietician were notified of the decline and the treatment was changed. A referral was completed for the Wound Specialist to evaluate the acquired wound on his next visit. The note did not include documentation of an assessment of the wound that included the location, the size, the stage, and the characteristic of the wound in the note. A Physician's Order, dated 3/15/24, indicated the facility-acquired, unstageable sacral wound was to be cleansed with normal saline or wound cleanser and patted dry. Skin prep was to be applied and allowed to dry and then covered with a hydrocolloid (wound protector and moist healing environment) dressing three times a week and as needed. A Physician's Order, dated 3/15/24, indicated a multivitamin was to be administered daily and 30 cc (cubic centimeters) of Prostat (protein supplement) was to be administered daily, and to be started on 3/16/24. The Physician's Orders, dated 3/15/24, had not included sufficient documentation that indicated complete pressure relief should be provided to the facility-acquired unstageable pressure injury on the sacrum. A Nurse's Progress Note, dated 3/27/24 at 3:54 p.m. for 3/18/244 at 3:30 p.m.,indicated a blood pressure of 96/64, a pulse of 108 per minute, respirations of 16 per minute, and temperature of 97.9 degrees. The oxygen saturation was at 87%. The NP (Nurse Practitioner) was notified and an order was received for a transfer to the emergency room for an evaluation and treatment. The Responsible Party was notified. The emergency room Physician's Progress Note, dated 3/18/24, indicated Resident C was febrile with a temperature of 102 degrees rectally. Respirations were 34 a minute, the blood pressure was 101/74 and the oxygen saturation was 99%. Resident C was ill appearing and a sacral wound was present. The lactic acid (blood test to determine sepsis/infection) was 4.0 (normal level less than 2) and Procalcitonin (test for presence of bacterial infection) was 0.74 (normal less than 0.05). There was significant leukocytosis (high white blood cell count). The chest x-ray did not demonstrate pneumonia. The urinalysis showed no infection. The hospital admission diagnoses were septic shock and sepsis due to skin infection. A Hospitalist Admission Note, dated 3/18/24 at 10:27 p.m., indicated the resident's family said the facility-acquired, unstageable sacral wound had developed about a week ago. The resident was diagnosed with sacral wound infection and septic shock. A Hospital Physician's Note, dated 3/22/24 at 9:32 a.m., indicated the resident presented to the hospital with septic shock, from the sacral wound. The wound culture resulted in polymicrobial (presence of multiple microorganisms) growth and a broad spectrum antibiotic was initiated. On 3/20/24, the superficial wound culture included staphylococcus aureus, e-faecalis, proteus [NAME], and e-coli. A Hospital Physician Progress Note, dated 3/21/24, indicated a surgical debridement of the unstageable sacral wound was scheduled for 3/21/24. The Hospital Operative Report, dated 3/21/24 at 6:28 p.m., indicated the unstageable sacral wound was surgically debrided down to the level of the bone. The area was measured at 7.0 cm length x 9.0 cm wide x 3.5 cm depth. During an interview, on 4/3/24 at 2:50 p.m., the DON indicated the IDT discussed changes of condition and pressure ulcers every morning. When a pressure wound was found, a Risk Management Form was to be filled out, and the Wound Nurse was to check for the Risk Management forms every morning, and then an assessment, treatment, and documentation was to be initiated. The DON indicated a Risk Management form had been filled out, and the Wound Nurse had indicated she had not seen the form, so an assessment of the area had not been completed. If the Wound Nurse had seen the Risk Management form, the Wound Specialist would have been able to see Resident C prior to the transfer to the Hospital. During an interview, on 4/3/24 at 3:13 p.m., the Director of Nursing (DON) indicated she had been the Manager on Duty (MOD) on 3/9/24. She had already put the barrier cream on the DTI on 3/9/24 and had not written the Physician's Order for the treatment until 3/14/24. LPN 1, the nurse on duty on evening shift on 3/6/24, was interviewed on 4/4/24 at 11:23 a.m., and indicated she did not recall a CNA reporting a discolored area on the resident's skin. During an interview, on 4/4/24 at 12:14 p.m., RN 3 (the Wound Nurse at the time of the unstageable sacral ulcer identification), indicated she reviewed the Risk Management Forms daily, and if a skin issue was found and the form was filled out, she then would have assessed the wound, notified the Physician and obtained a treatment. She would have also notified the family. RN 3 indicated she looked at the Risk Management Forms three times and the area marked was for a fall, so she had not reviewed the form any further. On 3/14/24, a nurse, unsure of the name, had informed her Resident C had an area on the buttocks. The nurse was directed to fill out a Risk Management Form. The DON had not verbally informed her of the area. If the Risk Management Form had been filled out, she would have assessed the area immediately. During an interview with CNA 2, on 4/4/24 at 2:41 p.m., she indicated the discolored area on 3/6/24 was on the buttocks and she had immediately reported it to the nurse on duty. She was unable to remember which nurse was on duty. A facility skin condition assessment and monitoring policy, dated 9/1/24 and received as current from the Administrator, indicated pressure ulcers would be assessed and measured at least weekly by a licensed nurse and documented in the clinical record. A skin condition assessment and pressure ulcer risk assessment (Braden) would be completed at the time of admission/readmission and would be updated quarterly and as needed. A wound assessment for each identified wound will be completed and will include, the site location, size (length x width x depth), and stage (if applicable). The resident's care plan will be revised as appropriate to reflect the alteration of the skin integrity, approaches and goals for care. A facility policy for pressure ulcer prevention, dated 9/1/20 and received as current from the Administrator, indicated to maintain clean/dry skin during daily hygiene measures, inspect the skin several times daily during bathing, hygiene, and repositioning measures, turn dependent residents approximately every two hours or as needed, and if redness does not disappear within 30 minutes the turning schedule may be shortened to an hour. Pressure reducing (foam) mattresses are used for all residents unless otherwise indicated. Specialty mattresses such as low air loss and alternating pressure, may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple stage two (partial thickness loss of the dermis) or one or more stage three (full thickness tissue loss) and stage four wounds (full thickness tissue loss with exposed bone, tendon, or muscle). Moisture barrier may be applied by CNA as needed to intact skin and may be kept at bedside. The past noncompliance immediate jeopardy began on 3/9/24. The immediate jeopardy was removed and the deficient practice corrected by 4/5/24, after the facility implemented a systemic plan that included the following actions: The facility determined a deficiency in their wound prevention, assessment, and treatment program on 3/14/24 and immediately implemented a plan of improvement. Interventions were initiated for Resident C on 3/16/24. All 19 of 21 nurses were educated on skin assessments at the time of admission and any newly identified skin concerns. They were educated on the policy if a new skin concern was found, a Risk Management Form was to be initiated, the Physician and family were to be notified, a treatment was to be obtained and initiated, and the DON and Wound Nurse was to be notified. Braden scales were to be completed and accurate with appropriate interventions, orders and care plans to be initiated for anyone with a low Braden score. The Clinical team were to audit and follow through with the treatments and plan of care. Additionally, 20 out of 47 CNAs were educated on 3/18/24 to ensure the nurses were notified of all new skin concerns found during care, interventions to be implemented and where to find those interventions. For any concerns, the DON, Wound Nurse, and Administrator may be notified. All residents have had updated Braden Scales and those with changes had interventions initiated for prevention. Four Nursing staff and five CNAs from different shifts were interviewed and all were knowledgeable of the policies and procedures they were educated on. The Administrator was interviewed on 4/8/24 at 11:30 a.m., and indicated staff who had not been educated would receive the education prior to working. Audits had been completed and were still ongoing to ensure Braden assessments, care plans, and interventions were in place. All information would be reviewed and submitted to the facility's Quality Assurance Program. This citation relates to Complaints IN00430826, IN00431391, and IN00431447. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to Resident B during a sit to stand mechanical lift transfer. Resident B required two staff assistance with transfers and was transferred with one CNA and not placed in the correct position on the bed and slid out of the sit to stand transfer sling with her right arm caught in the sling, onto the floor. This resulted in a fracture of the right humeral neck (shoulder). The facility also failed to ensure a fall prevention intervention was in place, related to a call light not with in reach for 2 of 3 residents reviewed for falls. (Residents B and F) Findings include: 1. During an interview on 4/1/24 at 8:52 a.m., Resident B was lying in bed with the head of the bed elevated. She indicated she was lowered to the floor after she slid out of a sling when she was being transferred to bed. She indicated there was only one staff member who assisted her with the transfer. Resident B's record was reviewed on 4/3/24 at 8:48 a.m. The diagnoses included, but were not limited to, stroke with right side paralysis and obesity. An Annual Minimum Data Set (MDS) assessment, dated 2/23/24, indicated an intact cognitive status, had clear speech, made self understood and understood other No behaviors were present, had an impairment of the upper and lower extremity on one side, had not ambulated, had one fall with no major injuries since the last assessment, and was dependent on staff for sit-to-stand position changes and transfers. A Care Plan, dated 12/11/23, indicated Resident B was at risk to experience falls related to a history of a stroke and right-sided paralysis. The interventions indicated the staff were to ensure the resident's needs were anticipated, the call light would be within reach, and she would be encouraged to use the call light when assistance was needed. The staff would ensure the resident was wearing non-skid footwear when ambulating and when she was in the wheelchair. Physical Therapy (PT) would evaluate the resident as ordered by the Physician and as needed. A) A, Post Fall Observation, dated 2/3/24 at 8:45 a.m., indicated two CNA's were using the sit-to-stand mechanical lift to transfer the resident and the resident fell while CNA 6 and CNA 7 was transferring her with the sit-to-stand mechanical lift. The resident was wearing non-skid footwear at the time of the fall. The Nurse indicated a 2.0 centimeter length by 2.0 centimeter width was found on the back of the head. Neurological assessment was without abnormal findings. The Nurse Practitioner (NP) was notified and messages had been left on the family's voicemail. A Nurse's Progress Note, dated 2/3/24 at 8:50 a.m., indicated Resident B experienced a witnessed fall and was observe lying in a supine (lying on the back) position on the floor of the shower room with one end of the sit-to-stand belt around the residents back and the other end connected to the mechanical lift. The resident indicated she had bumped her head and received a 2.0 cm by 2.0 cm hematoma (a solid swelling of clotted blood within the tissues) on the back of the head. The Neurological assessment was performed without abnormal findings. The NP and Director of Nursing (DON) were notified. There were several messages left for the Power of Attorney to return a call to the facility. A Care Plan, dated 2/3/24, indicated Resident B experienced a fall. The new intervention implemented to prevent further falls was to have a PT consult conducted to evaluate the resident's strength and mobility and to evaluate the resident's needs for safe transfers with appropriate mechanical lift equipment. The plan of care did not include documentation to show immediate and effective interventions were implemented to prevent further falls. A Fall Interdisciplinary Team(IDT) Progress Note, dated 2/5/24 at 9:38 a.m., indicated the resident experienced a fall during a transfer with the sit-to-stand mechanical lift. The resident started to slide. The root cause was the resident is a hemiplegic. The new intervention added, indicated therapy was to evaluate for full mechanical lift (Hoyer) usage for transfers. An Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 2/6/24, indicated the sit-to-stand mechanical lift for transfers was to continue to be used. The resident had not wanted the full mechanical (Hoyer) lift to be used. The note indicated OT services would be provided for strengthening exercises, wheelchair management, and self-care management. During an interview, on 4/3/24 at 10:57 a.m., the Therapy Supervisor indicated therapy staff recommended the staff use a full mechanical (Hoyer) lift for transfers after the resident fell on [DATE]. The Therapy Supervisor indicated the resident refused the recommendation to use the full mechanical (Hoyer) lift and said she would just not get out of bed if it was used. B) A Nurse's Progress Note, dated 3/12/24 at 8:51 p.m., indicated the CNA (Past Employee CNA 4) reported a witnessed fall and had slid from the sit-to-stand mechanical lift sling to the floor during a transfer from the wheelchair to the bed with the assistance of one staff. The note indicated the nurse observed the resident sitting on the floor of the bedroom and the resident reported pain to the right shoulder. No injuries were noted and the range of motion was within normal limits. The NP and family members were notified. A, Post Fall Observation, dated 3/12/24 at 11:35 p.m., indicated Past Employee CNA 4 had transferred the resident without the assistance of a second staff person using the mechanical sit-to-stand lift. The resident resident reported that Past Employee 4 guided her body to a sitting position on the floor during the fall. Non-skid footwear was not in use at the time of the fall and she experienced right shoulder pain that increased with range of motion. The NP and the resident's family member were notified. A Nurse's Note, dated 3/13/24 at 12 a.m., indicated the resident complained of right shoulder pain that radiated to the right hand. The pain was rated at a 7 out of 10. Pain medication was administered (as needed acetaminophen 325 milligrams, two tablets). The resident reported the pain started after her fall. The resident has a history of pain to the right shoulder and reported the pain was worse than what she usually experienced. There was no bruising or swelling observed on the right shoulder. The area was very tender with palpation . The NP was notified and an order was received to obtain an X-ray for the right shoulder, arm, elbow, and wrist as soon as possible. A voicemail was left with the Responsible Party. A Nurse's Note, dated 3/13/24 at 2 p.m., indicated the X-ray results were positive for a fracture. The NP, DON, and family member was notified and the resident was transferred to the Hospital emergency room for treatment. The X-ray results, dated 3/13/24, indicated a right humeral neck fracture with displacement of fracture fragments. A Nurse's Progress