Every finding on record at Envive of Anderson

Based on interview and record review, the facility failed to provide assessment and treatment of chronic wounds for 1 of 3 residents reviewed for wounds. (Resident B) This deficient practice resulted in the resident being hospitalized for the evaluation and treatment of infected lower extremity leg wounds with maggot infestation.The deficient practice was corrected on 7/6/26, prior to the start of the survey, and was therefore Past Noncompliance. Findings include:Review of an anonymous intake received by the Indiana Department of Health indicated Resident B had been found to have chronic cellulitis (inflammation and infection of the skin) to both legs with maggot activity noted in her wounds. The complainant indicated the resident had required hospitalization for treatment of her leg wounds.Resident B's clinical record was reviewed on 7/8/26 at 9:12 a.m. Diagnoses included gout, type 2 diabetes, peripheral vascular disease, stage 3 chronic kidney disease, and Parkinson's disease.The clinical record lacked orders for wound care.Review of the weekly skin assessment from 4/28/26 through 6/23/26 indicated the resident displayed no skin impairments or discoloration. The clinical record lacked a weekly skin assessment for the week of 7/20/26.Review of Resident B's facility shower sheets for the past 30 days indicated the following:On 6/3/26 and 6/10/26 the resident refused bathing.On 6/6/26, 6/7/26, 6/13/26, 6/24/26, and 6/27/26 no skin concerns were observed.On 7/1/26, the resident allowed staff to wash the back of her knees and no areas were identified.Review of a late entry progress note, dated 7/1/26 at 1:26 p.m., indicated LPN 1 documented resident education related to keeping legs elevated due to increased swelling.Review of a progress note, authored by LPN 6 and dated 7/4/26 at 2:36 a.m., indicated Resident B complained of bleeding, itching, and burning in the lower extremities. The resident had a gauze wrap to both extremities. When the bandage was removed, a seeping area infested with maggots was observed. The resident was transported to the hospital for further evaluation. No documentation for physician notification was noted.LPN 6 was unavailable for interview during the survey dates.Review of emergency department documentation, dated 7/4/26, indicated the resident arrived for evaluation of leg wounds. The resident reported her legs had been giving her trouble for approximately a month. The wounds worsened that night, and she reported to the nurse they were burning. The facility called an ambulance and transported the resident to the hospital. Emergency Medical Services noted maggots in the resident's leg wounds. The resident was positive for swelling in both legs and wounds were present. The resident had extensive chronic changes to both lower extremities with chronic thickening of the skin. There were maggots present in the wounds to both legs. The resident would require hospitalization for further evaluation and medical management. The resident reported pain at a 10 out of 10 on the pain scale.Review of a hospital wound care note, dated 7/6/27 at 1:36 p.m., indicated the wound to the right lower leg, measured 2 centimeters (cm) length x 2 cm width with approximately 100% red non-granulated (non-healing) tissue, scant serosanguinous (normal pale pink) drainage noted on the old dressing. The left lower leg wound measured 7 cm length x 5 cm width with approximately 50% red non-granulated tissue and 50% macerated (soggy) epidermis (top layer of skin) and small amount of serosanguinous drainage on the old dressing.During an interview, on 7/9/26 at 12:38 p.m., CNA 3 indicated she provided care to Resident B on 7/2/26. She had applied lotion to the resident's legs but was only able to see the front of her legs.During an interview, on 7/10/26 at 10:46 a.m., QMA 8 indicated she had seen the resident's legs wrapped in gauze.During an interview, on 7/10/26 at 10:59 a.m., CNA 9 indicated the resident would ask to have her legs wrapped because she thought they were bleeding.During an interview on 7/10/26 at 11:05 a.m., the facility Wound Nurse indicated she had been working at the facility since March 2026. She never received notification of or a request for consultation for Resident B. During an interview on 7/10/26 at 11:43 a.m., LPN 1 indicated, on 7/1/26, Resident B asked to have her legs wrapped. LPN 1 informed the resident she did not have an order to wrap her legs. LPN 1 removed the resident's socks, and they were literally stuck to her legs. LPN 1 indicated there was no drainage and the resident's skin was crusty. The resident had an order for hydrocortisone cream. The resident allowed LPN 1 to apply the cream if she wrapped her legs. LPN 1 applied the cream and loosely wrapped the resident's legs in gauze wrap. LPN 1 indicated she had never wrapped the resident's legs before, but knew other nurses had been wrapping them in the past because she had removed the dressings in the past. LPN 1 indicated she should have notified the physician or nurse practitioner (NP) to get an order for treatment.During an interview, on 7/10/26 at 1:30 p.m., the NP indicated she never received any notification from the facility with concerns related to Resident B's legs.A current facility policy dated 8/2024 and titled Acute Condition Changes-Clinical Protocol, provided by the Administrator on 7/9/26 at 4:32 p.m. indicated the following: Assessment and Recognition .3. Direct care staff, including nursing assistance will be trained in recognizing subtle but significant changes in the resident (. changes in skin color or condition) and how to communicate these changes to the Nurse.A current facility policy dated 8/2024 and titled Dressings-Sterile, provided by the Administrator on 7/9/26 at 4:32 p.m. indicated the following: Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Preparation: Verify that there is a physician's order for this procedure.Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. Check the treatment record. The deficient practice was corrected by 7/6/26 after the facility implemented a systemic plan that included the following actions: All residents have had a full head to toe skin assessment on 7/6/2026 by the DON and Wound Care nurse, newly identified areas skin impairment were assessed and documented, physicians and responsible parties were notified of newly identified skin impairments, appropriate treatments/orders were obtained from physician and implemented, care plans developed and reviewed/revised, licensed nurses re-educated by DON related to completing skin assessments, documentation of wound assessment, notification and treatment orders, and documentation of resident care refusals. This citation relates to Intake 3070979.410 Indiana Administrative Code 16.2-3.1-37(a)

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with pressure injury for 1 of 2 residents reviewed for pressure injury. (Resident 56) Findings include:Resident 56's clinical record was reviewed on 4/9/26 at 11:24 a.m. The resident was admitted [DATE]. A 4/1/26 admission assessment indicated the resident had a wound on his coccyx (tailbone). A risk for impaired skin integrity baseline care plan outline prompt was included in the assessment. Intervention options included diet as ordered, observe skin with daily cares, and notify the nurse of any new or worsening areas, and treatments as ordered. A current resident care plan, initiated 4/2/26, indicated the following: At risk for impaired skin integrity related to impaired mobility, self-care deficit. Goal: Resident will have no further skin breakdown through next review. Interventions included encourage good nutrition and hydration, keep skin clean and dry. Use lotion on dry skin, observe skin with daily cares. Notify nurse of any new or worsening areas, and treatments as ordered. The record lacked a baseline care plan with individualized interventions for the coccyx wound present on admission. During an interview, on 4/10/26 at 10:49 a.m. RN 4 indicated, during the admission assessment, certain questions within the assessment caused a baseline care plan to trigger and the responses to those questions create the problem, goal, and interventions. After admission, the baseline care plan should have been found in either the care plan or assessments tab of the Electronic Health Record (EHR). The baseline care plan included anything staff would have needed to start caring for the resident. During an interview, on 4/10/26 at 11:49 a.m., the DON indicated questions answered in the admission assessment generated a baseline care plan for residents. When the resident was seen by the providers or other staff, changes were made to the care plan. A wound found during the admission assessment should have been included in the baseline care plan. A current facility policy, titled Care Plans, Comprehensive Person-Centered, and revised 8/2024, indicated the following: .3. The care plan interventions are derived from a thorough analysis of the information gathered Cross reference F686.410 IAC (Indiana Administrative Code) 16.2-3.1-30(a)

Based on observation, interview, and record review, the facility failed to ensure treatment orders were in place and interventions developed and implemented to promote healing of a pressure injury for 1 of 2 residents reviewed for pressure injuries. (Resident 56)Findings include:Resident 56's clinical record was reviewed on 4/9/26 at 11:24 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included stage III chronic kidney disease, congestive heart failure, and atrial fibrillation (abnormal heart rhythm).A 4/1/26 Braden Scale assessment indicated the resident was at moderate risk for pressure injury formation. A 4/1/26 nursing admission evaluation indicated the resident presented to the facility with a stage 2 pressure ulcer to his coccyx (tailbone area). A 4/1/26 nurse's note indicated the resident arrived to the facility with a stage 2 pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) on his coccyx. The area was cleansed with wound cleanser and a bordered gauze was applied. A 4/3/25 Nurse Practitioner's (NP) note indicated the resident's representative reported a wound to the resident's left heel and coccyx. The physical exam included a left heel Deep Tissue Injury (DTI) (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue.), was present and a coccyx wound was reported prior to admission. The clinical record did not indicate implementation of a treatment plan. A 4/7/26 wound note indicated the resident admitted to the facility with a reported DTI to the left heel and a stage 2 pressure injury to the left buttock. Previous treatments for the wound included skin protectant, offloading heels with pressure-relieving boots and dry dressing to the left buttock. The wound assessment indicated a left medial foot DTI present on admission, measuring 0.5 centimeters (cm) length (L) by 0.5cm width (W) by no depth (pen cap tip - sized). Wound 2 was located on the left lateral foot, present on admission, and unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured), measuring 3cm L by 3.5cm W by no depth (half dollar sized). Wound 3 was a stage 2 pressure ulcer/injury, present on admission, measuring 1.1cm L by 1cm W by 0.1cm depth (dime sized).A 4/7/26, admission, Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired. The resident was fully dependent on staff for toilet hygiene and rolling left to right. He was always incontinent of bowel and bladder. The resident had two unhealed pressure injuries noted during the assessment as follows: one stage 2 pressure injury and one unstageable pressure injury. Treatments for the pressure injuries during the assessment period included use of a pressure reducing device for his chair and bed. A current resident care plan, revised 4/7/26, indicated the following: Requires the use of enhanced barrier precautions related to presence of wound to reduce the risk of transmission of Multi Drug Resistant Organisms (MDROs) (initiated 4/2/26) and the resident has a pressure ulcer related to immobility: left medial foot- DTI left lateral foot-unstageable, and left buttock-stage 2, initiated 4/7/26. The clinical record lacked an individualized care plan with goals for healing and individualized interventions to promote healing and comfort. During a wound care observation, on 4/9/26 at 1:04 p.m., LPN 6 indicated no other wound treatment orders were in place other than applying skin protectant to the resident's heels. The resident's pressure relief boots were removed, and skin protectant was applied to both heels. A large, irregularly circular, dark area was present on the resident's right heel. LPN 6 indicated he was unsure how long the area had been present and no orders were in place to treat the area. During the observation, Resident 56 declined observation of his coccyx. Current physician's orders included the following: Braden assessment (assessment to for measuring risk of skin breakdown) once a week for three weeks (ordered 4/8/26), mechanical lift with assist of two staff (ordered 4/1/26), and skin protectant to bilateral heels for protection twice a day (ordered 4/1/26).The clinical record lacked orders for wound treatment to Resident 56's coccyx wound. During an interview, on 4/10/26 at 9:20 a.m., LPN 3 indicated when residents were admitted , a head-to-toe assessment was performed and documented under the assessments tab. If any abnormalities were found, she would notify the provider and wound nurse using a secure messaging system. Resident 56 had treatment orders for his wound placed last night (4/9/26). Previous treatment orders only included skin protectant to both heels. During an interview, on 4/10/26 at 10:49 a.m., RN 4 indicated when a resident was admitted , a head-to-toe assessment was completed, including a skin and wound assessment. The results were documented in a progress note and if any abnormal findings were found, a message was sent to the provider through a secure messaging system. If wounds were found on the admission assessment and no orders were in place, she would reach out to the provider for treatment orders until the resident was seen by the provider or wound team. During an interview, on 4/10/26 at 11/49 a.m., the DON indicated when a resident was admitted , a head-to-toe assessment was performed to check for any abnormalities including wounds. Findings were placed in the chart in an admission assessment and then communicated with the providers in a secure message. If the physician worked at the facility the resident came from, wound orders were put in place on admission. When wounds were found during an admission assessment, treatment and monitoring should start as soon as practicable. A current facility policy, titled, Pressure Injury and Skin Condition Assessment, and reviewed 6/2022, included the following: .Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven (7) days by a licensed nurse and documented in the resident's clinical record.Procedures 1. A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer assessment will be updated quarterly and as necessary. 2. Residents identified will have a weekly skin assessment by a licensed nurse. 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by a licensed nurse. 3. Each resident will be observed for skin breakdown daily during care and on the assigned bath day by the CNA. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment.6. Care givers are responsible for promptly notifying the charge nurse of skin breakdown. 7. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes.10. Pressure injuries and other ulcers (arterial, diabetic, venous) will be measured at least weekly and record in centimeters in the resident's clinical record. 11. A wound assessment for each identified open area will be completed and will include: a. Site location b Size (length x width x depth) c. Stage of Pressure Ulcer d. Odor e. Drainage f. Description g. Date and initials of the individual performing the assessment.16. The licensed nurse is responsible for notifying the attending physician, Director of Nursing, and legal representative of any suspected wound infection. 17. The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches, and goals for care. 19. A licensed nurse shall observe the condition of wound incision daily, or with dressing changes as ordered. Observations such as drainage, dehiscence, redness, swelling, or pain will be documented in the nurse's notes. If observations are acute, the physician and responsible party will be notified by the charge nurse. Notification will be documented in the resident's clinical record. 410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(7)

Based on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies related to implementing interventions to promote healing of pressure injuries.Findings include:Review of the Summary Statement of Deficiencies (2567), for the facility's last annual recertification and licensure survey, completed on July 25, 2025, indicated the facility had deficiencies related to failure to obtain wound assessments, monitoring, and treatments in a manner to promote the healing of a pressure injury.During an interview, on 4/10/26 at 12:02 p.m., the Administrator indicated the facility Quality Assessment and Assurance (QAA) committee met monthly and reviewed areas of concerns, areas showing trends, and/or areas with an increase in occurrence. Previous annual survey citations are reviewed through the time frame listed on the Plan of Correction (POC), usually for six months. If the audits and/or evaluations met the required threshold, those areas were considered corrected and removed from the QAA committee's review tasks. The facility did not have a current QAPI plan or action plan in place related to pressure injury.Repeat concerns regarding pressure injuries were cited during the April 10, 2026, survey as follows:Based on interview, observation, and record review, the facility failed to provide wound assessments/monitoring and wound treatments in a manner to promote healing of a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers (injuries). A current facility policy, revised 8/24, titled, Quality Assurance and Performance Improvement (QAPI)-Governance and Leadership provided by the Administrator on 4/6/26 at 9:20 a.m., indicated the following: . 4. The responsibility of the QAPI committee are to: a. collect and analyze performance indicator data and other information; b. identify, evaluate, monitor, and improve facility systems and processes that support the delivery of care and services; c. identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process.e. help departments, consultants, and ancillary services implement systems to correct potential and actual issues in quality of care. Cross reference F686. 410 IAC (Indiana Administrative Code) 16.2-3.1-52(b)(2)

Based on observation, record review, and interview, the facility failed to follow enhanced barrier precautions (EBP) during a wound dressing change observation for 1 of 2 residents reviewed for pressure injuries. (Resident 9)Findings include:Resident 9's clinical record was reviewed on 4/8/26 at 10:55 a.m. Diagnoses included peripheral vascular disease, unspecified bipolar disorder, and stage 4 (full-thickness wound, extending through deep tissue to expose muscle, tendon, ligament, or bone) pressure injury of the sacrum (tailbone area).Current orders indicated to cleanse the sacrum pressure injury with an external wound cleanser, apply calcium alginate (a wound dressing) to the wound bed. Apply zinc paste (a barrier cream) around the wound bed and cover with a bordered silicone dressing. Change once daily and as needed (3/17/26) and required the use of EBP related to the presence of a wound and to reduce the risk of transmission of multidrug-resistant organisms (MDROs) (10/23/25).A 10/17/25, pressure injury care plan indicated Resident 9 had a stage 4 pressure injury. Interventions included administer treatments as ordered and monitor for effectiveness (10/17/25), monitor dressing to ensure it is intact and adhering (10/17/25), and assess/record/monitor wound healing (10/17/25).A 10/24/25, EBP care plan indicated Resident 9 required the use of personal protective equipment (PPE) for a wound to prevent the spread of organisms. Interventions included following CDC guidelines for enhanced barrier precautions when performing the following high-contact resident care (10/25/25).A 1/23/26, quarterly Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired and had one stage 4 pressure injury.A 4/7/26 wound progress note indicated a stage 4 pressure injury to the sacrum measuring 4.3 centimeters (cm) length (L) x 4.5 cm width (W) x 0.2 cm depth (D), (roughly the size of a large walnut). The wound was 100% granulized (bright red, moist connective tissue) tissue. Cleanse the sacrum wound with an external wound cleanser, apply calcium alginate (a wound dressing) to the wound bed. Apply zinc paste (a barrier cream) around the wound bed and cover with a bordered silicone dressing. Change once daily and as needed. The wound was improving.During a wound treatment observation, on 4/9/26 at 9:25 a.m., LPN 6 set up a clean area on the resident's bedside table and deposited his supplies. He completed hand washing and donned gloves. The resident was able to roll by himself onto his right side. The current bandage was dated 4/8/26. He removed the current dressing, placed it in the trash, and removed his gloves. He completed hand washing and donned new gloves. He opened a roll of gauze and moistened it with the external wound cleanser. He cleaned the wound bed. The wound bed was shallow, bright red, and oblong in shape, roughly the size of large walnut. The skin surrounding the wound appeared red and blotchy. LPN 6 applied the calcium alginate to the wound bed and skin protectant (a barrier wipe) to the area surrounding the wound. He covered the wound with a bordered silicone dressing. He removed his gloves and completed hand washing.During an interview, at the time of the observation, LPN 6 indicated Resident 9 required EBP to help prevent the spread of infection and that he (the nurse) had forgotten to wear the proper PPE for the wound treatment observation. He indicated he had gotten nervous and simply forgot to wear the gown during the process.During an interview, on 4/10/26 at 11:31 a.m., the DON indicated EBP was required for residents who had wounds, medical devices, and/or a history of MDRO's. This precaution required staff to wear specific PPE when providing direct care to residents. LPN 6 should have worn both a gown and gloves when changing the dressing and applying the new treatment to Resident 9's pressure ulcer.A current facility policy, dated 8/22, titled, Enhanced Barrier Precautions, provided by the Administrator on 4/10/26 at 9:54 a.m., indicated the following: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: . h. wound care (any skin opening requiring a dressing) . 410 IAC (Indiana Administrative Code) 16.2-3.1-18(a)

Based on observation, interview, and record review, the facility failed to post current and accurate nursing staff information daily for residents and visitors. This deficiency had the potential to affect 53 of 53 residents in the facility.Findings include:The facility nurse staffing information, dated 4/2/26 and observed on 4/6/26 at 6:13 a.m., was posted on a small table, to the right of the entrance doors and indicated the following:The form lacked a census number.Number of Registered Nurses (RN): Day shift hours: 0.00, Evening shift hours: 4.00, and Night shift hours: 8.00.Number of Licensed Practical Nurses (LPN): Day shift hours: 16.00, Evening shift hours: 16.00, and Night shift hours: 8.00.Number of Qualified Medication Aides (QMA): Day shift hours: 16.00, Evening shift hours: 0.00, and Night shift hours: 8.00Number of Certified Nursing Assistant (CNA): Day shift hours: 32.00, Evening shift hours: 32.00, and Night shift hours: 16.00.During an observation, on 4/6/26 at 9:22 a.m., the 4/6/26 facility nurse staffing posting indicated the following:Census: 53Number of RN: Day shift hours: 0.00, Evening shift hours: 4.00, and Night shift hours: 8.00.Number of LPN: Day shift hours: 8.00, Evening shift hours: 8.00, and Night shift hours: 8.00.Number of QMA: Day shift hours: 16.00, Evening shift hours: 4.00, and Night shift hours: 0.00Number of CNA: Day shift hours: 32.00, Evening shift hours: 32.00, and Night shift hours: 24.00.During an observation, on 4/7/26 at 9:06 a.m., the 4/6/26 facility nurse staffing posting remained. During an observation, on 4/7/26 at 11:30 a.m., the facility nurse staffing, dated 4/7/26, indicated the following:Census 53Number of RN: Day shift hours: 8.00, Evening shift hours: 4.00, and Night shift hours: 8.00.Number of LPN: Day shift hours: 16.00, Evening shift hours: 12.00, and Night shift hours: 8.00.Number of QMA: Day shift hours: 8.00, Evening shift hours: 4.00, and Night shift hours: 0.00Number of CNA: Day shift hours: 32.00, Evening shift hours: 32.00, and Night shift hours: 24.00.During an observation, on 4/8/26 at 9:07 a.m., the facility nurse staffing, dated 4/7/26, remained.During an observation, on 4/8/26 at 10:07 a.m., the facility nurse staffing information, dated 4/8/26, indicated the following:Census 54Number of RN: Day shift hours: 8.00, Evening shift hours: 4.00, and Night shift hours: 0.00.Number of LPN: Day shift hours: 16.00, Evening shift hours: 12.00, and Night shift hours: 16.00.Number of QMA: Day shift hours: 16.00, Evening shift hours: 8.00, and Night shift hours: 0.00Number of CNA: Day shift hours: 24.00, Evening shift hours: 24.00, and Night shift hours: 24.00.During an interview, on 4/10/26 at 11:35 a.m., the facility Scheduler indicated she created this document utilizing a system to calculate the nursing hours needed for each shift. She used the schedule to break down how many RNs, LPNs, QMAs, and CNAs would be on each shift, and noted the census number. She completed the form the night before and placed it underneath the current one posted on the table to the side of the entrance door as she left the facility. The management team would remove the previous days posting when they arrived the following morning. There were times when she had needed to remove the previous days staff posting when she arrived, at the start of her shift, which was at 9:00 a.m. She completed the form in advance for the weekends. She had worked on the floor as a CNA for the previous weekend, on 4/3/26, 4/4/26, and 4/5/26, and forgot to update the form. The staff posting would not have been updated and/or current on 4/3/26, 4/4/26, 4/5/26, or on the morning of 4/6/26. A current facility policy, revised 8/24, titled, Posting Direct Care Daily Staffing Numbers, provided by the Administrator on 4/10/26 at 9:54 a.m., indicated the following: .Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.

Based on observation, interview, and record review the facility failed to ensure dietary employees where competent in dishwasher sanitation testing. This deficient practice had the potential to impact 57 of 57 residents who consumed meals prepared in the facility kitchen. Findings include:During an observation of dishwasher operations in the facility kitchen on 7/24/25 at 8:48 a.m. the following was observed:The Dietary Manager indicated the dishwasher was a low temp machine, which used sanitizer in its final rinse. The sanitizer was a chlorine-based sanitizer. The dish machine that was in operation washing the breakfast dishes, plates, bowls, cups, glasses etc. The Dietary Manager placed a test strip inside the dish machine for testing. He indicated the test strip could be used to test the sanitizer level both internally and externally in the water well located on the outside of the dishwasher. The test strips used had red writing and a red band across the edges. They were not the traditional all white dip stick style. The Dietary Manager indicated, using the test strips with the red writing, he did not know how many parts per million of sanitizing agent needed to be reached to equal proper sanitation. He then displayed the test strip. The test strip indicated Temp-Dishwasher Temperature test strip. The test strip did not indicate it tested for chlorine content. The Dietary Manager indicated he was unable to find chlorine test strips and he would look for said product.During an interview on 7/24/25 at 9:35 a.m., the Dietary Manager indicated he had last seen the chlorine test strips on 7/21/25. He believed the test strips had gotten wet and were thrown away. He had not been told by staff when the test strips were thrown away. He could not find any other chlorine test strips. He had used the temperature test strips as a backup without knowledge of how they worked.During an interview with the DON on 7/25/2025 at 10:04 a.m., she indicated 57 of the facility's 58 residents consumed food orally and therefore ate meal prepared in the facility kitchen. A current, undated, facility policy titled Sanitization, provided by DON on 7/24/25 at 10:02 a.m. indicated: 3. All equipment, food, contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.5. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: .b. Low-Temperature Dishwashers (Chemical Sanitization):(1) Wash temperature (120 [degrees sign] F);(2) Final rinse 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in finale rinse;and(3) The chemical solution is maintained at the correct concentration. based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines Low-temperature dishwashers and chemical sanitization:The dishwashers rely on chemical sanitizers (like chlorine or quaternary ammonium) to disinfect dishes, rather than high heat 1.3-20(h)

Based on interview, observation, and record review, the facility failed to provide wound assessments/monitoring and wound treatments in a manner to promote healing of a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers. (Resident 1)Finding includes:Based on interview, observation, and record review, the facility failed to provide wound assessments/monitoring and wound treatments in a manner to promote healing of a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers. (Resident 1)Finding includes:During an interview on 7/21/25 at 10:15 a.m., Resident 1 was in her bed on a low air loss mattress and turned slightly to her right side. She indicated she had a wound on her buttock that was present on admission. She did not feel well and was uncertain why. The resident was dependent on staff for repositioning. Resident 1's clinical record was reviewed on 7/22/225 at 3:41 p.m. Diagnoses included multiple sclerosis, weakness, and pressure ulcer of the sacral region, stage IV (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). Current orders included cleanse area to the coccyx with Dakins External Solution (wound treatment) 0.25%, pack area with light Dakins fluffed gauze, cover with superabsorbent pad, and secure with a silicone bordered superabsorbent dressing daily and as needed. (7/23/25) Weekly skin assessments on day shift every Saturday. (2/11/25) Ensure a pressure reducing mattress to the bed every shift. (2/11/25)A 7/8/25, quarterly, Minimum Data Set (MDS) Assessment indicated the resident was cognitively intact. The resident required maximum assistance from staff for upper body dressing, bathing, and personal hygiene. She was dependent on staff assistance for lower body dressing, toileting hygiene, transfers, and repositioning. The resident was at risk for pressure ulcers and had a stage IV pressure ulcer, present on admission. Skin interventions included pressure ulcer treatments/care, a pressure reducing device for the bed, and nutrition or hydration. A current care plan, dated 2/19/25, indicated the resident had a stage IV pressure injury to the coccyx. Interventions included the following: Administer treatments as ordered and monitor for effectiveness. (2/19/25) Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. (2/19/25) Report improvements and declines to the MD. (2/19/25) Encourage and assist the resident to change position frequently. (2/19/25) Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. (2/19/25) A progress note, dated 2/10/25 at 6:06 p.m., indicated the resident admitted to the facility on [DATE]. A skin assessment was completed with a coccyx wound that measured 14 centimeters (cm) length by 14 cm width (size of a drink coaster) by 1.5 cm depth. Wound center notes included the following:On 5/27/25, the stage IV sacrum pressure injury measured 10 cm length by 10 cm width by 3 cm depth. Bone was exposed with moderate drainage. The resident's next wound center appointment was 6/24/25. The resident's most recent wound center progress note, dated 7/8/25, indicated the resident's stage IV sacrum pressure injury measured 9.5 cm length by 10.5 cm width by 3.3 cm depth, with 3.8 cm undermining present from 1:00 o'clock to 5 o'clock. Bone was exposed with moderate serosanguineous drainage. The plan included no brief use. The resident's next appointment was scheduled for 7/29/25. A progress note, dated 7/17/25 at 7:19 p.m., indicated the resident's wound was not assessed by the wound team due to a wound center appointment. The clinical record indicated Resident 1 was not seen by the wound center on this date.Review of the clinical record lacked weekly wound assessments of the sacrum pressure injury, including a description of the wound with measurements, from the resident's last wound clinic appointment on 7/8/25 through 7/25/25. A progress note, dated 7/23/25 at 3:38 p.m., indicated the wound to the coccyx area was noted to have purulent drainage with foul odor. The provider was notified.During a wound treatment observation on 7/23/25 at 2:25 p.m., Resident 1 was turned to her left side upon entrance to the room. Both LPN 7 and CNA 9 performed hand hygiene and donned a gown, gloves, mask, and face shield prior to entering the room. With gloved hands, LPN 7 picked up a bottle of Dakins Solutions, a stack of individually packaged 4x4 gauze, and a large super absorbent foam dressing that were directly against the top of the medication cart and carried them into the resident's room. Without a barrier, LPN 7 placed the wound care supplies on top of personal items on the resident's nightstand, beside the bed. CNA 9 and LPN 7 repositioned the resident onto her right side for wound care with their gloved hands. The resident's brief was removed by LPN 7. LPN 7 then removed the old foam bordered dressing and gauze packing in the wound bed from the resident's sacrum/coccyx. The foam dressing, dated 7/22/24, was saturated with purulent drainage and a foul odor was present. Purulent drainage was on the gauze packed in the wound bed. The wound was approximately the size of a softball with bone exposed in the wound bed. With the same gloves, LPN 7 used both hands, picked up 4x4 gauze packs, opened them, used both hands to pick up and open the Dakins Solution, then poured the Dakins Solution onto the gauze held with her gloves. She used the gauze to cleanse the open wound bed, working in an outward motion. LPN 7 picked up more gauze packs from the nightstand, opened them, then patted the wound bed with the gauze. More gauze was opened from the nightstand by LPN 7 with her gloved hands. As LPN 7 held the gauze in her right hand, she used her left hand and poured Dakins onto the gauze held in her right hand. LPN 7 used her right hand to pack the Dakins soaked gauze into the wound bed and covered the gauze with a super absorbent foam bordered dressing. No hand hygiene nor gloves changes were observed during the wound care until after the clean dressing was applied to the resident upon completion of the treatment. A clean brief was applied after the dressing change and the resident was positioned according to her preference. During an interview on 7/23/25 at 3:01 p.m., LPN 7 indicated she was familiar with the resident's care. She had not noticed much of a change in the resident's wound until the above wound observation. LPN 7 indicated the wound was approximately the size of a softball with bone exposure. The foul odor and copious purulent drainage was new. She did not typically measure the wound when she did the treatments because it was measured during wound rounds each week. The resident did not have any current treatment for a wound infection. During wound care, LPN 7 typically washed her hands after she removed the resident's old dressing, before cleaning the wound, and before she applied the new dressing. She did not perform hand hygiene or change gloves during the wound care observation because she was nervous. She typically used a towel or chuck on the surface where she placed her wound care supplies. Instead, she placed the wound supplies directly against personal items on the resident's nightstand. Failure to change gloves and perform hand hygiene, after touching contaminated surfaces and before providing wound care, was considered cross contamination. This placed the resident at risk for potential infection. On 7/24/25 at 2:55 p.m., the DON indicated it was not appropriate to avoid glove changes and hand hygiene during wound care when touching surfaces, removing old dressings, and applying the new dressings. Wound supplies should have been placed on a barrier rather than placed against a contaminated surface. These practices placed the resident at risk for introducing bacteria to the wound and development of an infection.On 7/25/25 at 12:00 p.m., the DON indicated the resident was last seen at the wound center on 7/8/25. The week of 7/15/25, the resident's wound assessment was not completed. The DON was unable to provide additional wound assessments from 7/8/25 to 7/25/25. She thought there may have been miscommunication, because the resident was not seen at the wound center on 7/17/25.A current facility policy, dated 8/2024, titled Wound Care, provided by the Corporate Nurse Consultant on 7/24/25 at 3:38 p.m., indicated the following: Purpose.The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. 3. Assemble the equipment and supplies as needed. Wipe nozzles, foil packets, bottle tops, etc., with alcohol pledget before opening, as necessary. Steps in the Procedure 5. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 6. Wash and dry your hands thoroughly. 8. Put on exam glove. Loosen tape and remove dressing. 9. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 10. Put on gloves. 11. Use no-touch technique. 12. Pour liquid solutions directly on gauze sponges on their papers. 14. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Documentation. The following information should be recorded in the resident's medical record: . 33. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.A current facility policy, dated 8/2024, titled Handwashing and Hand Hygiene, provided by the Corporate Nurse Consultant on 7/24/25 at 3:38 p.m., indicated the following: Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.3.1-40(a)(2)3.1-18(l)