Note, dated 3/13/24 at 10 p.m., indicated the resident returned to the facility with an immobilizer and soft cast with elastic bandage to the the right shoulder. An Interdisciplinary Team (IDT) Note, dated 3/14/24 at 9:47 a.m., indicated the resident slid out of the sling down to the floor while being transferred from the wheelchair to the bed. The intervention was to use the full mechanical lift (Hoyer) for all transfers. The note indicated the root cause of the fall was the resident slid out of the sling of the sit-to-stand mechanical lift while being transferred. The fall plan of care, dated 2/3/24, was revised and updated on 3/14/24 and the intervention to use a full mechanical lift (Hoyer) for all transfers. The Administrator provided an undated, unsigned, typed statement on 4/3/24 and indicated it was from Past Employee CNA 4. The statement indicated Past Employee CNA 4 had transferred Resident B without assistance from another staff member, with the mechanical sit-to-stand lift. She had seated the resident on the bed and before she could remove the transfer sling, the resident slid to the floor. She received assistance from another CNA, Nurse, and full mechanical lift (Hoyer) to transfer the resident back into the bed. The statement did not include sufficient documentation to show the CNA was aware two staff should have been present during the sit-to-stand mechanical lift transfer. The Job Specific Orientation Check List for Past Employee CNA 4, indicated orientation had been completed on 11/11/23 for use of the Hoyer and the sit-to-stand mechanical lift. During an interview on 4/3/24 at 11:55 a.m., the Nurse Consultant indicated the instructions on how to transfer the resident were located on the Resident's Dashboard in the computer under special instructions. She was unable to pull-up the past transfer intervention, though knew it was listed as a sit-to-stand mechanical lift and it required two staff to assist. During an interview on 4/3/24 at 1:02 p.m., the Administrator indicated the investigation found the resident still had the sling hooked up to the lift when she slid out and the resident's right arm was caught in the sling due to the paralysis. She indicated the resident had not been placed on the bed correctly and had slid out. Two staff members were supposed to assist with transfers when using any type of mechanical lift. Past Employee CNA 4 had not said why she had not obtained assistance to help with the transfer. A Facility Transfer and Mechanical lift policy, dated 9/1/20, and received from the Administrator as current, indicated a mechanical lifting device was to be used for any resident who required two-person assistance, or who could not transfer comfortably and /or safely by normal transfer technique. The -transferring needs of the resident would be assessed on an ongoing basis and would be designated into a categories, which included, sit to stand lift with two caregivers. 2. Resident F was observed lying in bed with her head of the bed elevated on 4/1/24 at 9:05 a.m. The resident was interviewed at the time of the observation and indicated she was unsure how to call the staff if she needed assistance. Resident F was observed lying in bed with her head of the bed elevated on 4/1/24 at 10:25 a.m. and at 10:43 a.m. with the call light draped over the side table to the right of the bed and out of the resident's reach. During an interview on 4/1/24 at 10:43 a.m., the DON indicated the call light was not in reach of the resident and placed the call light on the resident's bed. Resident F's record was reviewed on 4/3/24 at 9:42 a.m. The diagnoses included but were not limited to, diabetes mellitus and dementia. Nursing Progress Notes, dated 3/26/24, indicated the resident was found on the floor, assessed, no injuries noted, family and NP (Nurse Practitioner) were notified. A Care Plan, dated 3/11/24, indicated the resident required assistance with bed mobility and transfers. A Care Plan, dated 3/11/24, indicated a risk for falls with actual falls on 11/2/23, 12/28/23, and 2/12/24. The interventions included, but not limited to, ensure the resident's call light was within reach and encourage to use it for assistance as needed. There were no care plan updates or interventions added after the fall on 3/26/24. A fall prevention policy, dated 9/1/20 and received as current from the Administrator, indicated the call light would be placed within the resident's reach at all times. This citation relates to Complaint IN00430737. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure residents were free of any significant medication errors related to not receiving anticoagulant (blood thinner) medications which resulted in a re-hospitalization for pulmonary emboli (blood clots in lungs) and new onset cardiomegaly (enlarged heart) for 2 of 3 residents reviewed for anticoagulant use. (Residents F and R) The facility also failed to ensure insulin and intravenous (IV) antibiotics were administered for 2 of 4 residents reviewed for unnecessary medications. (Residents F and D) The immediate jeopardy began on 3/5/22 when the resident's anticoagulant was not delivered to the facility after admission from the hospital. The pharmacy had contacted the facility on 3/6 and 3/10/22 for a clarification order with no response from facility staff. On 3/10 and 3/14/22, the resident had complaints of chest pain and shortness of breath. The resident was sent out 911 on 3/14/22 after an abnormal EKG and was admitted to the hospital with bilateral large pulmonary emboli with new onset cardiomegaly. The Administrator was notified of the immediate jeopardy at 11:00 a.m. on 4/14/22. Findings include: 1. The closed record for Resident F was reviewed on 4/12/22 at 11:35 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE]. a. Prior to admission, Resident F was hospitalized from 1/31/22 to 3/4/22 for bilateral pulmonary with large saddle [CONDITION(S)], right heel [CONDITION(S)] (bone infection), and COVID-19 pneumonia. The Admission Minimum Data Set (MDS) assessment, dated 3/10/22, indicated the resident was cognitively intact and required extensive assistance with bed mobility. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on 3/12/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Pharmacist on 4/13/22 at 4:41 p.m., indicated the resident's [MEDICATION(S)] had not been sent to the facility due to a clarification order being needed. On 3/6/22, the Pharmacist spoke with LPN 1, indicating a clarification order needed to be obtained. He indicated he never received a response from the facility. On 3/10/22, another Pharmacist spoke with RN 1 and indicated a clarification order for the [MEDICATION(S)] needed to be obtained so it could be sent to the facility. The Pharmacy received no response from the facility. Nurse Practitioner (NP) Progress Notes, dated 3/10/22 at 4:15 p.m., indicated the resident had reported midsternal chest pain without [CONDITION(S)] or changes with breathing. The resident denied nausea, dizziness, or headache. At that time, the resident did not appear to be in any distress. No other needs, wants, or concerns were expressed. NP Progress Notes, dated 3/14/22 with a time stamp of 5:32 p.m., indicated the resident had her EKG that day. The resident continued to complain of chest pain and some shortness of breath (SOB). STAT EKG results were abnormal. Continued complaints of midsternal chest pain with occasional SOB. Discussed results with Physician. Sending resident out for further evaluation to determine if resident was having an active MI (heart attack). No abdominal pain or fevers were noted per nursing report. At that time, the resident did not appear to be in any distress. No other needs, wants, or concerns were expressed. Breath sounds clear but diminished to bilateral bases. The resident was sent out 911 on 3/14/22 at 4:00 p.m. The Hospital Admission Note, dated 3/14/22, indicated the resident was a recent admission for bilateral pulmonary emboli on full dose [MEDICATION(S)] (a blood thinner). The repeat CT scan redemonstrated bilateral pulmonary emboli with infiltrates. On 3/14/22, CT Chest [MEDICATION(S)] with MIP Imaging showed, bilateral large pulmonary emboli with cardiomegaly. Diffuse consolidative infiltrates bilaterally with small bibasilar effusions. Cardiomegaly is identified. The cardiomegaly (enlarged heart) was new onset. A two view Chest X-Ray Report, completed on 1/31/22 during the resident's previous hospital stay, indicated the resident's heart size was grossly within normal limits. Interview with the Administrator on 4/13/22 at 4:45 p.m., indicated the resident's March MARs still could not be found. The resident's [MEDICATION(S)] should have been received as ordered and the facility should have followed up with the pharmacy regarding the clarification order. b. Resident F had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician was to be notified if the resident's blood sugar was less than 60 or greater than 400. The March 2022 Insulin/Diabetic Flowsheet, indicated the resident's blood sugar was not monitored on the following dates and times: - 3/6/22 at 12:00 p.m. and 8:00 p.m. - 3/8/22 at 8:00 a.m., 12:00 p.m., and 8:00 p.m. - 3/10/22 at 8:00 a.m. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2022 Insulin/Diabetic Flowsheet, indicated the [MEDICATION(S)] insulin was not given as ordered at 8:00 a.m. on 3/6, 3/8, and 3/13/22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2022 Insulin/Diabetic Flowsheet, indicated the [MEDICATION(S)] insulin was not given as ordered at 8:00 a.m. on 3/6, 3/8, and 3/13/22. The 12:00 p.m. dose of insulin was not given on 3/8 and 3/13/22. Interview with the Director of Nursing on 4/14/22 at 2:20 p.m., indicated the insulin should have been given as ordered. He also indicated the resident's blood sugar should have been monitored as ordered. 2. The record for Resident D was reviewed on 4/13/22 at 9:45 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent out to the hospital on 1/27/22 and returned on 2/8/22 at 2:32 p.m. At that time, he had his pancreas and spleen removed. The Quarterly Minimum Data Set (MDS) assessment, dated 2/14/22, indicated the resident was cognitively intact and had major surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurses' Note, dated 2/8/22 at 2:45 p.m., indicated during report from another nurse, it was stated this resident was on IV (intravenous) [MEDICATION(S)] (an antibiotic), the order could not be found on the medication list from the hospital, also the resident had new allergies to [MEDICATION(S)] per the discharge papers. The nurse called admissions asking if they had the current medication list to see what antibiotic the resident was supposed to be on and were awaiting a call back. Nurses' Notes, dated 2/9/22 at 5:49 a.m., indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If side effects such as itching or rash occur, reach out to Physician for order to cope with effects. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Administration times were 12:00 a.m., 8:00 a.m., and 4:00 p.m. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - 12:00 a.m. on 2/10, 2/17, 2/28, and 3/8/22 - 8:00 a.m. on 2/9, 2/10, 2/13, 2/25, 2/26, 2/27, 2/28, 3/3, 3/4, and 3/7/22 - 4:00 p.m. on 2/9, 2/10, 2/13, 2/14, 2/15, 2/16, 2/26, 2/27, 2/28, 3/5, 3/6, and 3/7/22 Interview with the Director of Nursing on 4/13/22 at 2:15 p.m., indicated the [MEDICATION(S)] was not given when the resident came back from the hospital due to a new documented allergy of [MEDICATION(S)]. They called the doctor to clarify and he indicated to go ahead and give the IV [MEDICATION(S)] and monitor the resident for itching or an allergic reaction. The [MEDICATION(S)] should have been administered as ordered by the doctor. 3. The record for Resident R was reviewed on 4/14/22 at 11:00 a.m. The resident was admitted to the facility on [DATE] at 2:05 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses' Notes, dated 4/13/22 at 3:04 p.m., indicated the resident arrived to the facility per EMS. The resident was alert and oriented times 4 and able to make his needs known. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The fax sent to pharmacy from nursing staff indicated, [MEDICATION(S)] ([MEDICATION(S)]) solution; 5,000 unit/ml Directions: amount 0.5 mls (5,000 units); injection; three times a day special instructions: Inject (5,000 units) into skin every 8 hrs x 30 days. The discharge instructions from the hospital, dated 4/13/22, indicated the [MEDICATION(S)] was last administered on 4/13/22 at 5:37 a.m. Interview with Agency LPN 2 on 4/14/22 at 11:00 a.m., indicated she just printed off the resident's medication sheets, as he was admitted yesterday afternoon, and before the ambulance left, the family wanted a private room, so they moved him to a different room. He was only in that room for maybe 30 minutes. LPN 2 had worked a double shift that day, east unit in the morning and west unit for the evening shift. She helped the nurse with the admission and put the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She had overlooked the every 8 hours directive and did not double check the order or call the doctor and clarify the order. She came back today and was working on the east unit where the resident resided. There were no medication sheets available for review, so she had to print new medication sheets. She had not administered any of his medications today. The medication cart was observed at 11:20 a.m., and the resident's oral medications were located in the cart, however, the [MEDICATION(S)] medication was not in the cart. The LPN was unsure if the [MEDICATION(S)] medication was available in the EDK (Emergency Drug Kit). Interview with the Risk Management Consultant on 4/14/22 at 12:30 p.m., indicated the [MEDICATION(S)] order was faxed to the pharmacy yesterday, however, the wrong dose was documented/transcribed, therefore, the pharmacy did not send the medication because they needed a clarification. The immediate jeopardy that began on 3/5/22 was removed on 4/14/22 after the facility implemented a systemic plan that included the following actions: the pharmacy provided their policy related to clarification of medication orders, facility licensed nurses and agency nurses working onsite at the facility were inserviced regarding prompt follow up with the Physician/NP for any anticoagulant medication requiring order clarification when notified by the pharmacy, facility licensed nurses and agency nurses working onsite at the facility were inserviced regarding prompt follow up with the pharmacy for any anticoagulant medication order in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . All residents with orders for anticoagulants had the medication present and available. The facility requested the pharmacy to review any resident anticoagulant orders that had not been filled due to requiring clarification from the NP/Physician. The pharmacy verified there were no outstanding orders requiring clarification. The facility inserviced licensed nursing staff on pharmacy notification for any anticoagulation medication that required clarification from the NP/Physician so the medication could be dispensed by the pharmacy, prompt pharmacy notification for any anticoagulant medication listed in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did have an emergency medication (KAPSA) machine on site. The KAPSA could be accessed for missing anticoagulant medication and pharmacy could be called for any difficulty with access to the KAPSA machine. For any staff who had not received the inservice due to PRN status, agency status, or being unable to reach at the time, the facility would complete the above inservice prior to the start of their next scheduled shift. The DON/designee would complete an investigation for anticoagulants in which orders were not filled to determine the root cause of why the medication ordered was not filled/dispensed to the facility. The facility DON/designee would audit each new admission and readmission to verify that anticoagulant medications ordered had been delivered and secured in the medication cart. The pharmacy would be contacted immediately for any missing anticoagulant medication. The facility would complete a random audit twice weekly for all residents with orders for anticoagulant medications to ensure the medication was available and was being given as ordered and signed out on the MAR. An emergency QA meeting was held with the Medical Director, Administrator, DON, Social Service Director, HIM Director, and the Director of Nursing at Pharmacy on 4/14/22 at 2:00 p.m. The immediate jeopardy was removed on 4/14/22, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because not all staff had been educated and monitoring of the implemented systems was ongoing. This Federal tag relates to Complaints IN 097 and IN 606. 3.1-48(c)(2)