Based on observation, record review, and interview, the facility failed to follow physician's orders regarding placement of heel boots for a resident with current skin conditions for 1 of 2 residents reviewed for skin conditions. (Resident 36) Finding includes: During an observation, on 7/21/25 at 1:10 p.m., Resident 36 was lying in bed with bare feet. Resident 36 indicated she had a wound on her right ankle and foot. A dressing was noted to her right lateral ankle and foot. The resident's right ankle and foot was positioned with the dressing side facing down, flat on the bed. The resident was not wearing heel boots.On 7/22/25 at 10:10 a.m., Resident 36 was lying in bed with bare feet. A dressing was noted to her right lateral ankle and foot. The resident's right ankle and foot was positioned with the dressing side facing down, flat on the bed. The resident was not wearing heel boots.Resident 36's clinical record was reviewed on 7/23/25 at 9:10 a.m. Diagnoses included metabolic encephalopathy, unspecified severe protein-calorie malnutrition, and atherosclerotic heart disease of the coronary artery.Current orders included cleanse area to right lateral ankle with normal saline, pat dry, apply medical grade honey and cover with bordered foam every day for skin care and as needed. Apply padded boots (7/20/25). Cleanse area to right lateral foot with normal saline, pat dry, and apply medical grade honey and cover with bordered foam every day for skin care and as needed. (7/20/25)A current skin integrity care plan, dated 9/5/24, indicated the resident was at risk for altered skin integrity related to impaired mobility and dementia. Interventions included keep skin clean and dry (9/5/24), observe skin with daily care and notify nurse of any changes (9/5/24), and treatments as ordered (9/5/24).A 6/17/25 quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired and at risk for pressure ulcers. A 7/17/25 Wound Document indicated Resident 36 had a new open area to the right lateral foot with an undetermined cause and to apply medical grade honey, foam, and apply boots.A 7/18/25 wound infection/cellulitis care plan indicated Resident 36 had a wound infection or cellulitis to the right lateral ankle. Interventions included medications as ordered (7/18/25), monitor/document and report to doctor the following symptoms of cellulitis: red, swollen, tender skin, reddened area begins to spread, small red dots appear on the reddened skin, small blisters (7/18/25), and treatments as ordered (7/18/25).A 7/20/25 progress note indicated a new order was provided by the wound nurse practitioner for the right lateral ankle. Cleanse area with wound cleanser to normal saline. Apply medical grade honey and cover with bordered foam. Apply padded boots every day/shift for skin care and as needed.On 7/23/25 at 9:20 a.m. Resident 36 was seated upright in bed with bare feet. A dressing was on her right lateral ankle and foot. The resident's right ankle and foot was positioned with the dressing side facing down, flat on the bed. The resident was not wearing heel boots.On 7/23/25 at 12:45 p.m., Resident 36 was lying in bed with bare feet. A dressing was noted to her right lateral ankle and foot. The resident's right ankle and foot was positioned with the dressing side facing down, flat on the bed. The resident was not wearing heel boots.On 7/24/25 at 10:12 a.m., Resident 36 was sleeping in bed with bare feet. A dressing was noted to her right lateral ankle and foot. The resident's right ankle and foot was positioned with the dressing side facing down, flat on the bed. The resident was not wearing heel boots.During a wound observation, on 7/24/25 at 1:30 p.m., with the ADON and LPN 4, the resident was lying in bed with bare feet. A dressing was noted to her right lateral ankle and foot. The resident's right ankle and foot was positioned with the dressing side facing down, flat on the bed. The resident was not wearing heel boots.During an interview, on 7/24/25 at 2:00 p.m., the ADON indicated Resident 36 was not wearing heel boots as ordered. The purpose of the heel boots was to assist with wound healing, resident comfort, and to prevent further wound development.During an interview, on 7/25/25 at 10:05 a.m., the Corporate Nurse Consultant indicated the facility did not have a policy for following physician's orders. The staff followed the acceptable standards for care and followed all physicians' orders.

A. Based on record review and interview, the facility failed to provide bed hold policy and transfer/discharge notifications to the resident/representative for 2 of 5 residents reviewed for hospitalizations. (Resident 36 and 61)B. Based on record review and interview, the facility failed to provide notification of hospitalization to the Long-Term Care Ombudsman for 2 of 5 residents reviewed of hospitalization. (Residents 20 and 61) Findings include:A1. Resident 61's clinical record was reviewed on 7/22/25 at 2:36 p.m. Diagnoses included acute and chronic respiratory failure with hypoxia and malignant neoplasm of the right breast. A 6/23/25 progress note indicated the resident was non-responsive and transported to the local hospital. A 6/24/25 progress note indicated the resident was hospitalized for a change in level of consciousness. A 7/14/25 progress note indicated the resident remained hospitalized . The clinical record lacked information indicating the resident or the representative received a copy of the transfer/discharge form or the bed hold policy. During an interview on 7/25/25 at 11:14 a.m., LPN 7 indicated when a resident required a transfer/discharge to a hospital, she was required to get a provider's order, notify the DON, notify the family, and call report to the receiving facility. The face sheet, code status, medications list, and the last time the resident took their medications paperwork was provided to the paramedics or the family if they transported the resident to the hospital. Staff were required to document all the information in the resident's clinical record. During an interview on 7/25/25 at 11:25 a.m. the DON indicated she did not have further information to provide that indicated who may have received copies of the transfer/discharge form or the bed hold policy. She indicated Resident 61's paperwork was sent with the emergency transportation staff because the resident was unresponsive. When the information was not in the resident's clinical record, the facility did not have a way to ensure copies were provided to the resident or the resident representative. A2. Resident 36's clinical record was reviewed on 7/23/25 at 9:10 a.m. Diagnoses included metabolic encephalopathy, unspecified severe protein-calorie malnutrition, and atherosclerotic heart disease of the coronary artery. A 5/19/25 nurse's note indicated the resident was transferred to the emergency room for an evaluation and treatment. The physician, Director of Nursing, and resident representative were notified. A 5/19/25 Change of Condition Evaluation form indicated the resident was sent to the emergency room for evaluation and treatment. The resident's representative was notified. A 5/19/25 discharge MDS assessment indicated the resident discharged with a return anticipated. The clinical record lacked information indicating the resident or the representative received a written copy of the transfer/discharge form or the bed hold policy. During an interview, on 7/25/25 at 11:18 a.m., LPN 4 indicated when a resident was sent out to the emergency room she would print out the following documents: the resident's transfer/discharge page which had diagnoses, contact information, and code status, a bed hold policy, and any current orders. She printed out two copies and provided one copy to the emergency medical technicians (EMTs) and the hospital got the other copy. A current facility policy, revised 8/24 and titled, Bed Holds and Returns, provided by the Corporate Nurse Consultant on 7/25/24 at 10:04 a.m., indicated the following: . 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about the policies at least twice: .b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours) .3. Multiple attempts to provide the resident representative with the notice 2 should be documented in cases where staff were unable to reach and notify the representative timely. A current facility policy, revised 8/24 and titled, Transfer or Discharge, Facility-Initiated, provided by the Corporate Nurse Consultant on 7/25/25 at 10:04 a.m., indicated the following: . 17. Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility.18. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge. 19. Notice of transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable. B1. Resident 20's clinical record was reviewed on 7/22/25 at 2:11 PM. Diagnoses included vascular dementia, schizoaffective disorder, and chronic obstructive pulmonary disease (COPD). A progress note dated 6/29/25 at 11:24 a.m. indicated the resident was vomiting a foul-smelling black liquid and was unable to express himself. The nurse practitioner (NP) and DON were notified, and the resident was sent to the emergency room (ER). A progress note dated 7/1/25 at 5:40 p.m. indicated the resident returned to the facility on 7/1/25 at 5:40 p.m. The record lacked documentation of ombudsman notification. A review of the facility's June 2025 Discharge and Transfer Form Ombudsman Fax Log, provided by Corporate Nurse Consultant on 7/23/25 at 1:00 p.m., lacked notification of Resident 20's transfer. B2. Resident 61's clinical record was reviewed on 7/22/25 at 2:36 p.m. Diagnoses included acute and chronic respiratory failure with hypoxia and malignant neoplasm of the right breast. A 6/23/25, progress note indicated the resident was non-responsive and transported to the local hospital. A 6/24/25, progress note indicated the resident was hospitalized for a change in level of consciousness. A 7/14/25, progress note indicated the resident remained hospitalized . The clinical record lacked documentation of Ombudsman notification. A review of the facility's June 2025 Discharge and Transfer Form Ombudsman Fax Log, provided by Corporate Nurse Consultant on 7/23/25 at 1:00 p.m., lacked notification of Resident 61's transfer. During an interview with the Corporate Nurse Consultant on 7/23/25 at 1:32 p.m., he indicated Resident 20 was not on the ombudsman notification list for 6/2025. The ombudsman should have been notified of the transfer. During an interview on 7/25/25 at 10:58 a.m., the Social Service Director (SSD) indicated she typically submitted the notification of transfers and discharges to the State Ombudsman. The log for June 2025 included all of the residents' names of the transfer/discharge notifications submitted to the Ombudsman for June 2025. She was not at the facility to submit the June transfer and discharges. In her absence, the Corporate [NAME] President of Life Enrichment submitted the State Ombudsman Notifications for June 2025. During an interview on 7/25/25 at 11:00 a.m., the Corporate [NAME] President of Life Enrichment indicated the June 2025 transfer/discharge notifications sent to the State Ombudsman did not include all residents who were transferred or discharged in the month of June 2025. The report ran in the health record had been filtered incorrectly, resulting in missed transfers and discharges, including Resident 20. A facility policy, revised 8/24, titled, Transfer or Discharge, Facility-Initiated, provided by the Corporate Nurse Consultant on 7/25/25 at 10:04 a.m., indicated the following: . 20. Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer.25. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. 26. Notice to the Office of the State LTC Ombudsman will occur at the same time the notice of discharge is provided to the resident and resident representative. 3.1-12(a)(6)(A) 3.1-12(a)(6)(A)(i)

Based on interview and record review, the facility failed to ensure residents were afforded the opportunity to go outside per their preference, weather permitting, for 4 of 4 residents reviewed for resident rights. This deficient practice had the potential to impact 17 of 59 resident who were unable to go outside with out supervision. Findings include: 1. Resident B's clinical record was reviewed on 5/19/25 at 10:07 a.m. Diagnoses included chronic respiratory failure with hypoxia, chronic pulmonary disease, congestive heart failure, morbid obesity, overactive bladder, anemia, and depression. The most current admission MDS (Minimum Data Set) assessment, dated 3/19/25, indicated the resident was cognitively intact. The resident identified going outside to get fresh air when the weather was good as being very important to them. During an interview on 5/19/25 at 10:32 a.m., Resident B indicated she was unable to go outside without someone taking her. She liked going outside if the weather is nice and would go outside more if it were offered to her. 2. Resident C's clinical record was reviewed on 5/19/25 at 2:44 p.m. Diagnoses included dementia, anxiety, hypertension, history of falling, and metabolic encephalopathy. The most current admission MDS assessment, dated 9/13/24, indicated the resident was moderately cognitively impaired. The resident identified going outside to get fresh air when the weather was good as being very important to them. During the survey, the resident was admitted to the hospital and unable to be interviewed. 3. Resident D's clinical record was reviewed on 5/20/25 at 9:50 a.m. Diagnoses included chronic obstructive pulmonary disease, hypertension, depressive disorder with severe psychotic symptoms, schizoaffective disorder, and anxiety. The most current admission MDS, dated [DATE], indicated the resident was cognitively intact. The resident identified going outside to get fresh air when the weather was good as being very important to them. During an interview on 5/20/25 at 11:00 a.m., Resident D indicated she could go out to smoke with the other residents, but could not go outside without supervision. The resident indicated they would like to go sit outside in the front, but couldn't go by themselves. 4. Resident E's clinical record was reviewed on 5/20/25 at 10:00 a.m. Diagnoses included non-traumatic brain dysfunction, dementia, and hypertension. The most current admission MDS, dated [DATE], indicated the resident was cognitively intact. The resident identified going outside to get fresh air when the weather was good as being very important to them. During an interview on 5/20/25 at 8:45 a.m., LPN 2 indicated the residents who were allowed to sign themselves out could if they wanted to sit outside in front of the facility. The residents who could not sign themselves out could only go out if someone was available to watch them. On the weekends, there was no receptionist, so residents may not be able to go outside. During an interview on 5/19/25 at 8:42 p.m., LPN 3 indicated if there is no staff available to watch the residents, they couldn't go outside. During an interview on 5/20/25 at 10:34 a.m., RN 1 indicated the residents who smoke could go out for smoke breaks. There was also a group of residents who could sign themselves out and sit in front of the facility from 8:00 a.m. to 8:00 p.m. While the residents sat out front, the receptionist could watch them. On the weekends, the activity staff would sometimes take residents outside. During an interview on 5/20/25 at 10:44 a.m., Resident E indicated she went outside to sit if there was someone to watch her. She would tell staff she wanted to go outside, and if they were available, she would go. The resident indicated she would like to go outside more if it was nice outside, but staff were not available. During an interview on 5/20/25 at 11:34 a.m., the Activity Director indicated residents who smoked went out three times a day. The last smoke break was at 6:30 p.m. From Monday through Friday, the receptionist was stationed near the front lobby and could watch the residents who were cognitively intact enough to be outside without staff present. On the weekend, the cognitively intact residents signed themselves out to go out and sit on the patio (front of facility). There was a list of residents at the front of the facility. For all other residents, if there was a staff member who could sit with them outside, they tried to accommodate that to the best of the facility's ability. Not all residents could go as they pleased for safety reasons. A facility list of residents/instruction sheet who were allowed to sign themselves out to sit in front of the facility, dated 5/7/25, was provided on 5/20/25 at 10:58 a.m. by the DON. The sheet indicated the following: Residents must sign out to sit on the front porch when staff are not present! Residents must stay on the front porch only and no SMOKING ALLOWED! 8 P.M. ALL RESIDENTS MUST COME BACK IN THE BUILDING PER MANAGEMENT! There were 42 residents listed on the document. The list also contained a list of residents who were at risk for elopement. There were 6 residents listed under the heading * Attention staff these residents can not be outside unattended* The list also contained a list of five residents with guardians. This citation relates to complaint IN00456647. 3.1-3(a)(1)

Based on record review and interview, the facility failed to ensure medications were received from pharmacy in accordance with policy to ensure the safe handling of narcotics. Findings include: Review of a facility reportable, dated 11/25/24, indicated on 11/24/24, LPN 1 received medications from the pharmacy and did not secure a pill card of tramadol (opiod analgesic) immediately or properly. This deficient practice resulted in the 30 pill card becoming missing. Review of a written statement by LPN 1, provided by the facility, indicated on 11/24/24 at approximately 8:30 p.m., medications from the pharmacy were delivered to the facility. LPN 1 placed the 30 pill card of Tramadol (opiod analgesic) in the nurses' station, unsupervised. After checking the number of medications against the medications on the list, LPN 1 became distracted and placed the card of tramadol on the back of the desk in the nurses' station. As he continued with task throughout the shift, LPN 1 failed to realize the Tramadol had not been properly secured in the locked narcotic drawer of the medication cart. LPN 1 did not realize the medication were not present until the morning medication administration pass. LPN 1 was not available for interview during the survey. During an interview on 12/3/3/24 at 7:46 a.m., LPN 2 indicated medications from the pharmacy were checked and the nurse signed off receipt. If there were narcotics for another medication cart, the medications should be locked up in a cart until they could be delivered to the proper cart. Medications should never be left unsupervised. During an interview on 12/3/24 at 9:30 a.m., the DON indicated LPN 1 had received a medication delivery from the pharmacy. LPN 1 reported he had gotten distracted before he could put away the medications and left a card of tramadol at the nurses station. The card contained 30 pills. When LPN 1 returned to the nurses station, the medications were gone. The DON indicated medications should never be left at the nurses station. If something were to happen and he was unable to put all of the medications away, he should have locked them in the bottom of the medication cart. A current undated policy titled Controlled Medication-Ordering & Receipt was provided by the DON on 12/3/24 at 9:30 a.m. The policy indicated the following: 6. Medications listed in Schedule II, are stored under double lock in a locked cabinet or safe designed for that purpose, separated from all other medications. Alternatively, in a unit dose system, Scheduled III, IV, and V medications may be kept with other medications in the cart. In some States all controls must be secured in the lock box located in the medication cart if so, the State regulation will supersede. 7. The medication nurse on duty maintains possession of a key to controlled medications. The Director of Nursing keeps back-up keys to all medication storage areas, including those for controlled medications. This citation relates to Complaint IN00447984. 3.1-25(n)

A. Based on observation and interview, the facility failed to ensure insulin pens were labeled with appropriate resident identifier information on 1 of 3 carts reviewed for medication storage. (Front treatment cart) B. Based on observation and interview, the facility failed to ensure that expired vaccinations were disposed of timely for 1 of 1 medication rooms reviewed for medication storage. (Front medication room) Findings include: A. During a medication storage observation of the front treatment cart, accompanied by RN 6, on [DATE] at 9:31 a.m., the following were observed without resident identifiers or directions: One Humalog Kwikpen (insulin), dated [DATE], containing 130 units. One Humalog Kwikpen, dated [DATE], containing 220 units. One Humalog Kwikpen, dated [DATE], containing 150 units. One undated Humalog Kwikpen, containing 120 units. During an interview, at the time of the observation, RN 6 indicated she was unsure how long the unlabeled pens had been in the treatment cart, and the pens should have resident identifier information labels. There were 6 different residents who received insulin from the front treatment cart. B. During a medication storage observation of the front medication room, accompanied by RN 6, on [DATE] at 9:37 a.m., two boxes of Influenza Vaccine, containing 10 pre-filled single use dose syringes, with expiration dates of [DATE] and [DATE], were stored in the refrigerator. During an interview, at the time of the observation, RN 6 indicated these vaccines were expired, should not be given to residents, and should be disposed of promptly. A current facility policy, dated 2020, titled Medication Labels, provided by the Regional Nurse Consultant on [DATE] at 3:36 p.m., indicated the following: .1. Each prescription medication label includes: Resident's name, specific direction for use, including route of administration .strength of medication, physician's name, date medication is dispensed, quantity, expiration date, name, address, and telephone number of PharmcareUSA, prescription number . A current facility policy, dated 2020, titled Medication Storage in the Facility, provided by the regional Nurse Consultant on [DATE] at 2:54 p.m., indicated the following: .13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock . 3XXX,d+[DATE](k) 3XXX,d+[DATE](o)

Based on observation, interview, and record review, the facility failed to implement corrective and preventive actions to ensure systemic issues related to resident funds, medication labeling, and medication expiration were identified and quality assessment and performance improvement (QAPI) plans were implemented to prevent deficiencies from re-occurring. Findings include: On 7/25/24 at 3:13 p.m., the Administrator provided a QAPI action plan, dated 5/17/24. The root cause analysis indicated medication carts and rooms were not routinely inspected to ensure removal of expired medications. The concern included medication carts and rooms with expired medications. Action items of the plan included: the front medication room would be inspected with expired medications removed and destroyed. The actual completion date was 5/16/24. The back unit medication room was to be inspected with expired medications destroyed and lacked a completion date. An additional action plan indicated the medication rooms would be inspected weekly for four weeks from 5/23/24 through 6/20/24 and then weekly for two months from 6/27/24 through 8/22/24. During an interview on 7/26/24 at 4:28 p.m., the Administrator indicated the QAPI team met monthly and had last met on 6/28/24. The QAPI meeting agenda/ minute notes from that meeting addressed compliance issues noted on the last ISDH annual survey from 7/14/23. The included action plan development indicated the DON would perform the medication room and medication cart audits. At the same time, the Chief Operating Officer indicated he was unable to provide any audits related to acceptable accounting principles to manage resident funds. Survey Plan of Correction (POC) Audit tools for May, June, and July 2024 were provided by the Chief Operating Officer on 7/26/24 at 5:20 p.m. No identified concerns were indicated on the audit sheets. Comments on all three audits included: Any adjustments will be made as needed to ensure on-going compliance. Review of an undated current facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, provided by the Administrator on 7/23/24 at 9:18 a.m., indicated the following: .The objectives of the QAPI Plan are to: . 3. Provide structure and processes to correct identified quality and/ or safety deficiencies; 4. Establish and implement plans to correct deficiencies .7 . as a basis for demonstrating that there is an effective ongoing program Cross reference F568. Cross reference F761. 3.1-52(b)(2)

Based on observation, interview, and record review, the facility failed to ensure protective Peripherally Inserted Central Catheter (PICC) dressings were intact and changed as ordered for 1 of 6 residents reviewed for infection control. (Resident 151) Finding includes: During an observation on 7/22/24 at 2:51 p.m., to the left of the door, Resident 151's room indicated Enhanced Barrier Precautions. The resident was accompanied back to her room from the therapy room by an unknown staff member with an intravenous (IV) pole on her right side. Her single lumen PICC on her right upper arm was connected to the IV tubing and the PICC dressing was visible and loose from the skin around the top half of the dressing. During an interview on 7/22/24 at 3:58 p.m., Resident 151 indicated her PICC dressing was loose and had not been changed since before admission to the facility. The PICC dressing to her right upper arm was dated 7/16/24. The facility staff last administered her antibiotic through the PICC line on 7/22/24 at 2:30 p.m. and had not offered to change the PICC dressing. Resident 151's clinical record was reviewed on 7/23/24 at 4:31 p.m. The resident admitted to the facility on [DATE]. Diagnoses included cellulitis of the left upper limb and sepsis due to streptococcus group A (bacteria type). A current physician order, dated 7/18/24, included cefazolin sodium solution (antibiotic)- administer 2 grams intravenously every eight hours for bacteremia (infection). A current physician order, dated 7/17/24, included a PICC line IV dressing change every seven days and as needed. Review of the Treatment Administration Record (TAR) included IV antibiotic administration every eight hours from 7/22/24 through 7/24/24. The clinical record lacked evidence of PICC line dressing changes during the above mentioned times while the dressing was non-occlusive. An admission Minimum Data Set (MDS) assessment, dated 7/23/24, indicated the resident was cognitively intact. The resident received specialized services including IV medication and IV access. A current care plan, dated 7/18/24, indicated the resident had sepsis due to left upper arm cellulitis with a PICC line in the left upper arm. Interventions included the following: administer medications per orders, IV assessments as indicated, and treatments as ordered. A nurse's note, dated 7/25/24, indicated the resident's PICC was in the right upper arm. During an observation on 7/24/24 at 9:56 a.m., Resident 151 exited her room, walked down the 300 unit hallway into the main lobby, and continued to the activity room for an activity. The PICC line dressing to her right upper arm was visible and loose, with the top of the dressing hanging down midway. The dressing was dated 7/16/24. During an observation on 7/24/24 at 11:00 a.m., Resident 151 stood in the main lobby area. The PICC line dressing remained to her right upper arm, dated 7/16/24. During an IV administration observation on 7/24/24 at 2:25 p.m., RN 6 indicated she had just changed the resident's right upper arm PICC dressing because it was loose and hanging down the resident's arm. The resident received IV antibiotics several times a day and last received it on 7/24/24 at approximately 6:00 a.m. The PICC line dressing was ordered to be changed weekly and as needed when the dressing was loose. During an interview on 7/24/24 at 4:44 p.m., the DON indicated PICC line dressings should be changed every seven days or immediately when the dressing was not occlusive. PICC line dressings should be assessed to ensure they were occlusive each time the staff administered the resident's IV antibiotic. Non-occlusive PICC line dressings were an infection prevention and control concern. A current facility policy, revised March 2022, titled Central Venous Catheter Care and Dressing Changes, provided by the DON on 7/24/24 at 5:13 p.m., indicated the following: Purpose .The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings . General Guidelines 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised [e.g., damp, loosened or visibly soiled] 3.1-47(a)(2)

Based on interview and record review, the facility failed to manage Resident Funds in accordance with acceptable accounting principles for 1 of 4 residents reviewed for management of Resident Funds. (Resident 29) Findings include: A review of the facility's Resident Funds was completed on 7/24/24 at 3:55 p.m. The Business Office Manager provided a Resident Funds Trial Balance sheet. The facility managed personal resident funds for 37 residents. Resident 29 was listed with two separate accounts; account B had a current negative balance of $2,911.47 and account C had a current negative balance of $15.16. Resident 29's account B Resident Funds record indicated the following: On 11/1/23, the resident's account balance was $0.53. On 11/13/23, a personal check was credited for the amount of $3,000.00. On 11/13/23, a care cost auto withdrawal for the amount of $2,948.00. On 11/17/23, a return deposit item for the amount of $3,000.00. On 11/17/23, a return deposit item fee for the amount of $16.00. On 11/30/23, a personal check was credited for the amount of $ 3,300.00 On 11/20/23, a care cost auto withdrawal for the amount of $3,248.00. Resident 29's resident fund account B balance on 12/1/23 was in the negative of $2,911.47. During an interview, on 7/24/24 at 3:35 p.m., the Corporate Business Office Consultant indicated Resident 29 had a returned check in November 2023, and this resulted in the account having a negative balance. The check was covered a few weeks later. Care cost withdrawals were automated and deducted after deposits were made and a second care cost charge was made in error for November 2023. Additionally, the funds had been deposited into an inappropriate account for medical expenses. The facility Business Office Manager corrected this in December 2023, resulting in two accounts for Resident 29. During an interview, on 7/25/24 at 1:07 p.m., the Business Office Manager and Corporate Business Office Consultant indicated they had reached out by electronic mail (e-mail) to the third party billing company in December 2023 about the inappropriate charges, but had not received any response. The Business Office Manager did not send follow-up e-mails related to the inappropriate charges. The Corporate Business Office Consultant indicated she had spoken with a representative of the third party billing by phone on 7/24/24, and the charge error would be refunded no later than 7/25/24. A current facility policy, dated 10/23, titled, Resident Funds Management System, provided by the Regional Nurse Consultant, on 7/25/24 at 2:54 p.m., indicated the following: .Established to manage resident funds by following acceptable accounting principles Audits on resident accounts will occur monthly. LTC (consulting partners) and BOM will both audit accounts to ensure liabilities are paid monthly 3.1-6(e)

Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency in the required timeframe, and failed to complete a thorough investigation of the allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident D) Findings include: The clinical record for Resident D was reviewed on 3/14/24 at 3:21 p.m. Diagnoses included history of a stroke, left side hemiplegia, bipolar disorder, anxiety disorder and depression. An admission Minimum Data Set (MDS) assessment, dated 2/9/24, indicated the resident had moderate cognitive impairment. The resident had no hallucinations or delusions, rejection of care, and had no physical or verbal behaviors. Review of a facility self reportable, dated 3/6/24, indicated on 3/1/24, Resident D alleged a staff member had physical contact with his face. The resident had called the police. The nurse who assessed the resident noted no marks on their face and no evidence of physical contact of any kind. A pain assessment was performed. A follow up report was submitted on 3/12/24 and indicated that due to the resident's inability to provide consistent statements the allegation was determined to be unsubstantiated. The clinical record lacked a progress note regarding the incident on 3/1/24 or a pain assessment. Review of an undated witness statement completed by LPN 3 and included in the facility's investigation documents, indicated the Administrator was called to notify him of the resident's statement that the resident had been struck on his face by a staff member. During an interview on 3/15/24 at 10:07 a.m., the Administrator indicated staff had contacted him the evening of 3/1/24, but had said nothing about the resident's allegation of being struck. He was unaware the outcome of the facility's investigation, which was started on 3/6/24. During an interview on 3/15/24 at 12:50 p.m., QMA 2 indicated she heard LPN 3 talking with the Administrator regarding the resident's allegation that he had been struck in the face. During an interview on 3/14/24 at 3:21 p.m., Resident D indicated, following a smoke break, he had the cigarette tackle box on his lap and was returning it to the nurse's station after being asked to by a staff member. Another staff member accused him of taking it. He became upset and began to cuss. Another staff member came up behind him and hit him on the right side of his face from behind his wheelchair. He had waited for the Administrator to come and talk with him, but on 3/5/24, he went to the Social Services Director and the Administrator to ask about the incident. The Administrator indicated he had not seen anything on the surveillance cameras. During an interview on 3/15/24 at 8:45 a.m., the Administrator indicated he was unsure how to access the information on the surveillance cameras and did not have the password to access stored footage. During an interview on 3/15/24 at 9:36 a.m., the DON indicated the allegation of abuse report had not been completed until 3/6/24 because she had not been aware of any incident taking place. She had taken a verbal confirmation from the nursing staff that all assessments had been completed the evening of the incident on 3/1/24, but had failed to check the electronic health record for the information. She had not reviewed the staff written statements prior to submitting the report to the State Agency. During an interview on 3/15/24 at 1:18 p.m., the Corporate Nurse Consultant indicated the facility was unable to access the stored footage on the surveillance cameras at this time. A current facility policy, dated 9/2022, titled, Resident Abuse, Neglect and Exploitation Procedural Guidelines, provided by the DON on 3/15/24 at 9:36 a.m., indicated the following: .Purpose: Envive Healthcare (EHC) has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. Procedures: .4 f. Investigation i. The Executive Director is accountable for investigation and reporting.iv. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations v. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. vi. Providing complete & thorough documentation of the investigation This citation relates to Complaint IN00430011. 3.1-28(d)

Based on record review and interview, the facility failed to prevent staff to resident abuse (CNA 1 and Resident C) for 1 of 3 residents reviewed for abuse. Findings include: During an interview on 9/18/2023 at 12:36 p.m., Resident C indicated CNA 1 transported her from her room to the shower room while she was only wearing a bra. CNA 1 did not provide any covering of her exposed body parts. The resident told the CNA to stop, but the CNA did not stop, and told the resident they were almost to the shower room. The clinical record for Resident C was reviewed on 9/19/2023 at 9:05 a.m Diagnoses included chronic pain syndrome, cardiomyopathy, type 2 diabetes with diabetic neuropathy, Bell's Palsy, rheumatoid arthritis, depressive disorder and hypertensive heart disease. Review of the most current quarterly Minimum Data Set (MDS) assessment, dated 7/11/2023, indicated the resident was cognitively intact. During an interview on 9/19/2023 at 10:57 a.m., the Activity Director indicated she was coming out of the laundry room when she saw and heard Resident C yelling at CNA 1 because she could feel herself being naked as he was pushing her in a shower chair to the shower room. The only thing the resident was wearing was a bra. The Activity Director said the incident was inappropriate. She followed them to the shower room, and CNA 1 left. She called the Director of Nursing (DON) and provided the resident with a shower. The Activity Director indicated the resident was visibly upset and crying. During an interview on 9/19/2023 at 11:33 a.m., the DON indicated she was in a meeting and received a call from the Activity Director, requesting her to come to the 400 Hall shower room. When she arrived to the shower room, Resident C told her CNA 1 had pushed her down the hallway with nothing on. The resident was wearing a sports bra but nothing else. The Activity Director told her she had heard the resident yelling for CNA 1 to stop. The resident was upset. The DON went to the Administrator and reported the incident. CNA 1 came with her and told the Administrator he had transported the resident to the shower room without cover and the resident had told him to stop. CNA 1 indicated he had a lapse in judgement. Review of a current policy, dated 9/2022, titled Resident Abuse, Neglect and Exploitation Procedural Guidelines indicated the following: Purpose .Envive Healthcare (EHC) has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged=ed resident abuse and neglect. This Federal tag relates to Complaint IN00417071. 3.1-27(a)(1)