Based on record review and interview, the facility failed to consistently monitor food and fluid intake for at risk residents which resulted in hospitalization for dehydration for 2 of 3 residents reviewed for a change in condition. (Residents D and H) Findings include: 1. The closed record for Resident D was reviewed on 2/1/22 at 8:53 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 11/3/21, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. She needed extensive assistance with eating and received a mechanically altered diet. The Care Plan, dated 11/2/21, indicated the resident was limited in functional status in regards to eating and drinking independently. Interventions included, but were not limited to, notify Physician and Responsible Party with any change in condition, observe for and record intake of food and fluids, and provide assistance at the level the resident required. The resident received a mechanical soft diet 11/1 through 11/17/21. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Speech Therapy note, dated 11/17/21 at 1:00 p.m., indicated a diet downgrade recommendation to puree consistency as the resident was pocketing food. Nursing and dietary were notified of the change. A Registered Dietitian (RD) Progress Note, dated 11/18/21 at 3:08 p.m., indicated the resident's weights were reviewed and she had lost approximately 4.6 pounds over the past 9 days. Collaborated with speech therapy, resident was recently downgraded to puree textures. Resident with poor oral intake per food consumption records, typically less than 50% of most meals. Super cereal at breakfast was recommended and to continue with weekly weights. Nurses' Notes, dated 11/24/21 at 8:54 a.m., indicated the resident had a poor appetite that morning for breakfast and was resting in bed at the time. The next entry in the progress notes was completed by the Physician on 11/25/21 at 9:06 p.m., and indicated the resident was confused and suffered from severe dementia. He also indicated she needed to be assisted with feeding and to encourage oral intake. The Food and Fluid Intake Sheets for the month of November 2021, indicated no meal intake was documented for 11/11, 11/14, 11/20, 11/21, and no breakfast or lunch on 11/22/21. The resident did not consume any breakfast or lunch on 11/25/21 and there was no documentation for dinner. The resident's average food consumption was 1-25% on days documentation was completed. There was no fluid intake documented for 11/11, 11/14, 11/20 and 11/21/21. On 11/18/21 at 9:22 a.m., the resident consumed 236 milliliters (ml) of fluid. At 1:10 p.m., the resident consumed 240 ml of fluid. The next documented entry related to the resident's fluid intake was on 11/23/21 at 9:55 a.m. which was 120 ml. At 12:45 p.m., she also consumed 120 ml. On 11/24/21 at 8:54 a.m., she consumed 100 ml of fluid. On 11/25/21 at 9:08 a.m. and 1:14 p.m., she consumed 120 ml. Nurses' Notes, dated 11/26/21 at 2:50 a.m., indicated the resident was resting in bed with no acute distress noted. The next documented entry at 2:25 p.m., indicated during rounds, the resident appeared lethargic and was nonresponsive to tactile or verbal stimuli. Her blood pressure was 92/62, her pulse was 92, and her respirations were 20. Temperature was 98.1 and her oxygen saturation was 87% on room air. Oxygen was immediately applied. The Physician was in the facility and orders were obtained to send the resident to the emergency room via 911. The emergency room Progress Note, dated 11/26/21 at 3:20 p.m., indicated the resident was being evaluated for altered mental status. The resident was possibly last normal 7 days ago but exact date was unclear. The resident was unable to provide any history at that time. History and review of symptoms was limited secondary to altered mental status. History was obtained from EMS personnel and nursing staff. Upon arrival to the emergency room , the resident's blood pressure was 78/51, pulse 90, and respirations were 28. emergency room laboratory results indicated the resident's white blood cell count was elevated at 18.5, her blood urea nitrogen (BUN) level was elevated at 119 (normal 6-24, an elevated BUN is also indicative of dehydration or malfunctioning kidneys), and her Creatinine (a kidney function test) was elevated at 7.1 (normal level 0.59 to 1.04). The resident's sodium level was elevated at 164 (normal 135-145, elevated sodium levels can be caused by dehydration). The resident was admitted to the hospital with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Preadmission laboratory results, dated 9/15/21, indicated the resident's BUN was normal at 18 and her Creatinine was normal at 1.2. Interview with the Nurse Consultant on 2/1/22 at 3:32 p.m., indicated the resident's food and fluid intake should have been monitored more closely. 2. The closed record for Resident H was reviewed on 1/31/22 at 4:50 p.m. The resident was admitted on [DATE] and discharged to the hospital on 1/5/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 11/30/21, indicated the resident was alert and oriented and needed extensive assist with a 2 person physical assist for bed mobility. The resident needed extensive assist with a 1 person assist for dressing and personal hygiene, and was totally dependent on staff for toilet use and bathing. A Care Plan, dated 11/25/21, indicated the resident received a diuretic medication and was at risk for dehydration. The approaches were to observe the cardiovascular system and fluid status to determine effectiveness of diuretic therapy for example [CONDITION(S)], mental confusion, shortness of breath, abnormal breath sounds, or abnormal heart sounds, observe for and report symptom of dehydration such as dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry [MEDICATION(S)] membranes, sunken eyes, constipation, fever, or infection. A Care Plan, dated 11/25/21, indicated the resident was limited in functional status in regards to eating and drinking independently. The approaches were to observe and record intake of food and fluids and refer to OT/ST as needed. A NP (Nurse Practitioner) Note, dated 11/26/21, indicated the resident was being seen for a new admission. She presented to the ER (emergency room ) with stroke-like symptoms and the MRI demonstrated those findings. The resident was nonverbal and was admitted to the acute rehab at the hospital and then discharged to the facility for further rehab. The assessment and plan for the resident for the [CONDITION(S)] disorder was to monitor weekly weights, fluid intake, and provide a low sodium diet. Lab work from the resident's hospital admission of 11/9/21 indicated labs were drawn on 11/24/21 right before the resident was admitted to the facility. Her WBC count (White Blood Cell) was 10.54 (normal 4.5-11), BUN (Blood Urea Nitrogen, measures the function of the kidneys) was 21 (normal 6-24) and CR (Creatinine, measures the function of the kidneys) was 1.02 (normal 0.7-1.3). The resident weighed 156 on 11/24/21, 148 pounds on 11/30 and 12/2, and 150 on 12/7/21. There was no recorded weight for 1/2022. Meal consumption logs for 12/2021 indicated on 12/28 and 12/29 the resident consumed 76-100% of dinner. On 12/29, the resident consumed 76-100% of lunch. On 12/30 the resident consumed 26-50% of dinner. On 12/31/21 the resident consumed 1-25% for breakfast and lunch and 26-50% for dinner. Meal consumption logs for 1/2022 indicated 1/1-1/3 for all meals, the resident consumed 1-25%. There was no documentation on 1/4/22 of any meal and on 1/5 the resident consumed 1-25% for breakfast. The only fluid intake documented was on 12/28/21 which indicated the resident consumed 240 milliliters of fluid. There was no other documentation of any other oral intake. Physician Orders, dated 11/24/21, indicated [MEDICATION(S)] (a diuretic medication) 40 milligrams (mg) daily. There was no therapy ordered for the resident such as PT, OT, or ST. A RD (Registered Dietitian) Note, dated 11/28/21 at 1:16 p.m., indicated labs and weight were addressed. The resident was not at risk for malnutrition and recommend a no concentrated and no added salt diet and textures per Physician or speech therapy. The last RD Note was on 12/9/21 at 3:08 p.m., which indicated the resident's weights were stable and to discontinue weekly weights and follow up with monthly weights. A Physician Note, dated 12/17/21 at 3:33 p.m., indicated the resident was seen and had no new complaints. Vital signs were stable and she was seen by dietary. She would like to participate in PT. A Nurses' Note, dated 1/3/22, indicated the resident received a PCR COVID-19 test. The next entry in Nurses' Notes was on 1/5/22 at 1:30 p.m., which indicated Writer called 911 to report change in resident's status. Writer spoke with daughter and made her aware of resident's change in condition. Resident has a change in AMS [altered mental status] resident loss of appetite today, tolerated medications this AM without any difficulty, however resident is very lethargic now. Afebrile, VS [vital signs] abnormal. Resident will be sent out to the hospital to eval [evaluate] and treat. DON [Director of Nursing] is aware. Nurses' Notes, dated 1/5/22 at 1:51 p.m., indicated the Physician was made aware of the resident's change in condition. Nurses' Notes, dated 1/5/22 at 1:52 p.m., indicated the EMT's were present at the resident's bedside. The resident was transferred to the hospital and admitted with acute [CONDITION(S)] and acute [CONDITION(S)]. A Physician's Note, dated 1/5/22 at 11:22 p.m., (Recorded as Late Entry on 1/22/22 at 11:24 a.m.) indicated the resident was discharged to the hospital. The resident has been lethargic and had not been doing well and apparently had been dehydrated and not making urine. Discussed with staff will transfer to nearby hospital. Hospital emergency room Notes, dated 1/5/22 at 2:40 p.m., indicated the resident had altered mental status and was last seen normal at 8:30 a.m. at the nursing home. Apparently she was found unresponsive at some point and she cannot talk or open her eyes but can move her eyelids a little bit. She looks clinically dehydrated. Her vital signs were blood pressure 100/63, pulse 115 and oxygen saturation at 92%. Her weight was 137 pounds. Laboratory tests were obtained on 1/5/22 in the hospital and the resident's WBC was 22.5 (a high value), BUN was 103 (a high value) and CR was 5.9 (a high value). The resident was admitted with acute [CONDITION(S)] and acute [CONDITION(S)]. A Nephrology consult, dated 1/5/22 at 6:55 p.m., indicated the plan was for aggressive fluids, foley catheter and renal ultrasound. Hospital labs, dated 1/13/22, indicated the resident's BUN was now 17 and the CR was 1.4. There was no documentation from 1/1-1/5/22 regarding the resident's mental status or an assessment of her eating and drinking. Interview with the Nurse Consultant on 2/1/22 at 3:10 p.m., indicated there was no documentation from 1/1-1/5/22 regarding the resident's condition of not eating or drinking. The resident's fluid intake was not monitored, nor was her mental status. This Federal tag relates to Complaints IN 066 and IN 776. 3.1-46(b)

Based on observation, record review and interview the facility failed to ensure staff responded appropriately when an unlocked alarming exit door sounded resulting in a resident exiting the building, with whereabouts unknown for approximately 3 hours, for 1 of 3 residents reviewed for supervision. The resident was located off facility property in a wooded area by Police and admitted to the hospital for hypothermia. (Resident K) The Immediate Jeopardy began on 11/2/19 when Resident K exited an unlocked alarming Exit door. The facility failed to follow their elopement procedure when a staff member failed to open the door after an alarm sounded and look outside to determine if any residents had exited through the door to the parking lot. A Code Pink for elopement was not initiated. No other staff members in the facility were notified or aware a resident had exited the facility unattended. The resident was found by Police with a Canine dog and a Police air vehicle in a heavily wooded area across railroad tracks and a busy road approximately three hours after staff noted the resident was missing. The Administrator and Vice President (VP) of Operations were notified of the Immediate Jeopardy on 11/12/19 at 2:05 p.m. The Immediate Jeopardy was removed on 11/13/19, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: The closed record for Resident K was reviewed on 11/12/19 at 9:42 a.m. The resident was admitted from an acute care hospital on [DATE]. [DIAGNOSES REDACTED]. A Full Clinical Admission assessment was completed on 10/31/19 at 6:30 p.m. The resident was alert and orientated to person and place with reported increased confusion and short term memory loss. As per new admission status, 15 minute checks were initiated. A Facility Reported Incident occurred on 11/2/19. Resident K eloped from the facility and was found by local Police and was taken to the hospital. An investigation was initiated. The resident's family had visited on 11/2/19 from approximately 1:30 p.m. to 5:45 p.m. The facility received an anonymous phone call that a possible resident was on Sheffield Avenue trying to flag down drivers. A head count was initiated and staff immediately initiated a search outside the building. The Police were contacted. Per the investigation Elopement Timeline, Helicopter in air and K-9 (police dog) found the resident fully clothed and under saplings hiding at approximately 9:15. A (name of City) Police report, initiated on 11/2/19 at 6:35 p.m., indicated (name of City) Police were called to (name of facility) in regards to a missing female patient from a local Nursing Home. Staff reported (Resident K) was missing. The facility had received a call from a person stating they saw an elderly female standing on (name of busy street) in front of the facility. The person was waving at passing cars as if to get them to stop. Facility staff then conducted rounds and found (Resident K) was missing. Assistance from the county aviation unit was requested. The process for a Silver Alert was initiated by the Police. Staff present at the facility did not have access to the video surveillance system. The Administrator arrived at 7:20 p.m. and the foot age was viewed. The resident was seen walking through the parking lot, stood on the street in front of the facility and then crossed the street. The resident then headed through the rear yard of a residence on the other side of the street. A Canine Officer arrived around 8:10 p.m. and went to Resident K's room with the canine. They later were able to locate Resident K at 9:15 p.m. in a heavily wooded area with the assistance of the Canine team and the aviation team. Assistance from the city Fire Department and Ambulance service were called for. The Fire Department and EMS responded and needed to cut down some of the brush to gain access to Resident K. The resident was transported to the hospital. The resident did not return to the facility. The hospital Emergency Department documentation indicated the resident was seen for an evaluation of cold exposure which occurred prior to EMS arrival. She