A. Based on record review and interview, the facility failed to implement a water-borne pathogen prevention plan. This deficient practice had the potential to impact 49 of the 49 facility residents. B. Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies regarding implementation of transmission-based precautions for a resident with an antibiotic-resistant bacterial infection for 1 of 6 residents reviewed for infection control. (Resident 12) Findings include: A. During an observation on 7/10/23 at 10:37 a.m., no resident rooms on the 600 Unit had Transmission Based Precaution (TBP) signs posted. Readily available Personal Protective Equipment (PPE) was not observed in the 600 Unit hallway. During an observation on 7/11/23 at 12:18 p.m., no resident rooms on the 600 Unit had TBP signs up, and there was no readily available PPE. Resident 12's clinical record was reviewed on 7/11/23 at 4:43 p.m. Diagnoses included history of urinary tract infections and benign prostatic hyperplasia with lower urinary tract symptoms. A physician order, dated 5/9/23, indicated contact isolation due to ESBL (extended spectrum beta-lactamase) in the urine. A urine culture result, dated 2/10/23, indicated the resident was positive for ESBL. A quarterly Minimum Data Set, dated dated [DATE], indicated the resident had mild cognitive impairment. He required extensive assistance of two staff members for bed mobility, transfers, toileting, personal hygiene, and bathing. The resident was always incontinent of urine. A current care plan, dated 5/13/23, indicated the resident required contact isolation due to a a Multi-Drug Resistant Organism (ESBL) in the urine. Interventions included the following: instruct family/visitors/caregivers to wear a disposable gown and gloves during physical contact with the resident. Discard PPE in appropriate receptacle and wash hands before leaving the room and utilize isolation precautions as ordered. During an observation on 7/12/23 at 12:34 p.m., no resident rooms on the 600 Unit had TBP signs up, and there was no readily available PPE During an observation on 7/14/23 at 3:10 p.m., no resident rooms on the 600 Unit had TBP signs up, and there was no readily available PPE. During an interview on 7/14/23 at 3:12 p.m., Qualified Medication Aide (QMA) 4 indicated she was familiar with the resident's on the 600 unit. None of the residents on the the 600 unit were in any transmission based precautions, such as contact isolation or enhanced barrier precautions. Gowns were not required to provide care for any residents on the 600 Unit. During an interview on 7/14/23 at 3:17 p.m., Certified Nurse's Aide (CNA) 5 indicated she was familiar with the residents on the 600 Unit. None of the residents on the 600 unit were on specific precautions such as contact precautions or enhanced barrier precautions. When residents required specific precautions, a sign was placed on the resident's door to tell the required precautions, as well as a canister for PPE outside the resident's room in the hallway. Otherwise, the PPE was locked in a closet up front. A key would have to be obtained to access the PPE if it wasn't outside the resident's room. All urinals on the 600 unit could be emptied without wearing a gown. During an interview on 7/14/23 at 3:33 p.m., the DON indicated Resident 12 was in contact isolation precautions for ESBL in the urine. The facility should have had the following things in place: a contact isolation sign on his room door, a PPE canister outside his room with readily available PPE, and staff should have worn a gown and gloves to provide his care. Contact precautions should have been implemented by the DON or any other nurse if she was not in the building. Failure to place a resident in contact isolation as indicated was a risk for spreading infection to other residents. A current facility policy, dated 8/2022, titled Personal Protective Equipment, and provided by the Assistant [NAME] President of Clinical Operations on 7/14/23 at 4:27 p.m., indicated the following: .Policy Interpretation and Implementation 1. Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment [PPE] . 3. Not all tasks involve the same risk of exposure, or the same risk of exposure, or the same kind or extent of protection. The type of PPE required for a task is based on: a. The type of transmission-based precaution . 4.PPE required for transmission-based precautions is maintained outside and inside the resident's room . 7. Visitors and residents who are asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment 48146 B. During an interview on 7/14/23 at 11:13 a.m., the Maintenance Supervisor indicated he did a monthly review of the drain line and ice machines but did not document this information on any forms. He tried to remember when he last completed each task. He did not know when the last water sample was sent out for (legionella and/or water born pathogen) testing, or if it was indicated. The new administration had started the process to utilize a computerized environmental auditing tool for streamlining and documentation of maintenance, testing, and cleaning. During an interview on 7/14/23 at 12:06 a.m., the DON and AVP (Assistant [NAME] President of Corporate Clinical Services) indicated no resident had signs or symptoms of legionella infection. The AVP of clinical services indicated the city of [NAME] did test the water during the last annual survey. In a follow-up interview on 7/14/23 at 12:27 p.m., the Maintenance Supervisor indicated he did not have a written plan for water management or a schedule for identifying and monitoring possible opportunistic pathogens in the facility water system. The 100 hallway was under construction and those water lines could possibly hold water and accumulating pathogens. He had not been in the area of the hallway for weeks. A current facility policy, dated 5/2023, titled Water Borne Pathogen Prevention Policy, and provided by the Administrator on 7/14/23 at 3:10 p.m., indicated the following: .Policy: Facilities will utilize preventative measures to ensure inspection, cleaning and disinfection is completed for specific equipment to reduce the risk of legionella bacteria and other water-borne pathogens. Procedure: 1. The facility will conduct a risk assessment to identify where legionella and other opportunistic waterborne pathogens could grow and spread in facility water system .6. Cleaning and testing protocols will be followed and reported during the QAPI meeting, and what corrective actions were taken if needed As of the time of exit on 7/14/23 at 5:30 p.m., a water-borne pathogen prevention plan had not yet been provided by the facility. 3.1-18(a) 3.1-18(b)(2)

Based on interview, record review, and observation, the facility failed to resolve Resident Council concerns related to laundry services and housekeeping services. Findings include: 1. During a Resident Council interview, on 7/12/23 at 2:00 p.m., residents in attendance indicated they had voiced multiple concerns related to laundry services and missing clothing items as follows: Resident 40 indicated she had multiple shirts missing, which she labeled herself. Some had been returned damaged. Her items had not been replaced. Resident 9 indicated she had missing socks, even after she labeled them herself. Resident 8 indicated he had missing shirts. Review of the 3/29/23, 4/27/23, and 5/22/23 meeting minutes indicated concerns with laundry not being delivered or returned, and missing clothing items. An official grievance was completed for housekeeping and laundry for the 3/29/23 concerns. During an interview, on 7/13/23 at 3:16 p.m., Laundry Aide 16 indicated there was not a formal document for missing items and the housekeeping supervisor would let staff know if residents were looking for missing items. Residents would tell her if they were missing items as she delivered clean laundry. There was no process for identifying clothing, other than by word of mouth. At the time of the interview, there were two racks and two carts of lost and found items observed. 2. During the Resident Council interview, on 7/12/23 at 2:00 p.m., members indicated the following: a. 6 of 6 residents indicated they had voiced concerns related to facility and room cleanliness. b. 6 of 6 residents indicated the shower rooms on the 500 and 600 halls were not clean, and smelled badly. c. 6 of 6 residents indicated the dining rooms were not cleaned. d. 3 of 6 residents indicated they had cleaned their own bathrooms, because staff had not done so. e. 2 of 6 residents indicated the hallway carpet was nasty, dirty, and smells. Resident 40 indicated she utilized the shower room on the 600 hall. The shower room was dirty, smelled bad, and had a slow drain. She had cleaned up the shower room before she used it for her showers. Review of the 3/29/23, 5/22/23, and 6/29/23 meeting minutes indicated the resident council members had voiced concerns with resident rooms not being cleaned. Review of the Grievance Log, provided by the Administrator on 7/14/23 at 3:10 p.m., indicated grievances were filed for room cleanliness on the following dates: 2/21/23, twice on 2/22/23, 3/16/23, 6/22/23, and 6/29/23. The log indicated a resolution was reported to the person who had voiced the concern and a resolution had been agreed upon by the reporter and the facility. During an interview on 7/14/23 at 9:47 a.m., the Administrator indicated the current turn over of the management positions in the facility made interviewing previous staff members involved with grievances unattainable. A current facility policy, dated 8/23/22, titled Resident Concerns and Grievances, provided by the Administrator on 7/14/23 at 3:10 p.m., indicated the following: .Policy . Each resident has the right to: file grievance orally or in writing; file a grievance anonymously, and to obtain a written decisions regarding his or her grievance . Procedure .Definition: a grievance is any written or verbal concern by a resident, relative, or any other representative relating to resident care or the quality of services provided The Executive Director/Grievance Official will ensure appropriate corrective action is taken in accordance with State law if the alleged violation of the resident's rights confirmed by the facility . P. Resident Council .We will make all reasonable efforts to address any issues voiced by the residents at these meetings Cross reference F584 3.1-3(l)

Based on observation, interview, and record review, the facility failed to clarify an insulin order, administer needed insulin, and monitoring blood sugar levels, for a resident with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in the resident experiencing 19 days without insulin administration or blood sugar monitoring and a blood sugar reading of greater than 500 (five hundred) and being admitted to the hospital. The facility also failed to administer insulin as ordered; failed to maintain a wound vac as ordered. This deficient practice resulted in redness and swelling at the wound site and increased pain for the resident; The facility also failed to obtain weights as ordered for a resident with [CONDITION(S)] for 4 of 15 residents reviewed for provision of nursing services. (Residents E, B, G and F) Findings include: 1. During an 8/29/22, 3:41 p.m., interview Resident E's spouse indicated the resident was an insulin dependent diabetic and received [CONDITION(S)]. She had received insulin daily at home. While at home, she received [MEDICATION(S)] at a set amount and Humolog per sliding scale daily. After his wife had been at the facility approximately 19 days he realized he had never seen her have any blood sugar checks or receive any insulin. He continued that although his wife has confusion, she was at times reliable. When he asked his wife if they checked her blood sugar, she indicated no. He then on 8/27/22 (a Saturday) went to the nurse at the station and told them he was concerned his wife had not had accu-checks since admission. He further indicated the nurse at the station told him they would let the doctor know, however nothing would most likely be done until Monday because it was a weekend. This troubled him and he considered what he should do. The next morning 8/28/22, he brought his wife her blood sugar monitoring device from home and checked her blood sugar. His wife tested at a blood sugar level of 560 on the home device. He promptly got a nurse who check the resident's blood sugar and obtained a result of 500 and some. The facility notified the doctor and the resident was given 10 units of insulin immediately. The resident was put on insulin daily that day 8/28/22, 19 days after her admission. He indicated the facility only became aware of the problem with no insulin being given and no blood sugar test after he brought the error to the facility's attention. Resident E's clinical record was reviewed on 8/29/22 at 1:39 p.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record indicated the resident was admitted to the facility on [DATE]. An 8/28/2022 ,11:15 a.m., Nurses Note indicated Resident's husband to front Nurses station visibly upset states that he checked his wife's blood sugar with her home glucometer because he thought it might be high due to her behavior. Per the Resident's husband her blood sugar was 560. Writer to Resident's room and observed Resident sitting up in wheelchair with eyes open, noted to be very pleasant and cooperative with staff. Resident able to tell Writer her name, date of birth and Husband's name, unable to tell Writer month or year or where she was which is baseline for Resident. Speech is clear and easily understood. No signs or symptoms of [CONDITION(S)] noted. Writer used facility glucometer to check blood sugar at this time and obtained an accu-check reading of 506. Vital signs 133/65, 70, 18, 98.0, 18. No signs or symptoms of distress noted. Writer returned to Nurses station and contacted the On Call Practitioner and received new orders for [MEDICATION(S)] 100 unit/ml solution 10 units to be administered subcutaneously x1 dose NOW. Staff to perform accu-check 1 hour after administration of [MEDICATION(S)] 10 unit x1 dose NOW. If blood sugar continues to be over 400 contact Practitioner on call for further orders. New order received for accu-checks before meals and at bedtime with [MEDICATION(S)] sliding scale as directed. Writer to Resident's room immediately with [MEDICATION(S)] 10 units and administered subcutaneously to the right upper extremity. Resident tolerated well. Resident's husband in room and made aware of all new orders. Resident's husband expressed appreciation for the quick actions of the facility. Call light is within easy reach. Will continue to monitor. An 8/28/2022, 12:15 p.m. Nurses Note indicated Writer to Resident's room to perform follow up accu-check. Resident is sitting in wheelchair with lunch tray in front of her eating. Writer advised Resident again of new order and requested permission to perform accu-check, which Resident allowed without incident. Blood sugar noted to be 392 at this time. Vital signs obtained 130/60, 66, 17, 97.9, 96% on room air. Resident is not noted to be exhibiting signs or symptoms of [CONDITION(S)] at this time. No signs or symptoms of distress noted. Call light is within easy reach. The resident had a current, 8/28/22, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Solution 100 UNIT/ML (Insulin [MEDICATION(S)]) Inject as per sliding scale: if 0 - 69 Notify Practitioner; 70 - 150 = 0 Units; 151 - 200 = 2 Units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401+ 401+ Notify Practitioner, subcutaneously before meals and at bedtime for [CONDITION(S)]. Resident E's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had the following blood sugar results recorded in her record after the 8/28/22 10:45 a.m. result of 506:| 8/28/22, 12:03 p.m.-392 8/28/22, 4:25 p.m.-258 8/28/02, 10:01 p.m.-400 8/29/22, 10:06 a.m.-275 The resident had a current 8/16/22, care plan problem/need regarding a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Approaches to this need included diabetes medication as ordered and monitor for [CONDITION(S)]. The resident had an 8/12/22 (this test was completed after 3 days without receiving insulin) Hemoglobin A1C (cumulative blood sugar test) laboratory test result of 6.5 High, range 4.8-5.9%. An 8/8/22 hospital discharge summary indicated the resident was to continue these medications which have not changed .Send copy of sliding scale commonly known as [MEDICATION(S)] insulin. Last time this was given was August 8, 2022, 12:21 p.m. The resident had an 8/4/22, hospital progress note which indicated the following: ,,,Active Problems: .Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, with long -term current use of insulin .Mild nonproligerative diabetic retinopathy of both eyes associated with type 2 diabetes mellitus [CONDITION(S)] [end stage renal disease] . Assessment /Plan: .5, Diabetes mellitus, insulin dependent. The patient will be placed on [MEDICATION(S)] weight-based sliding scale, and we would defer any long-acting insulin at present. blood sugar 154, 244 . Resident progress notes from her 8/8/22 admission to 8/30/22 included, but were not limited to the following: a. An 8/9/2022, 1:15 p.m., Incident Note indicated Nurse called to pt room by CNA with report pt [patient] laying on floor. When arrived, pt laying on R side next to bed. Pt A&O x 3, [alert and oriented times 3] stated she was getting out of bed to make breakfast and slid of the side to the floor . b. An 8/9/2022, 10:02 p.m., Skilled Charting Note General Assessment indicated, Resident lethargic has slept most of the shift. c. An 8/13/2022, 10:15 a.m., Skilled Charting Note General Assessment indicated, Resident is alert and oriented to person with confusion to time, place and situation noted. Speech is mumbling in nature, incoherent at times, tangential thought processes noted, does not answer questions appropriately if at all. Staff has replaced resident's oxygen via nasal cannula multiple times this shift, as Resident continues to choose to remove cannula d. An 8/27/2022, 1:19 a.m., Skilled Charting Note General Assessment indicated Delusions present. Resident noted climbing out of bed around on matt & floor staff & writer assisted resident back into bed several time throughout the night. resident noted digging bowel from her brief laying bowel onto floor into individual groupings naming them & having conversation with each group of bowel. staff attempted several times to clean bowel off resident & under nails the resident refused care. e. An 8/28/2022, 3:38 a.m., Behavior Note indicated, Resident alert with baseline confusion. no s/s of pain or distress at this time. resident crawled out of bed & witnessed crawling down the hall. writer & staff assisted resident into wheel chair took her to foyer area activity & snacks provider to resident. resident allowed staff at that time to provide nail care. resident is happy & without behaviors at this time. f. An 8/30/2022, 6:00 a.m., Nurses Note Incomplete Documentation [late entry] indicated Resident lethargic during patient care. Resident easily aroused when called by name. Assisted resident with daily ADLS and breakfast set up. Resident goes into a deeper sleep where there is snoring present. Writer verbally calls out to resident by name, resident responds without issue. Writer checks BS d/t resident being a diabetic. Bs [blood sugar]WNLs [within normal limits] (around 240) coverage was given. Resident sent to [CONDITION(S)] where she became unresponsive, Resident sent to [name] hospital for evaluation and was later admitted . During an observation on 8/25/22 at 9:06 a.m., Resident E was in her room seated in a wheelchair, eyes closed, chin to chest. The resident's husband continually poked her in the arm and asked in a loud voice for her to open her eyes and look at him. The resident would occassionally stir slightly, but did not open her eyes. During an 8/29/22, 4:00 p.m., interview, the DON indicated the facility did not administer insulin to Resident from 8/8/22 to 8/28/22 when the problem was identified by her spouse. The facility was looking into the issue to prevent future concerns. A professional resource titled [CONDITION(S)] in diabetes found at the Mayo Clinic web site https://ww.mayoclinic,org/disease-conditions/[CONDITION(S)]/symptoms-causes/syc- 631 indicated the following: Long-term Complications keeping blood sugar in a healthy range can help prevent many diabetes-related complications. Long-term complications of [CONDITION(S)] that isn't treated include: Cardiovascular disease Nerve damage ([CONDITION(S)]) Kidney damage (diabetic [CONDITION(S)]) or kidney failure Damage to blood vessels of the retina (diabetic retinopathy) that could lead to blindness' Feet problems caused by damaged nerves or poor blood flow that can lead to serious skin infection, ulcerations and, in some cases, amputation Bone and joint problems Teeth and gum infection .If blood sugar raises very high or if blood sugar levels are not treated, it can lead to two serious conditions. Diabetic ketoacidosis .when fat is broken down for energy in the body, it produces toxic acids called ketones If it isn't treated, diabetic ketoacidosis can lead to a diabetic coma that can be life threatening . Hyperosmolar hyperglycemic state .if you develop this condition, your body can't use either glucose or fat for energy can lead to life-threatening dehydration and coma. A current, 8/2022, facility policy titled, Nursing Admission/Return Admission Policy and Procedure, which was provided by the RN Consultant on 8/30/22 at 9:29 a.m., indicated the following: 2. The admission nurse must review the pre-admission assessment, history and physical, hospital discharge summary, fall history, urinary continence prior to admission, usual bowel pattern, date of last BM, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Physician orders: 1. Upon admission, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Transcribe the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current 8/2022, facility policy titled, Blood Glucose Monitoring, indicated the following: If the resident has not received specific blood glucose call parameters the physician will be notified of any blood glucose less that 70 or greater than 400. 2. The clinical record for Resident B was reviewed on 8/26/22 at 10:26 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A health care plan, dated 3/7/22, indicated the resident had diabetes mellitus and was a risk for complications. Interventions included, but were not limited to, diabetes medication as ordered by doctor. Review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. Insulin Detemir Solution (to treat diabetes) 100 units per ML (milliliter). Inject 10 units at bedtime for diabetes. The order was dated 5/21/22. The eMAR indicated no insulin required on 6/4/22, and lacked an entry of administration for 65/22. The clinical record lacked documentation regarding the missed insulin administration. b. [MEDICATION(S)] [MEDICATION(S)] Solution (to treat diabetes) 100 units per ML. Inject per sliding scale, three times daily with meals: 80-149 = 0 units, 150-190= 2 units, 191-230 = 4 units, 231-270 = 6 units, 271-310 = 8 units, and 311-350 = 10 units. The order was dated 4/12/22. The eMAR indicated on 6/10/22 at 12:00 p.m., the resident's blood sugar was 168. The record indicated no insulin required. A current facility policy, revised April 2019, titled, Administering Medications, provided by the Nurse Consultant on 8/26/22 at 2:57 p.m., included, but was not limited to, the following: Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders .22. The individual administering the medication initials the resident's MAR {Medication Administration Record} on the appropriate line after giving each medication and before administering the next ones. 3. During an interview on 8/22/22 at 10:23 a.m., Resident G indicated she had a surgical wound on her right upper thigh due to [CONDITION(S)] and had a wound vac (appliance to treat open wounds) applied to the area. She indicated two agency nurses that worked over the past weekend, 8/13/22 and 8/14/22, had neglected my wound and it's infected again. She reported that her wound vac had stopped working and the nurses had not done anything for her. The wound vac remained in place all weekend without working. During an interview on 8/25/22 at 2:20 p.m., RN 1 indicated Resident G's wound vac stopped working the weekend of 8/13/22 and 8/14/22. The agency nursing staff working the 500 hall failed to notify the physician or the Director of Nursing and had not removed the wound vac and place a wet-to-dry dressing. On 8/15/22, RN 1 arrived to work and was informed by the resident that the wound vac had stopped working over the weekend and was not taken care of by the nursing staff. RN 1 removed the wound vac. She indicated the wound was warm, red, and swollen. The resident had a temperature. She called the nurse practitioner and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound vac had difficulty remaining sealed due to the increased swelling. Prior to weekend the residents wound was managed and improving. Resident G's clinical record was reviewed on 8/28/22 at 1:44 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physicians order, dated 7/30/22, and discontinued 8/18/22, indicated to cleanse right thigh wound with [MEDICATION(S)], then pack with lightly moistened kerlix, secure with kerlix and apply mesh briefs or other snug fitting garment to secure dressing for comfort. Do not use tape. A skilled charting note, dated 8/12/22 included, but was not limited to, Wound vac in place to R {right} upper thigh/groin wound and functioning appropriately. The clinical record lacked an order physician notification regarding the wound vac during the weekend of 8/13/22 and 8/14/22. A skilled charting note, dated 8/16/22, indicated the resident's temperature was 100.6. A nurses note, dated 8/16/22 at 7:35 a.m., indicated the resident was tearful and reporting right lower extremity pain to touch. Her temperature was 100.6. Facility physician was contacted provided the following orders: a. STAT labs including complete blood count and comprehensive metabolic profile. b. [MEDICATION(S)] (antibiotic) 500 mg (milligram), every 8 hours for 7 days. A nurses note, dated 8/16/22 at 12:10 p.m., indicated the resident had no fever following Tylenol administration. The resident's wound vac had to be changed three times in the last 24 hours. During an interview on 8/25/22 at 3:00 p.m., the Director of Nursing indicated the agency nurses who worked the weekend of 8/13/22 and 8/14/22 should have reported the wound vac had not been functioning to the physician or herself, but she had not been contacted. During an interview on 8/26/22 at 9:40 a.m., the Wound Care Physician indicated she had not been notified of the wound vac malfunction on the weekend of 8/13/22-8/14/22 or the need for antibiotics due to increased swelling and redness, until her follow-up visit on 8/19/22 when she performed wound rounds at the facility. She updated wound orders at that time to include wet-to-dry dressing orders in case the wound vac failed. 4. The clinical record for Resident F was reviewed on 8/24/22 at 10:19 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident admitted to the facility on [DATE]. A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current health care plan, dated 5/9/22, indicated the resident had altered cardiovascular status related to hypertension. Interventions included, but were not limited to, monitor/document/report as needed any changes in lung sounds on auscultation, [CONDITION(S)], and changes in weight. The clinical record indicated the following weights: a. On 5/4/22 (on admission), the resident weighed 279 pounds. b. On 5/24/22, the resident weighed 291.9 pounds, a 12.9 pound gain (4.62%) in 20 days. c. On 7/5/22 315.5 pounds, a 23.6 pound gain (8.08%) in 42 days and a gain of 36.5 pounds (13.08%) in two months. d. On 8/2/22 316.7 pounds, a 37.7 pound gain (13.51%) in three months. The clinical record lacked physician notification of the weight gains. During an interview on 8/29/22 at 2:35 p.m., the Director of Nursing (DON) indicated resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility progress notes lacked notification of physician notification of weight gains. A current facility policy, revised 8/2022, titled, Resident Change of Condition, provided by the Nurse Consultant on 8/30/22 at 11:02 a.m., included, but was not limited to, the following: Policy It is the policy of this facility that all changes in the resident's condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place. This Federal tag relates to Complaints IN 147. 3.1-37(a) 3.1-37(b)

Based on interview and record review the facility failed to provide services to prevent the worsening of vascular wounds, failed to ensure orders were followed and failed to ensure transportation to the wound center was arranged for 1 of 3 resident reviewed for wound care. This deficient practice resulted in the resident remaining in compression wraps for 14 days and worsening of venous ulcers to the resident's bilateral lower extremities. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/2/2021 at 9:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most current quarterly Minimum Data Set (MDS) assessment, dated 10/4/2021, indicated the resident was cognitively intact with a BIMS (Brief Interview for Mental Status Score) 15 out of 15. The resident had two venous/arterial wounds and required extensive assistance of 1 person for bed mobility, walking, toilet use and personal hygiene. Review of the resident's care plans indicated the resident had a care plan for Non-pressure Related Skin Condition Vascular Wound, dated 10/23/2021. Interventions included, but were not limited to, wound center appointments as ordered. Review of the resident's care plans indicated the resident had a care plan for Peripheral Arterial Vascular Disease. Interventions included, but were not limited to, wound center appointments as ordered, and treatment as ordered. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No clarification was sought by the facility. Review of the wound center's Patient Itinerary, which was located in the resident's facility clinical record, indicated all of Resident B's pre-scheduled wound center appointments from 10/15/2021 through 11/26/2021. The resident was pre-scheduled for weekly appointments on Fridays. Review of a wound center visit note dated, 10/29/2021, indicated the following: [Name of facility] to get compression stockings 15-20mmHg to have when patient is healed in a few weeks. Pt [patient] Must keep weekly appointments for compression wrap changes . Review of the facility's appointment calendar on 12/2/2021 at 1:00 p.m., indicated the calendar lacked any documentation of the resident's wound center appointment on 11/5/2021. A nursing progress note, dated 11/18//2021 at 1:00 p.m., indicated an order was received from the wound center for wound care. The note indicated the facility was to do the dressing changes on Mondays and Wednesdays. A nursing progress note, dated 11/19/2021 at 1:15 p.m., indicated during a dressing change, the resident's right lower extremity was found with moderate amount of foul smelling brown/yellow drainage. The physician was made aware and recommended the resident be seen in the emergency room . The resident refused to go to the emergency room . A nursing progress note, dated 11/19/2021 at 1:45 p.m., indicated the resident was transferred to the wound clinic for a pre-scheduled appointment. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was only seen in the wound center on Fridays. No clarification for this order was sought by the facility until 12/2/2021. The order was as follows: Peri-wound care: [MEDICATION(S)] Violet 1% [antifungal] Apply to peri-wound just in wound center 1 x per day x 30 days. Topical: Extra thick antifungal cream to peri wounds 1 x per day x 30 days Primary Dressing: Moist gauze apply to open wound bed 1 x per day x 30 days Secondary Dressing: ABD pad 5 x 9 ABD pad to red area at top of leg, dorsal and posterior ankle 1 x per day x 30 days Secondary Dressing: Kerlix 4.5 x 4.1 (in/yd) Apply Kerlix as instructed Secondary Dressing: Combine pad Compression wrap: Coban Review of the Treatment Administration Record for November 2021 (TAR) indicated the resident had a peri-wound care treatment order for [MEDICATION(S)] Violet 1% (antifungal) once daily for 30 days, (just in wound center) was written under the order. The resident was only seen in the wound center once a week. The treatment was documented as started in the facility on 11/23/2021, 6:00 a.m.- 2:00 p.m. The treatments were signed as given by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 11/23/2021 through 11/30/2021. The order was not dated nor signed by whoever transcribed the order. No one was able to identify who took or transcribed the order. The order did not get clarified until 12/2/2021. During an interview on 12/2/2021 at 3:01 p.m., the ADON indicated the [MEDICATION(S)] Violet 1% treatment had not been given because the facility could not get the medication from pharmacy. A nursing note, dated 11/24/2021, indicated the resident was started on [MEDICATION(S)] (antibiotic) 1 gram every 12 hours for 10 days and to continue the [MEDICATION(S)] for wound infections. Review of the clinical record a lack of nursing progress notes from 10/29 through 11/5/2021. Review of a wound center service note, dated 10/29/2021, indicated the resident was to return in one week and if there were any concerns related to the wound or care instructions, to call the wound center. At that time, the resident had five wounds: one on the left medial lower leg, one on the right lateral lower leg, one on the right medial lower leg, one on the right posterior lower leg and one on the right lateral proximal lower leg. Measurements for the wounds are as follows: a. Wound #12- Left medial- 2.8 cm x 4 cm x 0.2 cm, acquired 8/30/2021 b. Wound #14-Right lateral- 9.5 cm x 5.3 cm x 0.2 cm, acquired 8/30/2021 Review of the wound center's communication log note, dated 11/5/2021 at 9:19 a.m., indicated the resident was a no call no show for a pre-scheduled appointment. The wound center called the facility at 9:52 a.m. and was told the appointment had not been placed on the calendar and transportation had not been arranged. The appointment was rescheduled for the following Friday. Review of the wound center's communication log note, dated 11/5/2021 at 10:00 a.m., indicated RN 1 called the facility to inquire about the resident's bilateral compression wraps, that required to be changed every seven days. RN 1 requested to speak to the Director of Nursing (DON) and was told they were not available. RN 1 asked to speak to someone in management and was directed to the Administrator (not acting current Administrator). RN 1 explained the situation of the missed appointment and the resident's compression wraps that would need to be changed. RN 1 asked what type of compression wraps the facility had on hand and was told by the Administrator they did not know but would make sure the wraps were changed. RN 1 indicated they faxed the facility the compression wrap orders. Review of a wound center's communication log note, dated 11/12/2021 at 9:59 a.m., indicated RN 1 noted Resident B's compression wraps were to have been changed by the facility due to the missed appointment and had not been changed. The resident had on the same compression wraps for two weeks and the wounds were much worse. Review of the wound center service note, dated 11/12/2021, included but was not limited to, the following: a. Wound #14-Right Circumferential- 27 cm x 50 cm x 0.2 cm with foul odor after cleaning. The note also had pictures depicting the resident's gray sweat pant legs with visible stained with a yellow/brownish tinged substance and appeared wet. The dressings were discolored with the same yellow/brownish colored substance and appeared wet. Review of a visit summary for 11/12/2021, indicated the resident arrived for the appointment with thin black stockings on his foot and actively seeping purulent drainage though the stocking and saturating his sweatpants. Review of the facility Ongoing Assessment of Pressure Ulcers provided by the DON on 12/3/2021 at 1:30 p.m., lacked any documentation of wound measurements or specific location. Locations were documented as BLE (bilateral lower extremity). This form was provided as the wound management for the resident's venous ulcers. Wound assessments were dated 11/2, 11/9,11/16, 11/23 and 11/20/2021. During an interview on 12/2/2021 at 10:06 a.m., the Director of the wound center indicated on 11/5/2021 the resident had missed a scheduled appointment. The wound center called the resident's normal transport service and was told they did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director indicated when the resident arrived for the 11/12/2021 appointment, the dressings were saturated, and the wounds were weeping. The resident's pants were wet with the fluid from the wounds. The dressing/compression wrap had not been changed in two weeks. During an interview on 12/2/2021 at 10:06 a.m., RN 1 indicated they spoke with the Administrator (not the current Administrator) on 11/5/2021 about the compression wraps needing to be changed weekly. They indicated the Administrator assured them the dressings would be changed. During an interview on 12/2/2021 at 12:12 p.m., the DON indicated the resident's wound center appointment on 11/5/2021 had been missed. The facility did not set up transportation and she did not know how the appointment got missed. The DON indicated usually the resident returned from an appointment with a card or some type of documentation for the follow-up appointment. The appointments were placed on the calendar and transport was arranged at the same time. The facility did not have a written policy for making transportation arrangements. The DON indicated she was not made aware of the wound center's call on 11/5/2021. This Federal tag relates to Complaint IN 604. 3.1-37(b)