walked away from a nursing facility and was not found until three hours later. The patient had dementia. Vital signs at 10:26 p.m.: Blood pressure 125/94, Pulse rate 105 and Respiratory rate 21. A rectal temperature of 96.3 F was recorded. Skin was pink. Encounter Diagnoses: [REDACTED]. An ER (emergency room ) Nurse's noted indicated, 11/2/19 at 10:19 p.m. patient walked away from a SNF (long term care) facility and was not found until approximately 3 hours later. Patient was found near an embankment and stated she was cold and also complained of left knee pain due to kneeling in the woods . Past weather reports on Weather. com indicated outdoor temperatures for the city location were recorded as a low of 39 degrees F at 12:00 p.m. and a low of 34 degrees F at 6:00 p.m. Sunset was recorded at 5:43 p.m. The door Resident K exited from the facility on 11/2/19 was observed on 11/12/19 at 11:13 a.m. with the facility Administrator. The door was not one of the Main Entrance doors. The door was located to the North of the Main Entrance. The windows on the door looked out to the front parking lot. Two small contact alarms were noted on the upper left side of the door. An Exit sign was on the door. The Administrator opened the door and the alarms sounded. Interview with the Administrator at that time indicated family members and visitors often used this door. On 11/2/19, the Nurse from the attached Assisted Living center heard the alarm and went to the door and looked out the window to the parking lot. No Family members or residents were seen. The Nurse did not open the door to check if any Residents were outdoors. The Nurse then returned to her unit. The Nurse did not notify the Administrator or the Manager on duty at the time. No Elopement notices were announced in the building. Per the Elopement Protocol the Nurse was required to check the outside areas when she answered the alarm. This was not done. The resident was seen in the parking at 6:07 p.m. on the cameras. Contact with the Nurse was attempted, but unsuccessful. The Elopement and Search (Code Pink) Policy was reviewed on 11/12/19 at 10:45 a.m. All Nursing personnel were responsible for knowing the whereabouts of the residents they were assigned . Residents were not allowed to leave the facility without a physician's orders [REDACTED]. The Immediate Jeopardy that began on 11/12/19 was removed on 11/13/19 when the facility implemented continuous staff monitoring of the exit door until they installed a door alarm system on the exit door, completed on 11/14/19, which had a 15 second opening delay and a very loud alarm sounded continuously when the door was pushed. Most staff had also been inserviced and demonstrated understanding of the elopement procedure. The Immediate Jeopardy was removed on 11/13/19, but noncompliance remained at a lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because inservicing of all facility staff was yet to be completed and a monitoring system for assessing the ongoing functioning of the alarm was to be put in place. This Federal tag relates to Complaint IN 854. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure Cardio-Pulmonary Resuscitation(CPR) interventions were initiated for a resident observed with absence of vital signs when no Physician orders or Advance Directives were noted for the resident not to receive CPR or other resuscitation measures, resulting in death for 1 of 3 residents reviewed for death in the facility (Resident G). This had the potential to affect all residents in the facility with a Full Code Status. The Immediate Jeopardy began on [DATE] when Resident G was observed with absence of vital signs and facility staff did not initiate CPR and other life saving interventions resulting in death for 1 of 3 residents review for death in the facility. The facility Administrator, Director of Nursing, Assistant Director of Nursing, Corporate Nurse, and Assistant to the Administrator were informed of the Immediate Jeopardy on (MONTH) 19, (YEAR). The Immediate Jeopardy was removed and the deficient practice corrected on [DATE], prior to the start of the survey, and was therefore Past Noncompliance. Finding includes: The closed record for Resident G was reviewed on [DATE] at 8:44 a.m. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set(MDS) assessment was completed on [DATE]. The resident was rarely or never understood. No behaviors occurred. Extensive assistance of two staff members was required for bed mobility. Extensive assistance of one staff was required for dressing and personal hygiene. There were no plans for discharge and expects to remain in the facility. There was no Hospice care while a resident. The [DATE] Nursing Progress Notes indicated the following: On [DATE] at 8:58 a.m., the resident was in bed, no distress, respirations were even and unlabored. Resident alert to self. On [DATE] at 1:40 p.m., Nurse summoned to resident's room and noted resident without respirations. Skin warm, no vital signs found. Family in the room and aware of condition. Doctor was paged. No Physician orders were in place related to resident's Code Status for resuscitation. No Care Plans were in place related to related to Hospice Services, Advanced Directives, or Code Status. A Notice of Health Care Decisions form, dated [DATE], indicated the following: - Resident name and Physician name filled in, No checked next to columns for Living Will, Durable Power of Attorney, Guardianship. Healthcare Representative appointment Indiana is not checked. There was blank box in front of the following I have been offered information about state specific Advance Directives and choose not to execute any at this time. I have also been informed that I may reconsider this decision and will need to speak with the Social Service Representative if any Advance Directives are to be executed in the future. I understand that in the absence of a Do Not Resuscitate Order a Full Code is in effect. Any documents that have not been provided to the facility will be considered non-existent. The line for Resident signature and the date are blank. A Social Service Progress, dated [DATE] at 5:12 p.m., indicated Social Services meet with the resident for MDS (Minimum Data Set) information. The resident was unable to answer cognition questions with [DIAGNOSES REDACTED]. The Resident was to reside at the facility for long term status and is a Full Code. A Social Service Progress Note, dated [DATE], indicated staff met with resident and staff to complete a BIMS scale interview. Resident's speech was unclear and he was not able to complete an assessment. Resident to remain at facility for long-term and remains a Full Code status. A telephone interview with LPN 2 was initiated by the Director of Nursing on [DATE] at 9:51 a.m. The Surveyor and the Director of Nursing spoke with the LPN via speaker phone related to the expiration of Resident G on [DATE]. LPN 2 indicated after the meal service, a family member came out to get a Nurse and she went into the room. One of the female family members said he's gone isn't he? I replied yes to the Daughter. The family members did not voice any concerns or ask anything about CPR. Nursing staff is required to check the Code Status of the Resident or the Advance Directive book on the unit. I did look on the book and he had an unsigned Declination Form. The facility protocol is if there is a no DNR in place and the Advanced Directives are not signed, then CPR is to be initiated. The family and the facility had been discussing Hospice care and were supposed to be coming in to discuss it that day. To be honest I did take it for granted. I thought the DNR was already in place but the declination form was not signed. During a second telephone interview on [DATE] at 10:13 a.m., LPN 2 indicated the family did not ask about CPR at the time and she did not ask them if they wanted CPR. The resident had no blood pressure or pulse. His color was yellow and his mouth was open. No cyanosis was observed. The facility Administrator and the Director of Nursing (DON) were interviewed on [DATE] at 9:36 a.m. The Administrator indicated a meeting had been held and they spoke to resident's Physician related to his declining. The Physician was emailed about the decline in condition and the Doctor responded and came to the facility on that previous Saturday. The DON indicated LPN 2 had reported to her when she entered Resident G's room, he was already dead, family members were in the room and told her they did not want CPR, and it was not done. Interview with a family member of Resident G on [DATE] at 10:30 a.m., indicated he was the resident's Guardian since around 2012 and did not recall any interviews with staff related to advance directives. The resident was cold and gray when family arrived and no staff started CPR when they were brought in to check the resident. The current Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) policy was received from the Director of Nursing on [DATE] at 10:47 a.m. Interventions to be initiated include the following: - Unless it is known that a DNR (Do Not Resuscitate) order is in place CPR is to be started. - Check the victim for pulse and respirations. If they are absent, attempt to arouse the individual(for example, by shaking them or using a sternal rub). If the victim responds but is injured, follow the facility protocol for first aid or call 911. If the victim is unresponsive with no movement or response to stimuli, and no return of pulse and/or respirations, follow the following steps: Check the Code Status and if no DNR, call a code, designate staff to call 911 and contact the attending Physician ,unless a DNR order is in place the prohibits CPR and/or external defibrillation exists for that resident. Open the airway. Check for breathing. Administer rescue breaths Check for pulse Give chest compressions Document in the resident's medical record and report the event to the Medical Director, Administrator, and Director of Nursing as soon as possible. The current Resident Advance Directives policy was received from the Director of Nursing on [DATE] at 10:47 a.m. The policy indicated the Admissions Coordinator was to meet with the resident or the resident's legal representative to determine if the resident had any written Advance Directives related to choices regarding care and treatment. The IDT (Inter-Disciplinary Team) was to review the resident's advance directive status as documented in the medical record at the time of the initial Care Plan conference. The IDT was required to to review the resident's advance directive and treatment plan planning wishes quarterly and for any significant changes in condition during the care plan conference. On [DATE] at 9:10 a.m., the ADON provided staff Inservice Attendance Logs completed on [DATE] related to Nursing responsibility to check all resident code status and perform CPR as indicated. When interviewed on [DATE] at 3:30 p.m., the facility Administrator indicated the facility has been reviewing all deaths that occur in the facility since the [DATE] occurrence. Residents under Hospice care at the time of death are included. LPN 2 had been immediately re-educated with a Teachable Moment at the time of the incident on [DATE] regarding verification of Advanced Directives for any resident noted to be unresponsive or with an absence of any vital signs and verbalized understanding. A written Correction Plan, submitted by the Administrator on [DATE], indicated an audit was also completed in (MONTH) by the Corporate Clinical LCSW consultant for all facility residents to verify all Advanced Directives were in place. The facility was additionally going to be conducting mock codes weekly for practice. Staff interviews conducted throughout the survey indicated knowledge of facility policy and correct actions to be taken for any resident assessed to be without vital signs. The Past Noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and corrected on [DATE] when the facility completed staff inservices regarding code status and procedure and put into place audits for code status and all deaths. This Federal tag relates to Complaint IN 236. 3XXX,[DATE](a)

Based on observation, record review, and interview, the facility failed to ensure appropriate emergency care was provided during a choking incident resulting in the resident receiving the [MEDICATION NAME] maneuver at the inappropriate time and emergency care not contacted immediately resulting in the death of 1 of 1 residents reviewed for death. (Resident B). The facility also failed to monitor and/or assess bruises for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident G) Findings include: 1. The closed record for Resident B was reviewed on [DATE] at 9:22 a.m. The resident was admitted on [DATE] and expired on [DATE] at the facility. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was not cognitively intact, was an extensive assist with 1 person physical assist for bed mobility and needed supervision with set up for eating. The resident had no oral problems and was receiving a mechanically altered and therapeutic diet. The current ,[DATE] plan of care indicated the resident required a mechanically altered diet. The approach was to provide diet as ordered. Another plan of care, dated ,[DATE], indicated the resident was limited in functional status in regards to eating and drinking independently. The approaches were to assure resident was in good body alignment, instruct proper chewing and swallowing techniques, and provide assistance. A Physician order, dated [DATE], indicated the resident was to receive a puree diet with no added salt with double portions. A Nurse's note, dated [DATE] 6:15 p.m., indicated Summoned to room per CNA, stated Nurse come here for a minute, this nurse rushed to room, upon entering noted resident lying in bed with head of bed elevated. Resident noted to be in distress at this time, CNA whom was at bedside assisting with feeding stated, I think he choked. Dinner tray sitting on the side counter next resident's bed, appears to have just started eating, tray significantly untouched. Resident skin pink and dry with lower extremities cool to touch. Resident verbally responsive at this time, but words unclear, performed helmich (sic) maneuver on resident appeared to be attempting to regurgitate fluid, but was noted swallowing instead of spitting, resident continued talking, words clearer at this time, stated, God please let me just lay back down explained to resident that he was unable to lay down at this time, observed resident sounding like he was gurgling, appeared to have fluid in mouth, encouraged resident to spit out fluid, resident noted to be concerned about were to spit, this nurse picked up container from feeding tray and told to spit in it, resident spit up moderate amount of clear secretions with very small fragments of meat. This nurse told CNA to obtain vital sign machine so that O 2 (oxygen) sats could be obtained, CNA brought vital signs machine, O 2 sat did not read at this time, auscultated resident lung sounds noted gurgling sounds, resident lungs sounded very wet, resident sitting on side of bed with CNA, this nurse called east wing manager, unit manager came right away, auscultated resident's lung sounds and stated It sounds like he's gurgling, this nurse stated That's what I heard too, east wing unit manager stated You need to call the doctor, we're going to need a STAT chest X-ray. Resident noted sitting up in bed, breathing and responsive but not to normal self. House supervisor entered room at this time, upon writer leaving the room to go call MD a staff member stated that the resident appeared to be changing colors and was responding differently. Called (name of) ambulance, the staff stated it'll be about a ,[DATE] minute wait, I think you better call 911. House supervisor poked head out of room at this time and stated Call 911, he's unresponsive. Called 911 informed the dispatcher that resident was unresponsive, and that a paramedic was needed, overheard code blue being called overhead, another staff member stated He's a DNR upon reentering the room noted resident appeared to be pale yellow and unresponsive, appeared to be not breathing. Checked resident's DNR status, noted resident to be a DNR in the computer system, informed staff resident is indeed a DNR. Local police and paramedics arrive on scene. Family and Medical Doctor (MD) notified of resident's change in status. (sic) Nursing Progress notes dated [DATE] at 9:45 p.m., indicated the resident's body was released to the funeral home. Interview with LPN 7 on [DATE] at 8:50 a.m. indicated she was Resident B's nurse on evening shift [DATE]. She had been preparing for an admit and a discharge when, at approximately 6:00 p.m., CNA 10 indicated she needed a nurse in Resident B's room. The resident's room was diagonal from the Nurses' Station so it was not far for her to go. Upon entering the room, the resident was in bed and the head of the bed was between a 75 and 90 degree angle and his legs were extended. The resident's dinner tray was on his overbed table which was positioned in front of the resident. The resident was served a pureed diet (polish sausage) which was barely touched. The CNA told her the resident's skin color was off. She indicated she was not familiar with resident, and was not sure if his skin color had changed or not. The resident was in distress, his tongue was hanging out of the side of his mouth and was trying to talk and was making noises. The resident was not turning blue or purple and continued to try and speak to her. She could not understand the resident, and it was like he had a mouth full of food and his speech was garbled. She felt the resident's airway was compromised but he still had an airway and was making sounds. The LPN had the CNA turn the resident around in bed to where he was sitting straight up and his feet were dangling from the side of the bed. She patted the resident's back and then proceeded to do the [MEDICATION NAME] maneuver. She completed three thrusts and immediately after, the resident had a lot emesis come up through his mouth with small particles of food. The resident did not know to spit out the fluid and she believed he swallowed some of it. She kept instructing the resident to spit out the emesis and grabbed the plate cover for him to spit it out. After the resident spit it out, he was talking and she could understand him, and he kept asking to lay down. The LPN told the CNA to go get the vitals machine. The LPN indicated she did not call 911 or call the Physician after performing the [MEDICATION NAME] Maneuver. She did not ask for another nurse to come and evaluate or assess the resident before she performed the [MEDICATION NAME] maneuver. The LPN obtained the vital signs and assessed his lung sounds. At that time, she asked the East Unit Manager to come to the room. The LPN was then instructed by the East Unit Manager to call the Physician for a chest X-ray. She left the room and called the transport service to come and transport the resident to the hospital. She indicated that was all she ever knew was to call the transport company. The LPN indicated she was never made aware of the facility's policy for Emergency services or the [MEDICATION NAME] Maneuver. The transport company told the LPN they would not arrive for another ,[DATE] minutes and advised her to call 911. The House Supervisor entered the room and instructed staff to call a code blue and to notify 911. The LPN indicated from the time she first entered the resident's room and when 911 was called, about 7 minutes had lapsed. The resident's clothes were changed because they thought he was going to be transported to the hospital due to all the emesis and he had been incontinent. The LPN indicated the resident had expired before the paramedics had arrived. Interview on [DATE] at 10:26 a.m., with the Director of Nursing, indicated she was aware LPN 7 had to perform the [MEDICATION NAME] on Resident B. Based on the resident's status, i.e. was not blue, had an airway, was making sounds, she would question why the [MEDICATION NAME] was performed. The DON indicated the transport ambulance service was called first rather than 911. The DON was not notified of the incident until the next day. The DON indicated her expectations for the situation would have been for LPN 7 to call for help, as well as call for another nurse to assess the situation prior to performing the [MEDICATION NAME]. If the [MEDICATION NAME] was indeed warranted, she would expect 911 to be called. Interview on [DATE] at 10:51 a.m. with the Administrator, indicated, when the East Unit Manager and the House Supervisor entered Resident B's room on the evening of [DATE], they immediately called 911 and took over in the room. Based on this incident, the Administrator indicated it had been identified the Agency Nurse orientation was slim and would be changed. Interview on [DATE] at 3:02 p.m. with the East Unit Manager, indicated when she arrived in the resident's room the resident was all wet and making gurgling sounds and that was when she told LPN 7 to get a STAT chest x-ray. She indicated his color was pink and he was talking. They sat the resident on the side of the bed and emesis started coming out of his mouth and nose and that was when she told LPN 7 to call 911. At that time, the resident's color started changing. The East Unit Manager indicated she had no idea LPN 7 performed the [MEDICATION NAME] maneuver until she read her documentation later that night. Emergency services like 911 should have been notified immediately as soon as she performed the [MEDICATION NAME] maneuver. Interview with the Director of Nursing (DON) and Administrator on [DATE] at 2:45 p.m., indicated the DON was not made aware of the event until the next day, however, the Administrator was notified immediately. The Administrator had spoken to the resident's Physician, who felt the resident's death was most likely a [MEDICAL CONDITION] event. The current ,[DATE] [MEDICATION NAME] Maneuver policy, provided by the Administrator on [DATE] at 10:15 a.m., indicated Ask the resident if he or she is choking. Remember, a choking victim cannot speak or breathe and needs your help immediately. Ask the resident to cough or speak if at all possible to determine if his or her airway is obstructed. Call for help but stay with the resident. If the resident cannot cough, only then should abdominal thrusts be performed. 2. On [DATE] at 10:35 a.m., Resident G was observed. There was a quarter sized purple/bluish bruise noted to the top of her left hand. Interview with the resident at the time, indicated she bumped her hand and was on anticoagulant therapy. The record for Resident G was reviewed on [DATE] at 1:37 p.m. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was alert and oriented. She required limited one person physical assistance with transfers. The current plan of care, dated [DATE], indicated the resident was at risk for abnormal bleeding and bruising related to the use of [MEDICATION NAME]. The interventions included protect the resident from injury/trauma as able and report abnormal labs and signs and symptoms of bleeding. The ,[DATE] physician's orders [REDACTED]. The ,[DATE] Bath and Skin Report Sheet indicated the following: ,[DATE] - bruising noted to both arms and left hand ,[DATE] - bruising noted to both arms ,[DATE] - bruising noted to right arm ,[DATE] - bruising noted to right arm and left hand ,[DATE] - bruising noted to right arm and left hand The Treatment Administration Record indicated the resident was not currently being monitored for bruising. The [DATE] Skin Integrity Events - Bruise form indicated the following: bruising to right hand measuring 2.4 x 3 cm (centimeters) bruising to left upper thigh measuring 2.0 x 0.5 cm bruising to left lateral thigh measuring 1.3 x 1.5 cm A Nursing progress note, dated [DATE], indicated writer was made aware of bruise to resident's left hand (2.4 x 3.0 cm), upon further assessment writer noted bruise to left lateral thigh (1.3 x 1.5 cm), and left upper thigh (2.0 x 0.5 cm). Notified Physician, orders given to monitor until healed, family also made aware. Interview with the Unit Manager, on [DATE] at 1:37 p.m., indicated the resident was not currently being monitored for bruising. An Event - Bruising should have been initiated and the resident should have been monitored per the facility policy. The current Measurement of Alterations in Skin Integrity policy, dated ,[DATE], provided by the Assistant Director of Nursing, on [DATE] at 11:45 a.m., indicated 1. At first observation of any skin condition, the charge nurse or treatment nurse is responsible to measure and/or describe skin condition in the clinical record. 2. All measurements will be recorded in centimeters. All wounds/ulcers (i.e. pressure, arterial, diabetic, venous) will be measured weekly and results recorded in the clinical record. This Federal tag relates to Complaint IN 777. 3XXX,[DATE](a)

Based on observation, record review, and interview, the facility failed to ensure appropriate emergency care was provided during a choking incident resulting in the resident receiving the [MEDICATION NAME] maneuver at the inappropriate time and emergency care not contacted immediately resulting in the death of 1 of 1 residents reviewed for death. (Resident B). The facility also failed to monitor and/or assess bruises for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident G) Findings include: 1. The closed record for Resident B was reviewed on [DATE] at 9:22 a.m. The resident was admitted on [DATE] and expired on [DATE] at the facility. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was not cognitively intact. The resident was an extensive assist with 1 person physical assist for bed mobility and needed supervision with set up for eating. The resident had no oral problems and was receiving a mechanically altered and therapeutic diet. The current ,[DATE] plan of care indicated the resident required a mechanically altered diet. The approach was to provide diet as ordered. Another plan of care, dated ,[DATE], indicated the resident was limited in functional status in regards to eating and drinking independently. The approaches were to assure resident was in good body alignment, instruct proper chewing and swallowing techniques, and provide assistance. A Physician order, dated [DATE], indicated the resident was to receive a puree diet with no added salt with double portions. A Nurse's note, dated [DATE] 6:15 p.m., indicated Summoned to room per CNA, stated Nurse come here for a minute, this nurse rushed to room, upon entering noted resident lying in bed with head of bed elevated. Resident noted to be in distress at this time, CNA whom was at bedside assisting with feeding stated, I think he choked. Dinner tray sitting on the side counter next resident's bed, appears to have just started eating, tray significantly untouched. Resident skin pink and dry with lower extremities cool to touch. Resident verbally responsive at this time, but words unclear, performed helmich (sic) maneuver on resident appeared to be attempting to regurgitate fluid, but was noted swallowing instead of spitting, resident continued talking, words clearer at this time, stated, God please let me just lay back down explained to resident that he was unable to lay down at this time, observed resident sounding like he was gurgling, appeared to have fluid in mouth, encouraged resident to spit out fluid, resident noted to be concerned about were to spit, this nurse picked up container from feeding tray and told to spit in it, resident spit up moderate amount of clear secretions with very small fragments of meat. This nurse told CNA to obtain vital sign machine so that O 2 (oxygen) sats could be obtained, CNA brought vital signs machine, O 2 sat did not read at this time, auscultated resident lung sounds noted gurgling sounds, resident lungs sounded very wet, resident sitting on side of bed with CNA, this nurse called east wing manager, unit manager came right away, auscultated resident's lung sounds and stated It sounds like he's gurgling, this nurse stated That's what I heard too, east wing unit manager stated You need to call the doctor, we're going to need a STAT chest X-ray. Resident noted sitting up in bed, breathing and responsive but not to normal self. House supervisor entered room at this time, upon writer leaving the room to go call MD a staff member stated that the resident appeared to be changing colors and was responding differently. Called (name of) ambulance, the staff stated it'll be about a ,[DATE] minute wait, I think you better call 911. House supervisor poked head out of room at this time and stated Call 911, he's unresponsive. Called 911 informed the dispatcher that resident was unresponsive, and that a paramedic was needed, overheard code blue being called overhead, another staff member stated He's a DNR upon reentering the room noted resident appeared to be pale yellow and unresponsive, appeared to be not breathing. Checked resident's DNR status, noted resident to be a DNR in the computer system, informed staff resident is indeed a DNR. Local police and paramedics arrive on scene. Family and Medical Doctor (MD) notified of resident's change in status. (sic) Nursing Progress notes dated [DATE] at 9:45 p.m., indicated the resident's body was released to the funeral home. Interview with LPN 7 on [DATE] at 8:50 a.m. indicated she was Resident B's nurse on evening shift [DATE]. She had been preparing for an admit and a discharge when, at approximately 6:00 p.m., CNA 10 indicated she needed a nurse in Resident B's room. The resident's room was diagonal from the Nurses' Station so it was not far for her to go. Upon entering the room, the resident was in bed and the head of the bed was between a 75 and 90 degree angle and his legs were extended. The resident's dinner tray was on his overbed table which was positioned in front of the resident. The resident was served a pureed diet (polish sausage) which was barely touched. The CNA told her the resident's skin color was off. She indicated she was not familiar with resident, and was not sure if his skin color had changed or not. The resident was in distress, his tongue was hanging out of the side of his mouth and was trying to talk and was making noises. The resident was not turning blue or purple and continued to try and speak to her. She could not understand the resident, and it was like he had a mouth full of food and his speech was garbled. She felt the resident's airway was compromised but he still had an airway and was making sounds. The LPN had the CNA turn the resident around in bed to where he was sitting straight up and his feet were dangling from the side of the bed. She patted the resident's back and then proceeded to do the [MEDICATION NAME] maneuver. She completed three thrusts and immediately after, the resident had a lot emesis come up through his mouth with small particles of food. The resident did not know to spit out the fluid and she believed he swallowed some of it. She kept instructing the resident to spit out the emesis and grabbed the plate cover for him to spit it out. After the resident spit it out, he was talking and she could understand him, and he kept asking to lay down. The LPN told the CNA to go get the vitals machine. The LPN indicated she did not call 911 or call the Physician after performing the [MEDICATION NAME] Maneuver. She did not ask for another nurse to come and evaluate or assess the resident before she performed the [MEDICATION NAME] maneuver. The LPN obtained the vital signs and assessed his lung sounds. At that time, she asked the East Unit Manager to come to the room. The LPN was then instructed by the East Unit Manager to call the Physician for a chest X-ray. She left the room and called the transport service to come and transport the resident to the hospital. She indicated that was all she ever knew was to call the transport company. The LPN indicated she was never made aware of the facility's policy