Based on interview and record review, the facility failed to prevent staff to resident sexual abuse for 1 of 3 residents reviewed for abuse ( Resident B). The immediate jeopardy began on 1/8/19 when Resident B reported sexual abuse by a staff member to the Activity Director. The Administrator was notified of the immediate jeopardy on 1/24/19 at 12:32 p.m. The immediate jeopardy was removed on 1/25/19, but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview on 1/24/19 at 10:20 a.m., Resident B indicated he was not sure how long he had been at the facility and denied having a girlfriend. He indicated the staff were friendly towards him, then smiled. He indicated a housekeeper provided a service for him. The service was clarified as a oral sex. He indicated he had spoken to the Social Service Director (SSD) about the incident. He preferred to not provide the staff persons name. The clinical record for Resident B was reviewed on 1/24/19 at 9:32 a.m. [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, dated 11/29/18, indicated the resident was cognitively intact. The resident received Level 2 Preadmission Screening and Resident Review (PASRR) services and had a legal guardian. A current health care plan, dated 11/15/18 and revised 1/3/19, indicated the resident had poor decision making skill related to [MEDICAL CONDITIONS]. Interventions included, but were not limited to, encourage resident and/or resident representative adherence with plan of treatment and provide psychiatric services. On 1/24/19 at 10:43 a.m., the SSD was asked about the allegation a housekeeper had performed a sexual act on Resident B. The SSD indicated yes and indicated any further questions to be made to the Administrator. He indicated the incident had occurred about two weeks ago. During an interview on 1/24/19 at 10:49 a.m., the Administrator indicated the resident came into her office to talk about the incident and was all smiles. Housekeeper 1 was interviewed and admitted to sending naked pictures of herself to Resident B after a night of drinking too much wine. They waited for the guardian to first look at the cell phone pictures. The guardian did not want to pursue the incident. The Administrator indicated Housekeeper 1 did not admit to the allegation of performing the sexual act on Resident B. About one week later, the guardian showed the Administrator the pictures sent by the housekeeper. The Administrator saw two pictures and Housekeeper 1 was naked in both. The resident had already told his guardian about the incident and his guardian felt the resident was not an innocent participant. They initiated an internal investigation and called the local police. The local police did not feel a crime was committed and nothing further was done. Review of the facilities internal investigation, provided by the Administrator indicated the following time line of events for 1/8/2019-1/9/2019: a. On Wednesday, (MONTH) 9, 2019, at 9:45 a.m., the Administrator was informed by .had received oral sex from an employee. b. A hand written review of the text exchange indicated on (MONTH) 8th, at approximately 10:32 p.m., the text sent from the resident stated, ' .I got a (slang words for oral sex) from an employee' Resident then texted, 'Yanking your chain ' c. At 10:15 a.m, the Administrator interviewed Resident B. He indicated it was not last night, but a couple days ago. He indicated Housekeeper 1 was the perpetrator. d. At 10:45 a.m., Housekeeper 1 was contacted and told she was suspended pending an investigation. e. At 1:30 p.m., Housekeeper 1 was interviewed at the facility by the Administrator, Regional Director and Nurse Consultant. She denied performing the sexual act on the resident, but admitted to sending him naked pictures of herself. Housekeeper 1 was terminated. f. At approximately 2:10 p.m., the residents legal guardian was informed of the incident. The guardian indicated she had already been told of the incident by the resident. g. At approximately 4:15 p.m., the guardian indicated she did not want to file a report with the police department. She indicated the resident was a willing participant. h. At approximately 4:50 p.m., the local police were notified. The officer took the identifying information of the resident and the employee, but stated there would be no further investigation or report filed. An internal investigation statement provided by the AD and signed on 1/9/19, indicated the following: On this date Tuesday, (MONTH) 09, 2019 .received a text message from (name of resident) stating 'Hey I just wanted to let you know that I got a (slang words for oral sex) from an employee I know she's gonna get fired .probably arrested AD then text back (name of resident) what am I going to do c(with) you. Res (resident) texted .'I'm twisted.' AD did not respond to res (resident) texted anymore. AD then reported this to (name of Administrator) .9:45 am. Review of a General Employee Orientation Checklist, Housekeeper 1 signed she understood the policy on employee conduct, resident abuse and rights on 11/27/18. Review of a current facility policy, revised 9/17, titled ABUSE PROHIBITION, REPORTING AND INVESTIGATING, which was provided by the Administrator on 1/24/19 at 9:32 a.m., indicated the following: POLICY: .Sexual Abuse .Any staff to resident sexual contact and/or sexual relationship is considered to be abuse. The relationship between a resident and their caregiver is a professional relationship. The facility strictly prohibits relationships between an employee and a resident of any type beyond professional The Immediate Jeopardy (IJ) that began on 1/8/19 was removed on 1/25/29 when interviews with staff confirmed the facility had begun inservicing staff on abuse and the reporting process. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because monitoring was on-going. This Federal tag relates to Complaint IN 776. 3.1-27(a)(1)

Based on record review and interview, the facility failed to ensure a staff member who had an allegation of staff to resident sexual abuse immediately reported the allegation to the facility Administrator for 1 of 3 residents reviewed for abuse (Resident B). The facility also failed to report the allegation to the Indiana State department of Health. The immediate jeopardy began on 1/8/19 when Resident B reported sexual abuse by a staff member to the Activity Director. The Administrator was notified of the immediate jeopardy on 1/24/19 at 12:32 p.m. The immediate jeopardy was removed on 1/25/19, but the noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview on 1/24/19 at 11:52 a.m., the Activity Director (AD) indicated she would often get text messages from Resident B related to items she may need to purchase for him. She indicated she had gone to bed early that evening and because she did not feel well and had taken some medication. She woke up when she received the text from the resident around 10:30 p.m. She was unsure of the exact date and time because her phone was not working and she did not have it with her. She indicated the resident had texted her saying he had just received oral sex from an employee. She responded back with what and who. The resident then indicated he was just yanking her chain and he would not give the name of the employee. She went back to bed and woke up the next morning wondering if she had dreamt the entire conversation. She looked at her phone and realize she had received the text messages from the resident. She reported the conversation to the Administrator later that morning, after the morning meeting. She knew she should have reported it right away. The resident had not ever made such an allegation in the past. The clinical record for Resident B was reviewed on 1/24/19 at 9:32 a.m. [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, dated 11/29/18, indicated the resident was cognitively intact. The resident received Level 2 Preadmission Screening and Resident Review (PASRR) services and had a legal guardian. A current health care plan, dated 11/15/18 and revised 1/3/19, indicated the resident had poor decision making skill related to [MEDICAL CONDITIONS]. Interventions included, but were not limited to, encourage resident and/or resident representative adherence with plan of treatment and provide psychiatric services. During an interview on 1/24/19 at 10:20 a.m., Resident B indicated he was not sure how long he had been at the facility and denied having a girlfriend. He indicated the staff were friendly towards him, then smiled. He indicated a housekeeper provided a service for him. The service was clarified as oral sex. He indicated he had spoken to the Social Service Director (SSD) about the incident. He preferred to not provide the staff person's name. During an interview on 1/24/19 at 10:49 a.m., the Administrator indicated the resident came into her office to talk about the incident and was all smiles. Housekeeper 1 was interviewed and admitted to sending naked pictures of herself to Resident B after a night of drinking too much wine. They waited for the guardian to first look at the cell phone pictures. The guardian did not want to pursue the incident. The resident had already told his guardian about the incident and his guardian felt the resident was not an innocent participant. They initiated an internal investigation and called the local police. The local police did not feel a crime was committed and nothing further was done. She indicated the incident was not reported to the Indiana State Department of Health because the guardian did not want to pursue it and they did not feel it was abuse. She indicated all staff have since been inserviced on abuse. She indicated the pictures were taken outside of the facility and sent to the resident's personal phone. Review of a current facility policy, revised 9/17, titled ABUSE PROHIBITION, REPORTING AND INVESTIGATING, which was provided by the Administrator on 1/24/19 at 9:32 a.m., indicated the following: .Investigation, Protection and Reporting .3. All reports of abuse must be reported to the Administrator immediately and to the resident's representative 4. Residents shall be protected from abuse through provisions of this policy 5. It is the responsibility of every employee of this facility to not only report abuse situations, but also suspicion of abuse and unusual observations and/or circumstances The Immediate Jeopardy (IJ) that began on 1/8/19 was removed on 1/25/29 when interviews with staff confirmed the facility had begun inservicing staff on abuse and the reporting process. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because monitoring was on-going. This Federal tag relates to Complaint IN 776. 3.1-28(c)