for Emergency services or the [MEDICATION NAME] Maneuver. The transport company told the LPN they would not arrive for another ,[DATE] minutes and advised her to call 911. The House Supervisor entered the room and instructed staff to call a code blue and to notify 911. The LPN indicated from the time she first entered the resident's room and when 911 was called, about 7 minutes had lapsed. The resident's clothes were changed because they thought he was going to be transported to the hospital due to all the emesis and he had been incontinent. The LPN indicated the resident had expired before the paramedics had arrived. Interview on [DATE] at 10:26 a.m., with the Director of Nursing, indicated she was aware LPN 7 had to perform the [MEDICATION NAME] on Resident B. Based on the resident's status, i.e. was not blue, had an airway, was making sounds, she would question why the [MEDICATION NAME] was performed. The DON indicated the transport ambulance service was called first rather than 911. The DON was not notified of the incident until the next day. The DON indicated her expectations for the situation would have been for LPN 7 to call for help, as well as call for another nurse to assess the situation prior to performing the [MEDICATION NAME]. If the [MEDICATION NAME] was indeed warranted, she would expect 911 to be called. Interview on [DATE] at 10:51 a.m. with the Administrator, indicated, when the East Unit Manager and the House Supervisor entered Resident B's room on the evening of [DATE], they immediately called 911 and took over in the room. Based on this incident, the Administrator indicated it had been identified the Agency Nurse orientation was slim and would be changed. Interview on [DATE] at 3:02 p.m. with the East Unit Manager, indicated when she arrived in the resident's room the resident was all wet and making gurgling sounds and that was when she told LPN 7 to get a STAT chest x-ray. She indicated his color was pink and he was talking. They sat the resident on the side of the bed and emesis started coming out of his mouth and nose and that was when she told LPN 7 to call 911. At that time, the resident's color started changing. The East Unit Manager indicated she had no idea LPN 7 performed the [MEDICATION NAME] maneuver until she read her documentation later that night. Emergency services like 911 should have been notified immediately as soon as she performed the [MEDICATION NAME] maneuver. Interview with the Director of Nursing (DON) and Administrator on [DATE] at 2:45 p.m., indicated the DON was not made aware of the event until the next day, however, the Administrator was notified immediately. The Administrator had spoken to the resident's Physician, who felt the resident's death was most likely a [MEDICAL CONDITION] event. The current ,[DATE] [MEDICATION NAME] Maneuver policy, provided by the Administrator on [DATE] at 10:15 a.m., indicated Ask the resident if he or she is choking. Remember, a choking victim cannot speak or breathe and needs your help immediately. Ask the resident to cough or speak if at all possible to determine if his or her airway is obstructed. Call for help but stay with the resident. If the resident cannot cough, only then should abdominal thrusts be performed. 2. On [DATE] at 10:35 a.m., Resident G was observed. There was a quarter sized purple/bluish bruise noted to the top of her left hand. Interview with the resident at the time indicated she bumped her hand and was on anticoagulant therapy. The record for Resident G was reviewed on [DATE] at 1:37 p.m. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was alert and oriented. She required limited one person physical assistance with transfers. The current plan of care, dated [DATE], indicated the resident was at risk for abnormal bleeding and bruising related to the use of [MEDICATION NAME]. The interventions indicated protect the resident from injury/trauma as able and report abnormal labs and signs and symptoms of bleeding. The ,[DATE] physician's orders [REDACTED]. The ,[DATE] Bath and Skin Report Sheet indicated the following: ,[DATE] - bruising noted to both arms and left hand ,[DATE] - bruising noted to both arms ,[DATE] - bruising noted to right arm ,[DATE] - bruising noted to right arm and left hand ,[DATE] - bruising noted to right arm and left hand The Treatment Administration Record indicated the resident was not currently being monitored for bruising. The [DATE] Skin Integrity Events - Bruise form indicated the following: bruising to right hand measuring 2.4 x 3 cm (centimeters) bruising to left upper thigh measuring 2.0 x 0.5 cm bruising to left lateral thigh measuring 1.3 x 1.5 cm A Nursing progress note, dated [DATE], indicated writer was made aware of bruise to resident's left hand (2.4 x 3.0 cm), upon further assessment writer noted bruise to left lateral thigh (1.3 x 1.5 cm), and left upper thigh (2.0 x 0.5 cm). Notified Physician, orders given to monitor until healed, family also made aware. Interview with the Unit Manager, on [DATE] at 1:37 p.m., indicated the resident was not currently being monitored for bruising. An Event - Bruising should have been initiated and the resident should have been monitored per the facility policy. The current Measurement of Alterations in Skin Integrity policy, dated ,[DATE], provided by the Assistant Director of Nursing, on [DATE] at 11:45 a.m., indicated 1. At first observation of any skin condition, the charge nurse or treatment nurse is responsible to measure and/or describe skin condition in the clinical record. 2. All measurements will be recorded in centimeters. All wounds/ulcers (i.e. pressure, arterial, diabetic, venous) will be measured weekly and results recorded in the clinical record. This Federal tag relates to Complaint IN 777. 3XXX,[DATE](a)

Based on observation, record review, and interview, the facility failed to ensure a resident was free from accidents related to a transfer without using a gait belt which resulted in a large laceration requiring 15 sutures for 1 of 1 residents reviewed for accidents. (Resident D) The facility also failed to supervise a resident who was able to smoke related to smoking materials, including a lighter, observed in her room for 1 of 2 residents who were observed smoking. (Resident L) Findings include: 1. During an interview with Resident D on 10/18/17 at 10:41 a.m., indicated a CNA had been transferring her from the bed to the wheelchair, her leg got caught and cut her skin and she had to go to the hospital for sutures. She indicated there was only 1 person helping her at that time during the transfer. The resident was asked if the staff member had a belt around her waist during the transfer, and she stated No there was no belt around my waist. The record for Resident D was reviewed on 10/10/17 at 1:20 p.m. The resident was admitted to facility on 8/22/17. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was alert and oriented to person, place and time. The resident needed extensive assist with 2 person physical assist for transfers. The care plan, dated 8/25/17, indicated the resident was limited in functional status in regards to the ability to transfer self. The goal indicated in order improve quality of life and participate in chosen activities, resident will safely transfer utilizing a gait belt through next review. The Nursing approaches were to ensure safe placement of extremities during transfers, ensure proper transfer techniques, ensure wheelchair was locked and secure, maintain body in functional alignment during transfers, provide applicable footwear, and utilize additional staff with transfers when needed. Another care plan, dated 9/25/17, indicated the resident was at risk for alteration in skin tears and bruises related to fragile skin. The nursing approaches were to dress resident in long pants and long sleeves and handle the resident with care during transfers. Nursing progress, dated 4/11/17 at 8:30 a.m., indicated writer made aware the resident had a skin tear during transport from bed to the wheelchair after a.m. care. When assessed writer noted laceration and skin tear with a bruise on left lower leg. Received order to transport to the hospital. A hospital note dated 4/11/17 indicated an approximately 5 to 6 centimeter U shaped laceration over the mid left fibular region. 4 sutures placed in left lower leg. Nursing notes, dated 9/25/17 at 7:15 a.m., indicated received orders to send resident to emergency room for evaluation for laceration to left lower leg. Orders noted. Relayed to attending nurse and carried out. Ambulance estimated time of arrival was 15-20 minutes. Family member made aware and voiced no concerns at this time. A hospital note dated 9/25/17 indicated the resident had a 5 centimeter (cm) by 4 cm laceration to the left lower leg. The resident received 15 sutures to the left lower leg. The resident had also sustained a laceration to the left lower leg with sutures required on a previous admission. Interview with Certified Occupational Therapy Aide (COTA) 1 on 10/23/17 at 8:17 a.m., indicated they let the nurse know the transfer status of a resident immediately after their evaluation. The information was passed out to restorative, the Unit Manager, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Resident D was evaluated on 8/24/17 and needed maximum assist times 1 for transfers. Staff were supposed to use a gait belt for transfers at all the times. On 10/23/17 at 1:50 p.m., CNA 9 and the DON walked into Resident D's room. At that time, CNA 9 demonstrated how she transferred the resident from the bed to the wheelchair. She indicated the chair was positioned by the bed facing the wall, the leg rest closest to the bed was removed and the other one was pushed away from the chair. The CNA indicated she placed her arms under the resident's arms and grabbed her by her pants and placed her in the chair, however, her pant leg got stuck on the leg rest that was pushed away from the wheelchair. The CNA indicated she did not use a gait belt during the transfer. Interview with the DON at that time, indicated the CNA should have used a gait belt with the transfer. Interview with the East Wing Unit Manager on 10/23/17 at 3:00 p.m., indicated when she arrived that morning the midnight nurse came and got her immediately and told her the resident received a laceration to her leg. She indicated the resident's pant leg tore and was noted on the post of the leg rest. They had to lift the pant leg up to get it out of there and noted the deep laceration to her leg. 2. During a room observation on 10/18/17 at 11:40 a.m., Resident L was seated in her wheelchair by her bed. At that time, the resident indicated she had her own smoking materials in her top drawer. The resident opened the drawer and there was a lighter and a pack of cigarettes noted. On 10/25/17 at 1:00 p.m., the resident was seated in her wheelchair in her room. The resident was asked her if she had any cigarettes in her room, she stated, Yes I have a pack in my purse in the top drawer. The resident indicated her son brought her the pack of cigarettes and she placed them in the drawer. The record for Resident L was reviewed 10/25/17 at 1:47 p.m. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 10/19/17, indicated the resident was cognitively intact. A plan of care, dated 10/16/17, indicated the resident smoked tobacco. The approaches were staff will encourage resident to comply with the smoking policy. A Smoking Risk assessment, dated 10/16/17 indicated the resident smoked cigarettes and had reviewed the smoking policy and was determined to be compliant. Interview with the Administrator on 10/25/17 at 1:15 p.m., indicated she was unaware the resident had smoking materials in her room. The current 11/2013 Resident Smoking policy, provided by the Director of Nursing on 10/19/17 at 1:30 p.m., indicated Possessing, carrying, or holding materials use to smoke, (including, but not limited to, cigarettes, cigars, loose tobacco, pipes, lighters, and matches) by residents is prohibited inside the building. Residents must give smoking materials to staff when they enter the building, even if the resident has been assessed to be independent carrying such materials when off the premises. This Federal tag relates to Complaint IN 446. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure each resident was free from a significant medication error related to the excessive dose of a diuretic medication given which resulted in a 20 pound weight loss and decreased kidney function for 1 of 5 residents reviewed for unnecessary medications. (Resident C) Finding includes: Interview with Resident C on 10/18/17 at 2:59 p.m. indicated she has to ask them about her medication. She indicated the Nurses were giving her 3 of her water pills a day and that was not right. She indicated she was looking dehydrated. The record for Resident C was reviewed on 10/23/17 at 9:05 a.m. The resident was admitted on [DATE] from another Long Term Care Facility. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 8/1/17, indicated the resident was alert and oriented to person, place and time. She had no mood or behavior problems and it was very important to have family involved in care. The resident was receiving a diuretic medication for 6 days. The resident's weight was 169 pounds with no weight loss and no oral problems. Discharge instructions and on the transfer form from the Long Term Care Facility, dated 7/25/17, indicated the resident's list of all her medications. She was to continue [MEDICATION NAME] ([MEDICATION NAME], a diuretic medication) 2 milligrams (mg) daily. Physician orders, dated 7/25/17, indicated [MEDICATION NAME] 2 mg three times a day at 9:00 a.m., 2:00 p.m., and 8:00 p.m. Nursing Progress notes, dated 7/25/17, indicated the doctor was notified of resident's return to the facility and the medications were verified. The Medication Administration Record [REDACTED]. The resident's lab testing results were reviewed. On 7/27/17 a GFR (Glomerular Filtration Rate) (a test to measure kidney function and determine the stage of kidney disease) was 43 (a normal rate was between 100-130). The BUN (Blood Urea Nitrogen) (a blood test to evaluate kidney function and diagnose kidney disease) was 33 (normal range 6-20) and the CR (Creatinine) (a blood test to evaluate kidney function) was 1.21 (normal range 0.5-1.1). On 8/1/17 the resident's GFR was 35, the BUN was 35 and the CR was 1.44. On 9/8/17 the resident's GFR was 30, the BUN was 98, and the CR was 1.67. The ckdstage.com ([MEDICAL CONDITION]) website indicated A drop of GFR can be caused by severe dehydration. Dehydration is a condition that can occur when the loss of body fluids, mostly water, exceeds the amount that is taken in. Due to the excessive loss of water, the blood volume reduces and thus blood pressure lowers. As a result, the Glomerular Filtration Rate (GFR) declines. The resident's weight record was as followed: 7/26/17 - 169 8/2 - 149 8/9 - 140 8/15 - 141 8/22 - 127 8/23 - 129 8/29 - 129 9/5 - 129 A Registered Dietitian (RD) note dated, 7/26/17, indicated the resident's weight was 169 pounds. A RD note dated, 8/2/17, indicated the resident's weight was 149 pounds. The RD spoke with resident and indicated her weight was usually in the 140's, question admission weight for accuracy. The resident had a 20 pound weight loss from 8/2-9/5/17 in 1 month while receiving the [MEDICATION NAME] medication three times a day rather once daily. A Physician history and physical dated 7/27/17 indicated there was no information or documentation for the increase of the [MEDICATION NAME] medication. Nursing Progress notes dated 7/25/17-7/31, 8/1-8/31, and 9/1-9/7/17 indicated there was no documentation the resident had [MEDICAL CONDITION] to her lower extremities. On 9/7/17 at 12:58 p.m., Nursing notes indicated the resident's Nephrologist was contacted and a new order for the [MEDICATION NAME] was obtained to decrease the medication to 2 mg daily. Interview with the Administrator on 10/23/17 at 3:09 p.m. indicated they identified the weight loss in a nutrition at risk meeting and when they notified the resident's daughter she had asked why her mother was receiving 3 tablets of the [MEDICATION NAME] a day instead of 1. The Administrator indicated after her investigation, it was determined the medication was transcribed incorrectly from the time the resident was admitted and she received 6 mg a day rather than 2 mg a day of the [MEDICATION NAME]. This Federal tag relates to Complaint IN 355. 3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to ensure acceptable parameters of nutritional status were maintained related to failure to monitor weights as recommended by the Registered Dietitian. This resulted in further weight loss for 2 of 3 residents reviewed for weight loss in a sample of 9. (Residents J & K) Findings include: 1. The record for Resident J was reviewed in 8/3/17 at 12:05 p.m. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A Multivitamin with iron was ordered on [DATE]. No additional dietary interventions were added after 7/12/17. The quarterly MDS (Minimum Data Set) assessment, completed on, 6/16/17, indicated Resident J as requiring a therapeutic diet and supervision with eating. No weight loss was assessed. A current Care Plan, initiated on 10/1/16, indicated the resident received a therapeutic diet. The Care Plan goal was to maintain weight without any significant changes such as 5% in 30 days or 10% in 180 days. The three Interventions were to honor food preferences, monitor oral intakes and weights, and provide the diet as ordered by the Physician. An RD (Registered Dietitian) Progress Note, completed on 7/12/17 at 3:03 p.m., indicated the resident received a regular no added salt diet. Oral intake per food consumption logs was variable. Weekly weights were recommended. A 5.5 % weight loss was noted. Recorded weights: 1/09/17- 188.7 pounds 4/11/17- 189.2 pounds 6/30/17- 189.6 pounds 7/07/17- 179.2 pounds 8/03/17- 170.4 pounds (resident weighed per request of surveyor) No physician progress notes [REDACTED]. 2. On 8/2/17 at 12:15 p.m., Resident K was seated at an assist table in the Main Dining Room. A Restorative aide was present at the table with the resident. The resident was served a plate of chicken stew, roll, and carrots. A glass of juice and a carton of 2% milk was also served. The resident was able to feed herself. The record of Resident K was reviewed on 8/3/17 at 12:56 p.m. [DIAGNOSES REDACTED]. Current Physician orders [REDACTED]. The quarterly MDS (Minimum Data Set) assessment, completed on 5/25/17, indicated Resident K's weight as 165 pounds, no weight loss noted, and a therapeutic diet was ordered. A Care Plan, initiated on 5/18/17, indicated the resident required a mechanically altered therapeutic diet related to dysphagia and diabetes. The goal was for the resident to maintain weight without significant change of 5% in 30 days or 10% in 180 days. Interventions included, but were not limited to, provide diet and supplements as ordered, and monitor/record weights. A Care Plan, initiated on 5/27/17, indicated the resident was a risk for malnutrition related to having no natural teeth. Interventions included, but were not limited to, consult RD and follow recommendations. An RD (Registered Dietitian) Progress Note, completed on 7/12/17, indicated the resident's weight on 6/14/17 was 164.2 and on 7/11/17 was 154.2. There was a 6.1% weight loss in the past month. Recommendations included, but were not limited to, continue weekly weights. An RD Progress Note, completed on 7/26/17 indicated the resident's weight on 7/19/17 was 155.4. No additional recommendations were made. Recorded weights: 5/31/17- 167.6 pounds 6/07/17- 167.2 pounds 6/14/17- 164.2 pounds 6/20/17- 160.8 pounds 6/27/17- 157.2 pounds 7/07/17- 157.2 pounds 7/11/17- 154.2 pounds 7/19/17- 155.4 pounds 8/03/17- 150.6 pounds (requested to be weighed by surveyor) During an interview on 8/3/17 at 1:30 p.m., Shower Aide 2 indicated she is assigned to do the showers and weights for the residents on the unit and does complete showers and weights for Resident K . She had not been informed Resident K was on weekly weights. During an interview on 8/3/17 at 2:20 p.m., Nurse Consultant 2 indicated the Registered Dietitian informed the facility she noted weekly weights were not being completed at one of the last two Nutrition At Risk meetings. Weekly weights for Residents J and K should have been completed and monitored. This Federal Tag relates to Complaint IN 753. 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to ensure treatments were completed as ordered and preventative interventions and treatments were implemented related to heels not elevated off the bed and low air mattresses not in place for 3 of 3 residents reviewed for pressure ulcer development. This resulted in the development of a new Stage III pressure ulcer which worsened to Unstageable. (Residents D, E, and F) Findings include: 1. During Orientation Tour on 7/12/17 at 8:44 a.m., Resident D was observed in bed. The resident was positioned on his back. The mattress on the bed was not a Low Air Loss mattress. No heel boots were in place and his heels were resting on the mattress. Unit Manager 1 was present and repositioned the resident on his side. The resident had two disposable incontinence briefs on. The Unit manager removed the briefs and a dressing was noted to the coccyx area. On 7/12/17 at 9:55 a.m., Wound Nurse 2 was observed providing wound care for Resident D. The coccyx wound was open with a pink center and scant yellow areas. The surrounding skin was intact with no redness. The Wound Doctor entered the room during the treatment to verify the wound measurements and questioned why the resident was not on a Low Air Loss mattress. The Wound Doctor instructed Nursing staff to obtain a Low Air Loss Mattress (provides a flow of air to assist in managing the heat and humidity of the skin) for the bed and a Roho (pressure relieving) cushion for the chair. The record for Resident D was reviewed on 7/12/17 at 3:47 p.m. The [DIAGNOSES REDACTED]. A Braden Scale for predicting pressure ulcer risk, completed on 3/3/17, assessed the resident as being at high risk for the development of pressure ulcers. The Significant Change MDS (Minimum Data Set) assessment, completed on 6/9/17, indicated Resident D required extensive assistance of two staff members for bed mobility and dressing and had limitation in range of motion of both upper and both lower extremities. A Stage III (full thickness skin loss, no bone or tendon present slough may be present) pressure ulcer was noted and measured 2.4 cm x 6.0 cm x .2 cm at the time of the assessment. A Skin Integrity Condition report, completed on 4/13/17, indicated the resident acquired a new Stage III pressure ulcer to the coccyx. The ulcer measured 4.5 cm x 4.5 cm. A Skin Integrity Condition report, completed on 5/4/17, indicated the coccyx pressure ulcer was currently Unstageable (full thickness tissue loss with the base covered slough or eschar) with 30% necrotic tissue. A Care Plan, initiated on 1/19/17, indicated Resident D was at risk for further skin breakdown related to incontinence, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Care plan interventions included, but were not limited to, may suspend/off load heels while in bed. Physician orders, obtained on 4/20/17 included, but were not limited to, off load boots as a Nursing intervention. An order was also written on 6/1/17 to cleanse the coccyx wound with normal saline, apply a collagen foam dressing every Monday, Wednesday, and Friday. During an interview on 7/12/17 at 8:45 a.m., Unit Manager 1 indicated residents should only have one brief in place for incontinence. During an interview on 7/13/17 at 12:31 p.m., the Director of Nursing indicated the resident should have had a Low Air Loss mattress in place per protocol for his pressure ulcer. On 7/12/17 at 12:25 p.m., the Director of Nursing provided the Support Surface Guidelines policy, dated January 2017, and indicated the policy was the one currently being used by the facility. Guidelines indicated the use of support systems along with interventions such as turning and repositioning can reduce pressure injury development by 50%. 2. The closed record for Resident E was reviewed on 7/12/17 at 10:05 a.m. [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, completed on, 5/22/17, indicated Resident E required extensive assistance of staff with bed mobility, transfers, dressing, and personal hygiene. No current pressure ulcers were present. The resident was at risk for developing pressure ulcers. An Admission Clinical Assessment, completed on 5/4/17, indicated the resident had an abrasion to the coccyx. No pressure ulcers were documented. A Braden Scale assessment for determining risk for the development, completed on 5/4/17, indicated the resident as at risk for the development of pressure ulcers. A Treatment Record, initiated on 5/16/17, indicated an order was written to apply as a preventative, [MEDICATION NAME] dressing the coccyx, change every five days and as needed. The treatment was signed out as completed on 5/16/17, 5/23/17, 5/30/17, and 6/6/17, and not every (5) days as ordered. The 6/2017 Bath and Skin Report was reviewed. On 6/2/17 other was checked and Nursing entry noted a treatment was in place. No documentation of the area noted as other was completed. On 6/6/17 an Unstageable (full thickness tissue loss with the base covered slough or eschar) pressure ulcer with slough was documented. A Nursing Progress Note, dated 6/6/17 at 8:57 a.m., indicated the Nurse was called into the resident's room after a shower. The resident was observed on her left side. An open area to the coccyx was observed. The wound bed was yellow and gray with 100% slough. A Physician order [REDACTED]. The Wound Doctor assessed the resident on 6/8/17. The coccyx wound measured 3.0 cm x 2.5 cm with 100% thick adherent devitalized necrotic tissue. The wound was debrided. Interview with the Director of Nursing on 7/13/17 at 12:31 p.m., indicated the 6/2/17 entry marked other on skin sheet did not indicate the area involved and should have been completed. 3. During Orientation Tour on 7/12/17 at 8:32 a.m., Resident F was observed in bed. Dressings were in place to the right and left feet with her heels resting on the bed. No boots or heel protectors were in place. On 7/12/17 at 10:20 a.m., the resident was in a wheelchair next to her bed. Dressings remained to both feet and her feet were touching the floor. The resident was not wearing any socks, shoes, or heel protector devices. The record for Resident F was reviewed on 7/13/17 at 10:40 a.m. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) quarterly assessment, completed on 6/20/17, indicated the resident required assistance of staff for bed mobility, transfers, dressing, and personal hygiene. The resident was at risk for the development of pressure ulcers. A Care Plan, initiated on 2/11/14 and last revised on 5/16/17, indicated the resident was at risk for the development of pressure ulcer related to dementia and incontinence. Interventions included, but were not limited to, offload/ boots to heels while in bed (initiated on 5/16/17). A Wound Care Physician Note, completed by the Wound Doctor on 7/12/17, indicated Resident F had an Unstageable pressure ulcer (due to necrosis) to the right heel. The wound was 2.0 cm x 1.5 cm with 80% necrotic tissue and 20% granulation tissue. A second Unstageable pressure ulcer was present to the left heel. The wound measured 4.0 cm x 8.5 cm with 50% thick adherent black necrotic eschar tissue. On 7/12/17, the Physician order [REDACTED]. The resident had a significant deterioration with rapid skin breakdown. Multiple contributing factors and overall decline make these wounds unavoidable. Discuss fitness for hospice and heels to be floated in bed. During an interview on 7/12/17 at 10:15 a.m., the Wound Care Physician indicated he assessed the resident this morning and the Unstageable ulcer to the left heel was a newly developed ulcer. During an interview on 7/13/17 at 12:31 p.m., The Director of Nursing indicated the resident had pressure ulcers on the heels. Interventions included offload the resident's heels while in bed. The resident also should have had boots on per care plan and the dressings to the feet should not have been directly touching the floor. This Federal Tag relates to Complaint IN 038. 3.1-34

Based on record review and interview, the facility failed to ensure a resident who had a history of [REDACTED]. The resident fell and received an injury of an intercranial hemorrhage (brain bleed), which resulted in a hospitalization , for 1 of 1 resident reviewed for falls. (Resident B) Finding includes: Resident B's record was reviewed on 07/13/17 at 12:15 p.m. [DIAGNOSES REDACTED]. The admitted was 06/01/17 from the facility's Assisted Living side. An admission fall risk assessment, dated 06/01/17 at 1:34 p.m., indicated intermittent confusion, visual impairment, balance problem with standing, decreased muscular coordination, had 1-2 falls in the past 3 months and was a high risk for further falls. An admission Minimum Data Set assessment, dated 06/07/17, indicated moderate impaired cognition, transfers and toileting required supervision of one person, unable to determine if the resident had a prior fall and had no falls since admission. A care plan, dated 06/08/17, indicated limited functional status for transfers. The interventions included, ensure proper transfer technique, ensure wheelchair is locked and secured prior to transfer, and remind resident to not transfer without assistance. A care plan, dated 06/08/17, indicated the resident had a history of [REDACTED]. The interventions included, encourage to ask for assistance, keep personal items and frequently used items within reach, and provide toileting assistance as needed. A care plan, dated 06/07/17, indicated short term memory deficits. The interventions included, provide verbal and physical cueing during activities of daily living. Nurses' Progress Notes indicated: 06/02/17 at 3:19 a.m. - Resident was sitting in wheelchair in doorway with call light cords tangled on the floor, was unsteady on her feet and required one assistance with transfer. 06/02/17 at 1:04 p.m. - The resident was educated about using the call light and waiting for help instead of self transferring for safety purposes and should be monitored for self transferring. 06/08/17 at 7:25 a.m. - Resident was sitting on the floor next to the toilet in an upright position with one sock on her left foot. There were no injuries. 06/08/17 at 2:04 p.m. - Had a fall this a.m., intermittent confusion. 06/08/17 at 2:16 p.m. - (late entry on 06/09/17 at 10:19 a.m.) very confused, had not attempted to self transfer this shift. 06/08/17 at 6:10 p.m. - Resident had Fall this evening sitting in wheelchair and attempting to stand multiple times at nurses station at this time. while charting I heard loud noise and noted resident lying on floor face down. Resident conscious and speaking and trying to get up. noting bleeding from rt (right) side of forehead. 911 called and vitals attempted. 06/08/17 at 11:37 p.m. - admitted into hospital with head injury. A Summary of Event, signed by the LPN 1, indicated, Resident sitting in wheelchair after dinner at nurses station. talkative. Trying to stand up at times. Reminded to please stay in w/c (wheelchair) asked if she needed anything and resident said no. Resident appears to have fallen forward out of w/c to floor . The Fall Event, dated 06/08/17 at 6 p.m., indicated the resident appeared to have fallen forward, prior to the fall the resident was confused, the fall was unwitnessed, and there was a laceration to the right side of the head with bleeding. A hospital history and physical, dated 06/09/17, indicated the resident had fallen, a CT scan was completed, developed an intercranial hemorrhage, and was admitted into the hospital with no aggressive treatment per family wishes. During an interview on 07/13/17 at 3:20 p.m., LPN 1 indicated the resident was sitting at the Nurses' Station to be supervised. LPN 1 asked the resident if she needed anything and and asked her to please stay in the wheelchair. There were no other interventions initiated with multiple attempts made by the resident to stand on her own. LPN 1 indicated the resident must have gotten up when I was looking at the computer. There was another Nurse and CNA's at the desk also. A facility policy, dated 08/2008, titled, Falls - Clinical Protocol, received from the Corporate Nurse Consultant as current, indicated, .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions . 3.1-45(a)(2)

Based on observation, record review, and interview the facility failed to ensure safety devices were in place to prevent accidents related to bed not left in the lowest position, alarms not in place, floor mats not in place, and wheelchair locks not in place for 3 of 4 residents reviewed for falls in the sample of 11. This resulted in a fracture for one resident (Resident #B) and a head laceration requiring staples (Resident #G). (Residents #B, #G, & #L) (CNA #1) (CNA #2) Findings include: 1. On 12/19/13 at 10:30 a.m., Resident #G was observed sitting in a high back chair in her room. The resident was awake and did not responded to verbal questions. The record for Resident #G was reviewed on 12/19/13 at 12:50 p.m. The resident's [DIAGNOSES REDACTED]. The 11/20/13 Minimum Data Set (MDS ) quarterly assessment indicated the resident's cognitive skills for decision making were moderately impaired. The assessment also indicated the resident required extensive assistance (resident involved in activity with staff providing weight bearing support) of 2+ staff members for bed mobility and transfer. The MDS assessment also indicated the resident had impairment in range of motion to her right and left upper and lower extremities and had no falls since her last admit, reentry or assessment. Review of the 11/19/13 quarterly Fall Risk assessment indicated the resident's score was (10). This score indicated the resident was at high risk for falls. The residents' current care plans were reviewed. A care plan initiated on 11/28/13 indicated the resident was at risk for falls. The care plan was last reviewed with a target goal date of 2/25/14. Care plan interventions included for the resident's bed to be kept in the low position with the brakes locked. This intervention was initiated on 11/28/11. The 12/2/13 Nursing Progress Notes were reviewed. An entry made on 12/2/13 at 1:50 p.m. indicated staff responded to the resident being on the floor. Blood was noted to the right side of the resident's forehead. Ice and pressure were applied to the area. Neurological checks (checks to evaluate the resident's neurological status) were started and the resident was awake and alert. The Physician was notified. A physician's orders [REDACTED]. An Observation Report note was initiated on 12/2/13 at 1:59 p.m.. The note was completed by a LPN. The note indicated a CNA informed the LPN to come to the resident's room as the resident was found laying on the floor . The resident was found laying on her right side with a moderate amount of bright red blood coming from the forehead area. A laceration measuring 2 cm (centimeters) x .8 cm was noted. The ambulance service was contacted to transfer the resident to the hospital. The 12/2/13 hospital emergency room records were reviewed. The Emergency Department Provider Notes indicated the resident was seen in the emergency room at 2: 12 p.m. with a laceration to the right side of the head after a fall. A Physical Examination indicated the resident had a 3 cm (centimeter) laceration. The wound was closed with (3) staples. The resident's emergency room [DIAGNOSES REDACTED]. The facility investigation into the resident's fall/ injury was reviewed on 12/2/13 at 2:00 p.m. Interviews from the involved staff members were obtained. An interview obtained from CNA#1 (the CNA assigned to care for the resident at the time of the fall) indicated she and CNA #2 transferred Resident #G into bed and both CNA's left the resident's room. CNA #1 returned to the resident's room about 5-6 minutes later and upon walking into the room found the resident on the floor. CNA #2's interview indicated she assisted CNA #1 with putting Resident #G into bed with the Hoyer lift (a mechanical device used to transfer residents). The interview indicated the CNA did not lower the bed and both CNA #2 and CNA#1 walked out of the room with the resident's bed not in the low position. Corrective Action notices were completed for both the above CNA's. CNA #1 was suspended related to the resident's bed not being place in the lowest position and the resident sustained [REDACTED]. CNA #2 received a formal warning related to the above. When interviewed on 12/19/13 at 4:20 p.m., the Director of Nursing indicated the resident's 12/2/13 fall was investigated and several staff members were interviewed. The Director of Nursing indicated two CNA's transferred the resident from the chair into her bed. The staff members were CNA#1 and CNA #2. CNA #1 was assigned to care for the resident on the day of the fall. CNA #2 assisted CNA#1 in transferring the resident into bed prior to the resident's fall. The staff members left the resident's room with the bed not in the lowest position. CNA #1 returned to the resident's room approximately 5-6 minutes later and observed the resident on the floor. The Director of Nursing indicated the CNA #1 was educated and suspended related to the event and CNA #2 was counseled. The Director of Nursing indicated the resident's bed should have been in the lowest position as per her plan of care to prevent injury and accidents. 2. The record for Resident #B was reviewed on 12/20/13 at 9:35 a.m. Resident #B is a DNR (Do Not Resuscitate) status. The resident's [DIAGNOSES REDACTED]. The fall investigation provided by the DoN (Director of Nursing) on 12/19/13 for Resident #B's reportable fall on 12/12/13 indicated, "12/13/13 Fall Reviewed: Res (Resident) stood up from wheelchair and leaned to the right and fell . Fall not witnessed but heard. MD in facility, res (resident) assessed & sent to ER (emergency room ). Spoke (with) CNA & CNA counseled R/T (related to) alarm not in place to alert staff. Will review ..." The written investigation interview with CNA #3, who had worked the 6 am - 2 pm shift on 12/12/13, indicated she had gotten Resident #B up in her broda chair with chair alarm for breakfast, had to adjust alarm several times throughout the shift & the alarm was in place before the end of the shift. A corrective action notice was included in the investigation and indicated, "This CNA did not ensure that all intervention were in place, which resulted in a fall with injury." The written investigation interview with CNA #4 who worked the 3 - 11p.m. shift on 12/12/13, indicated she arrived on the unit around 2:23 p.m. from the other unit, had filled her cart and was receiving report from a staff nurse when she was told one of her residents had fallen. The interview further indicated she "then came to the nurse station were {sic} resident fell and noticed no chair alarm. Went to her room grabbed alarm and placed on her chair." A Restorative fall intervention checklist dated 12/12/13, provided by the DoN on 12/20/13, indicated fall interventions were in place, including a chair alarm, as ordered for Resident #B at 11:00 a.m. The hospital emergency room physician examination notes dated 12/12/13 indicated "status [REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 11/1/13, indicated Resident #B had severe cognitive impairment and required extensive assist (resident involved in activity with staff providing weight bearing support) of two staff for transfers. Progress notes for Resident #B indicated additional falls documented on 10/19/13 (2 different times) and 11/15/19. The event report for the first fall on 10/19/13 at 6:45 p.m. indicated, "Resident fell out of chair in hallway on buttocks trying to stand up, hit head on wheelchair." The event report for fall #2 on 10/19/13 at 8:00 p.m. indicated "Resident slid out of bed onto buttocks." The event report for 11/15/13 at 12:55 a.m., indicated Resident #B "got out of bed (bolsters in place) wearing regular socks walked across floor carrying a brief, washcloth and empty can of cleaning foam. Was found sitting on floor outside of room ... states she had gotten tired and lowered herself down the wall ... Res incontinent of BM (bowel movement). 10 minutes prior she was toileted and had large BM and moderate amt. (amount) urine." There were two scratches noted to her mid back. Care plans for Resident #B indicated "3/15/13 Resident at risk for falling R/T Visual and cognitive impairment." The following fall prevention interventions were to be put into place: 3/15/13: Provide proper, well-maintained footwear; keep call light in reach, bed in lowest position and provide incontinent care after each episode. 3/22/13 added: Bolsters to bed 4/9/13 added: High back reclining wheelchair 10/20/13 added: Wheelchair alarm, 2 person assist for transfers, Dycem (a pad placed on the chair to prevent sliding or slipping), and padded wheelchair arms. 11/15/13 added: Bed alarm R/T fall, thin floor mat next to bed while in bed, and non skid slipper socks while in bed and at bedtime. An interview was conducted with the DoN on 12/20/13 at 10:45 a.m. She indicated, based on the investigation of Resident #B's fall on 12/12/13, the chair pad alarm was not on the wheelchair at the time of the fall, nor was it found in the area. She further indicated the protocol to ensure proper interventions were in place was for Restorative to do daily rounds and each CNA was also to check. The DoN also indicated Resident #B had a history of [REDACTED]. In a continuation of the interview at 1:54 p.m., the DoN indicated the Dycem was not addressed during the fall investigation and she did not know if it had been in place on the wheelchair. In an interview with the Restorative Program Director (RPD) on 12/20/13 at 1:15 p.m., she indicated Resident #B was part of the Restorative program since she was discharged from therapy (after her fall on 11/15/13) and had been much more energetic. The intervention for Restorative staff to ambulate Resident #B daily along with her range of motion exercises was put into place to attempt to help occupy the resident. The RPD indicated she had seen Resident #B ambulating and she did well. The RPD further indicated daily rounds by Restorative staff were completed on all residents with any fall prevention in place and a master flow sheet is used. The information comes from morning meetings and physician's orders [REDACTED]. The staff also notifies the nursing staff and the RPD. The RPD indicated that the Restorative staff have notified her of missing or non-working items on a regular basis and she herself then checks the status of the intervention, rechecks the physician's orders [REDACTED]. 3. During Orientation Tour on 12/19/13 at 8:58 a.m. Resident #L was observed in bed. No staff members or visitors were in the room at the time. The resident was in bed. The resident's bed was in the low position. There was a blue mattress on the floor near the lower half of the bed. The mattress was approximately 3 feet away from the resident's bed. On 12/19/13 at 12:05 p.m., the resident was observed in bed. The resident was eating his lunch. A blue floor mat was observed on the floor approximately 2- 2/12/ feet away from the resident's bed. There were no staff members or visitors in the resident's room at this time. On 12/19/13 at 12:15 p.m., the resident was observed in bed. The blue floor mat remained in the same position. There were no staff members or visitors in the resident's room. On 12/19/13 at 12:35 p.m., the resident was observed in bed. The resident's meal tray was not in the room at this time. The blue floor mat remained in the same position. There were no staff members or visitors in the resident's room. On 12/19/13 at 1:30 p.m., the resident was observed in bed. A Hoyer lift machine (a mechanical device used to transfer residents) was observed in the doorway of the resident's room. CNA #5 walked into the doorway and removed the Hoyer lift from the room. The blue floor mat was not next to the resident's bed at this time. The CNA took the Hoyer lift out to the hallway and did not return to the resident's room. On 12/19/13 between 1:30 p.m. and 1:35 p.m., several staff members were observed in the hallway near the resident's room. No staff members entered the resident's room. On 12/19/13 at 1:45 p.m., the resident was observed in bed. The blue floor mat was not next to the resident's bed. There were no staff members or visitors in the resident's room at this time. On 12/20/13 at 7:40 a.m., Resident #L was observed sitting in wheel chair in the unit Dining Room. There were no auto locks on the resident's wheel chair. On 12/20/13 at 8:20 a.m., the resident was observed sitting in his wheel chair in his room. There were no auto locks on the resident's wheel chair. There were no staff members or visitors in the room. The record for Resident #L was reviewed on 12/20/13 at 8:00 a.m. The resident's [DIAGNOSES REDACTED]. A Fall Risk assessment completed on 12/5/13 indicated the resident's score was (20). The assessment indicated the resident had three or more falls in the last three months and had balance problems while standing and walking. A score greater then (10) indicated the resident was at risk for falls. The resident's care plan were reviewed. A care plan initiated on 3/30/13 indicated the resident had a history of [REDACTED]. The care plan was last reviewed on 10/29/13. Care plan interventions included for the resident to have a floor mat at the bedside and wheel chair auto locks. The 9/19/13 Minimum Data Set (MDS) quarterly assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was (3). This score indicated the resident's cognitive patterns were severely impaired. The assessment also indicated the resident required extensive assistance (resident involved in activity with staff providing weight bearing support) of two persons for bed mobility and transfers. Review of the 12/2013 Nursing Progress Notes indicated an entry was made on 12/5/13 at 5:30 p.m. This entry indicated the Nurse was called to the resident's room by the CNA and found the resident sitting on the floor next to his bed mat. The resident stated he was trying to put himself back to bed. The resident denied pain, discomfort, or hitting his head. An entry made on 12/4/13 at 2:33 p.m. indicated at 12:30 p.m., the resident was noted getting out of his chair and laying himself on the bedside mat. The 10/2013 Nursing Progress Notes were reviewed. An entry dated 10/29/13 at 6:20 p.m., indicated the resident was found sitting on the floor in his room next to the wheel chair. The resident reported he was trying to transfer himself to bed from the wheel chair. No injuries were noted. When interviewed on 12/20/13 at 8:20 a.m., the Director of Nursing indicated the wheel chair the resident was currently in did not have auto locks in place. The Director of Nursing indicated this was not the wheel chair the resident had in the past. When interviewed on 12/20/13 at 8:25 a.m., CNA #5 indicated she was assigned to care for the resident this shift The CNA also indicated the resident's hall was her normal run (assignment). The CNA was interviewed in the resident's room and the resident was in the wheel chair. The CNA identified the wheel chair as the resident's wheel chair that she had been getting him into all week on her run. When interviewed on 12/20/13 at 10:45 a.m., the Director of Nursing indicated the resident had been placed on Hospice care a few weeks ago and the resident's wheel chair was switched by Hospice. The Director of Nursing indicated the current wheel chair did not have auto locks in place as per the resident's plan of care. This Federal tag relates to Complaints IN 945 and IN 418. 3.1-45(a)(2)