Based on observation, interview and record review, the facility failed to identify and prevent the development and progress of multiple pressure ulcers for 1 of 5 residents reviewed for pressure ulcers. This deficient practice resulted in the resident developing multiple unstageable pressure ulcers. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/23/18 at 9:41 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 5/8/18, indicated the resident was severely cognitively impaired. The resident was dependent of staff with one person assistance for bed mobility and transfers. During an observation with LPN 2 on 7/23/18 at 10:33 a.m., Resident B was in bed, lying on his right side. He had a transparent dressing to the upper left arm with a peripherally inserted central catheter (PICC) in place. The dressing was undated. He had a dressing to the left hip, dated 7/23/18 and a dressing to his right hip, dated 7/23/18. He was observed to have a gauze dressing covering his left foot. A health care plan, dated 11/22/17 and revised 5/24/18, indicated the resident was at risk for the development of pressure ulcers related to the presence of a pressure ulcer to the left inner foot and one to two person assistance for bed mobility. Interventions included, but were not limited to, encourage and assist with turning, repositioning and notify the nurse of any skin concerns and possible physician and resident representative notification. Another health care plan, dated 7/12/18 and revised 7/22/18, indicated the resident had the following pressure ulcers: left shin, right mid-back, left great toe, left inner foot, left hip, right foot-fifth toe, right outer ball of foot, right outer foot, right hip and right lower hip. Interventions included, but were not limited to, dressing and treatment as ordered and turn every one hour. A (MONTH) weekly skin assessment, indicated an assessment was not completed on 6/28/18. A progress note, dated 7/4/18 at 2:00 p.m., indicated re's (resident) has 3 areas to R (right) foot measuring 1.5 x 1 cm (centimeter), 4.5 x 4.3 cm .2 x 1.2 cm. Areas are red around the edges .info left for md ( physician). Call placed to dtr (daughter) but unable to leave voicemail. DON (Director of Nursing) made aware of areas. Skin sheets completed .given to DON. Review of a note, dated 7/4/18, provided by the corporate consultant on 7/24/18 at 1:11 p.m., indicated (name of DON) - please look at areas on (name of resident) R foot outer aspect. They do not look to be new but I didn't see a treatment ordered for them. I made skin sheets .what you would want to treat with. The three Initial Pressure Ulcer Assessment sheets, dated 7/4/2018, indicated the following measurements and locations of the wounds: a. Right foot, outer aspect, medial measured 4.5 cm x 4.3 cm with no depth or drainage. b. Right foot, outer aspect, distal measured 1.5 cm x 1.0 cm with no depth or drainage. c. Right foot, outer aspect, proximal measured 2.0 cm x 1.2 cm with no depth or drainage. All three wounds were documented as stage one pressure ulcer. A (MONTH) weekly skin assessment, indicated an assessment was not completed on 7/5/18. A physician order, dated 7/5/18, indicated to apply skin prep (protective film to help reduce friction) to the right hip and areas on right foot twice daily. Review of the (MONTH) Treatment Administration Record (TAR), the treatment was not completed on 7/6/18 or 7/8/18. The treatment was completed once on 7/7/18. The TAR also indicated skin prep treatment the bilateral areas on the shoulder blades and areas on the spine. There was no documentation the treatment was completed on any day to the shoulders or spine areas. The treatment was changed on 7/9/18. On 7/9/18, the following Initial Pressure Ulcer Assessment sheets indicated the following measurements and locations of the wounds: a. Right lateral bottom of foot, 3.0 cm x 2.4 cm, deep tissue injury. b. Right lateral top of foot, 2 .0 cm x 1.5 cm, deep tissue injury. c. Left hip, 1.5 cm x 1.5 cm, stage two. d. Right hip, 4.2 cm x 1.8 cm, unstageable. The following wound assessment for the left, inner foot were noted: 7/12/18, 1.0 cm x 1.3 cm, unstageable 7/19/18, 1.0 cm x 1.0 cm, unstageable 7/22/18, 1.0 cm x 1.0 cm, unstageable. The following wound assessment for the left, great toe were noted: 7/12/18, 3.2 cm x 3.4 cm, unstageable 7/19/18, 3.0 cm x 3.5 cm, unstageable 7/22/18, 3.0 cm x 3.5 cm, unstageable. The following wound assessment for the right, outer foot were noted: 7/12/18, 2.0 cm x 1.6 cm, unstageable 7/19/18, 1.7 cm x 1.1 cm, unstageable 7/22/18, 1.7 cm x 1.1 cm, unstageable. The following wound assessment for the right, outer ball of foot were noted: 7/12/18, 3.0 cm x 3.1 cm, unstageable 7/19/18, 2.5 cm x 2.1 cm, unstageable 7/22/18, 2.5 cm x 2.1 cm, unstageable. The following wound assessment for the right foot- fifth toe were noted: 7/12/18, 1.3 cm x 0.4 cm, unstageable 7/19/18, 1.0 cm x 1.0 cm, unstageable 7/22/18, 1.0 cm x 1.0 cm, unstageable. The following wound assessment for the right, medial back were noted: 7/12/18, 0.6 cm x 0.7 cm, unstageable 7/19/18, 0.7 cm x 0.7 cm, unstageable 7/22/18, 0.7 cm x 0.7 cm, unstageable. The following wound assessment for the right, distal hip were noted: 7/12/18, 1.0 cm x 1.0 cm, unstageable 7/19/18, 0.8 cm x 1.4 cm, unstageable 7/22/18, 0.8 cm x 1.4 cm, unstageable. The following wound assessment for the right, proximal hip were noted: 7/12/18, 2.7 cm x 3.9 cm, unstageable 7/19/18, 2.7 cm x 3.4 cm, unstageable 7/22/18, 2.7 cm x 3.4 cm, unstageable. On 7/24 12:36 p.m,. the Assistant Director of Nursing (ADON) indicated the previous DON resigned on 7/9/18. At that time, the facility knew they had a problem with skin assessments and reports being completed. The facility brought in a nurse to do a facility wide skin sweep of all residents. The first time she had visualized the wounds on the resident was 7/9/18. During an interview on 7/24 at 3:10 p.m., Corporate Nurse 3 indicated following the skin sweep, they did an in-service related to Resident B only. The inservice did not included a facility wide education on pressure ulcers. Review of a current facility policy, dated 10/2013, titled SKIN MANAGEMENT PROGRAM, which was provided by Corporate Nurse 1 on 7/24/18 at 3:36 p.m., indicated the following: POLICY: This facility will assess/identify the presence of risk factors .development of pressure ulcers .in an effort to prevent skin breakdown .A comprehensive head to toe assessment will be completed by a licensed nurse upon admission, readmission and at least weekly thereafter. .A resident with a newly identified skin condition will have the appropriate assessment ongoing monitoring form initiated on the basis of the type of skin condition. .Notification of physician and resident or legal representative shall occur upon initial observation of a new skin condition This Federal tag relates to complaint IN 896. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review and interview, the facility failed to ensure air conditioning units were functioning, resulting in resident room with temperatures above 81 degrees Fahrenheit for 13 of 15 resident on 1 of 4 hallways in the facility. (Rooms 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513, 514 and 515). The facility also failed to keep the residents cool and comfortable for 4 of 4 residents reviewed for comfortable temperatures Residents B, C, D, and E) . This deficient practice resulted in Resident C being sent to the emergency room with signs and symptoms of heat exhaustion. The immediate jeopardy began on 5/25/2018 when the Maintenance Supervisor noted the air conditioning units on the 500 Hallway were not working. The Administrator was notified of the immediate jeopardy on 5/29/2018 at 8:13 PM. Findings include: During a facility tour, accompanied by the Administrator and the Maintenance Supervisor, on 5/29/2018 at 4:00 PM, the following temperatures were noted in regard to resident room temperatures: room [ROOM NUMBER]: 82.6 F room [ROOM NUMBER]: 83.9 F room [ROOM NUMBER] 81.6 F During an interview at this time the Administrator indicated the cooling units on the 500 hall had become dysfunctional on 5/25/2018 and were replaced 5/29/2018. During the tour the Maintenance Supervisor indicated he had taken air temperatures throughout the weekend, but had no temperature log and did not document his findings. During a facility tour on 5/29/2018 at 6:31 PM, accompanied by the Administrator, the following temperatures were noted: room [ROOM NUMBER]: 82 F The resident was in the room sweating and indicated it was too hot and she was uncomfortable. There was a fan running in the room. room [ROOM NUMBER]: 84 F Two fans were running in the room. room [ROOM NUMBER]: 81 F A fan was present in the room. room [ROOM NUMBER]: 82 F A fan was present in the room. room [ROOM NUMBER]: 82 F A fan was present in the room. room [ROOM NUMBER]: 82 F The resident had moved to room [ROOM NUMBER]. room [ROOM NUMBER]: 82 F A fan was present in the room. room [ROOM NUMBER]: 83 F A fan was present in the room. room [ROOM NUMBER]: 83 F Two fans were running in the room. room [ROOM NUMBER]: 84 F A fan was present in the room. room [ROOM NUMBER]: 85 F A fan was running in room. room [ROOM NUMBER]: 86 F A fan was present in the room. room [ROOM NUMBER]: 86 F A fan was running in the room. The temperatures were obtained by the Administrator using a facility thermostat. No fresh water or wet clothes were noted in the resident rooms during this tour. Review of the outside area temperatures, obtained from www.underground.com on 5/29/2018 at 10:00 p.m., were as follows: 5/25/2018 there was a high of 86 F 5/26/2018 there was a high of 86 F 5/27/2018 there was a high of 93 F 5/28/2018 there was a high of 95 F 5/29/2018 there was a high of 91 F The clinical record for Resident C was reviewed on 5/29/2018 at 4:55 PM. [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 3/5/18, was reviewed on 5/30/18 at 12:02 PM. The MDS indicated Resident C was cognitively intact. During an interview on 5/29/2018 at 5:30 PM, Resident C indicated she had to be taken to the hospital on [DATE] due to being a sweaty, shaking mess. She had been moved to another room on the 500 Hall because her room was too hot. Two fans were noted running in the resident room. The clinical record indicated an order, dated 5/28/2018, to send the resident to the emergency room for headache, numbness and weakness in lower extremities and shakiness. The clinical record lacked vital signs for the resident prior to leaving the facility. Review of the hospital history and physical, dated 5/28/2018, indicated the resident's temperature at arrival was 99.5 degrees Fahrenheit. The chief complaint listed was abdominal pain and weakness. The resident also complained of nausea and vomiting and had been unable to keep anything down. During an interview on 5/30/2018 at 10:37 AM, Employee 8, who was nursing staff, indicated the residents were complaining about the heat. Resident C was overheated and shaking on 5/28/2018. The employee indicated there had been no monitoring for heat related illnesses for the residents initiated during this time. The clinical record for Resident B was reviewed on 5/29/2018 at 5:00 PM. [DIAGNOSES REDACTED]. The most recent Significant Change Minimum Data Set (MDS) assessment, dated 2/14/2018, was reviewed on 5/30/18 at 5:55 PM. The MDS indicated Resident B was cognitively intact. During an interview on 5/29/2018 at 5:01 PM, Resident B indicated his room was too hot. The temperatures in the building had been uncomfortable for the past couple of weeks. During the interview, the resident was seated in a wheelchair wearing no shirt and a fan blowing directly on him. The clinical record for Resident D was reviewed on 5/29/2018 at 5:11 PM. [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 5/3/2018, was reviewed on 5/30/2018 at 5:11 PM. The MDS indicated Resident C was cognitively intact. During an interview on 5/29/2018 at 5:06 PM, Resident D indicated uncomfortable temperatures in her room for 2-4 weeks. We were told they had to buy a part, then they had to buy a whole new unit. The fans in the room belonged to the resident and were not provided by the facility. She was offered to move to another room for her comfort. I stayed one night , it was just as bad as this room. It wasn't any cooler. I woke up Monday morning and I was dizzy. The resident blamed her dizziness on the heat. The resident was visibly sweating during the interview. The clinical record for Resident E was reviewed on 5/31/2018 at 10:00 AM. [DIAGNOSES REDACTED]. During an interview on 5/30/2018 at 1:06 PM, a family member of Resident E indicated they had visited the resident on 5/28/2018. He/She indicated they went into the room to get clothing and it was so hot you couldn't breathe. During an interview on 5/30/2018 at 1:10 PM, a family member of Resident E indicated he/she had been visiting the resident on 5/27/2018 in the afternoon. It was sweltering hot inside his room. You could feel the difference in the temperature as soon as you walked onto that hallway (500 Hall). That is why we insisted on moving him to another room. He/She indicated they checked the temperature on the hall thermostat, it read 94 degrees. The minute you got on the hallway it was sweltering He/She indicated it seemed dangerous to them and they were sweating as they stood there in the room. During an interview on 5/30/2018 at 2:57 PM, Resident E indicated on 5/28/2018 it was hot. The resident had returned to the facility that afternoon. A family member observed the thermostat in the hallway outside of the resident's room and noted the temperature was 94 degrees F. The resident stated he wanted to move to another area of he facility because he was not comfortable During an interview on 5/29/2018 at 6:48 PM, Employee 3 indicated it was hot in the building and the temperatures on the 500 Hall had been elevated for approximately one week. During an interview on 5/29/2018 at 6:50 PM, Employee 4, who was nursing staff, indicated it was hot in the building and the temperatures on the 500 Hall had been elevated for over one week. The employee also indicated there had been no resident monitoring for heat related illnesses initiated during the period of elevated temperatures in the facility. The employee was unaware of any extra water, ice or wet towels being offered to the residents. During an interview 5/29/2018 at 7:03 PM, Employee 5 indicated it was hot in the building and the temperatures on the 500 Hall had been elevated since 5/25/2018. During an interview with the Administrator and Maintenance Supervisor on 5/30/2018 at 10:00 AM, the Administrator provided a temperature log dated 5/26 through 5/30/2018. The Maintenance Supervisor indicated he took the temperatures and called them to the Administrator, but had forgotten about the log. During an interview on 5/30/2018 at 10:50 AM, Employee 6 indicated over the past weekend it was very hot on the 500 Hall and it was worse on Monday 5/28/2018. It was unbearable. During an interview on 5/30/2018 at 11:44 AM, the Maintenance Supervisor indicated the corporation's plan was to first fix malfunctioning part in the air conditioning unit, but decided to replace both units on the 500 Hall due to their age. The part was not available until Tuesday due to it being a holiday weekend. The place they get the parts from was closed on the weekends and closed early because it was a holiday weekend. During an interview on 5/30/2018 at 12:39 PM, Employee 9 indicated the residents were complaining about the heat. The employee was unaware of any wet towels being offered to the residents as an interventions to help them stay cool. During an interview on 5/30/2018 at 12:47 PM, Employee 3 indicated during the weekend if she thought a resident looked hot she would take their temperature, but did not document that it had been done. There were no resident assessments performed every 4-6 hours due to the elevated building temperatures and no fluid intake and output monitoring had been done. During an interview on 5/30/2018 at 3:00 PM, the Corporate Maintenance Supervisor indicated he had been made aware of the air conditioning on 5/25/2018 in the late afternoon. He arrived at the facility on the same day to inspect the units. It was determined a part was needed to repair the unit and the other unit would need to be replaced. The company had a contractual agreement with a supply company and could not purchase the part from anywhere else. It was a holiday weekend and the company had closed and the part would need to be ordered on [DATE]. On 5/29/2018 the decision was made to replace both units. During an interview on 5/30/3018 at 3:35 PM, a representative from the contractual supply company indicated the Indianapolis locations operated under normal business hours 7:30 AM to 4:30 PM, on 5/25/2018. The company has a location in the Indianapolis area open on Saturdays from 8:00 AM to 12:00 PM. The company also has an emergency open service for a fee of $75.00. During an interview on 5/31/2018 at 9:13 AM, Employee 7 indicated drinking water and ice were provided to the residents at the beginning and end of the shift. Residents received more water during medication administration pass and if they requested for it. The Employee stated they did not leave extra wash clothes to residents as they had been instructed not to in the past. Review of the Medication Administration and Treatment Administration Records for residents on the 500 Hall on 5/31/2018 at 9:16 AM indicated the records lacked any documentation of vital signs or intake and output documentation unless it had been ordered previously. Review of the temperature logs provided by the Administrator on 5/30/2018 at 9:00 AM, indicated the following dates and times temperatures in resident rooms on the 500 Hall exceeded 81 degrees F: 5/26/2018 at 2:00 PM -room [ROOM NUMBER]: 81.1 F 5/26/2018 at 4:00 PM -room [ROOM NUMBER]: 81.8 F 5/26/ at 4:00 PM -room [ROOM NUMBER] 81.2 F 5/26/2018 at 4:00 PM -room [ROOM NUMBER] 81.9 F 5/26/2018 at 4:00 PM -room [ROOM NUMBER]: 81.7 F 5/26/2018 at 4:00 PM -room [ROOM NUMBER]: 81.5 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.2 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.6 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.6 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.9 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.4 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.3 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.4 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.4 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.9 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.5 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.6 F 5/28/2018 at 12:00 PM -room [ROOM NUMBER]: 81.2 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.1 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.3 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.4 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.1 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.3 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.4 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.5 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.6 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.3 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.6 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.8 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.8 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.9 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.3 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.4 F 5/28/2018 at 2:00 PM -room [ROOM NUMBER]: 82.6 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.4 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.5 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.4 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.1 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.2 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.6 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.3 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 82.9 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.4 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.6 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.8 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.4 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.2 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.1 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.7 F 5/28/2018 at 4:00 PM -room [ROOM NUMBER]: 83.6 F Review of a current policy, dated 12/2017, titled Facility Temperature, indicated the following: Policy: This facility shall uphold each resident's right to a safe, clean, comfortable and homelike environment, including maintaining the facility temperature between 71-81 degrees Fahrenheit. This policy was provided by the Administrator on 5/29/2018 at 8:10 PM. Review of a current policy, dated 1/2015 and revised 9/2017, titled Extreme High Temperature Procedure, indicated the following: Purpose: Should the temperature index for relative humidity and temperature in the facility rise above the state required indicated for facility shall implement the appropriate high temperature procedures. Department Specific Procedures: Nursing Monitor residents for intake and output of fluids. Encourage fluids. Monitor residents closely for signs of discomfort and adverse physical symptoms High-risk residents should be identified and monitored closely during periods of extremely high temperatures. High-risk residents include those with heart, circulatory, or respiratory problems, and those taking [MEDICATION NAME], diuretics, sedatives, and hypnotics. Physicians of high risk residents must be informed of their resident's conditions and the heat situation. Check resident's temperature and vital signs every 4-6 hours Monitor all residents frequently for symptoms of heat stroke and heat exhaustion Dress residents in or encourage resident to wear light-weight, loose-fitting clothing Monitor the resident's activities, and encourage the elimination of strenuous activities programming If necessary, transfer residents to areas of the facility that are better ventilated and cooler in temperature Dietary Operate exhaust systems while equipment is in use to reduce excess heat Make provisions for additional supplies of water and ice Check food supplies Maintenance Monitor air temperatures at least every 2 hours between 8 am and PM in resident areas Make provisions for an adequate supply of fans for resident rooms Monitor all ventilation systems and assure their working conditions Monitor all exhaust systems and assure their working conditions Maintenance of air conditioning systems. Clear areas around conditioning units of vegetation and debris to allow better air flow. Clean all air conditioner filters Assure that water lines to the building are working appropriately If possible, hose down roof with water in order to cool down building Administration Alert the State Department of Health and your regional corporate staff about high temperature situation, and request support . Keep residents as cool as possible. Review of a current undated policy on 5/30/2018 at 3:41 PM, titled Signs/Symptoms of Extreme Temperature Exposure, indicated the following: Policy: A resident who has been in an environment of extreme temperature (i.e., heat or cold) for an extended period of time shall be properly assessed by a licensed nurse for signs/symptoms indicative of needed intervention. Extreme hot temperatures: High environmental temperatures can be dangerous to the body. In the range of 90 degrees and 105 degrees F (32 degrees and 40 degrees C), an individual can experience heat cramps and exhaustion. Between 105 degrees and 130 degrees F (40 and 54 degrees C), heat exhaustion is more likely. An environmental temperature over 130 degrees F (54 degrees C) often leads to heatstroke. Other heat-related illnesses include: heat exhaustion heatstroke muscle cramps heat swelling [MEDICAL CONDITION] Symptoms Symptoms of heat related illnesses depend on the type and the severity of the illness. Some common symptoms of heat exhaustion include: . exhaustion or fatigue . feelings of nausea vomiting . The immediate jeopardy that began on 5/25/2018 was removed on 5/29/2018 when the facility replaced the air conditioning units, began educating employees on extreme heat and signs and symptoms, began monitoring the air temperatures in the 500 hall, but noncompliance remained at the lower scope and severity level of no actual with the potential for more than minimal harm because all staff members had not yet been educated and monitoring was still on-going. This Federal tag relates to Complaint IN 696. 3.1-19(i)

Based on record review and interview, the facility failed to investigate reported sexual abuse by a facility employee toward a resident and promptly notify facility administration of an allegation of sexual abuse for 1 of 3 residents. This deficient practice resulted in an inappropriate sexual relationship between a facility employee and a resident. (Resident C) The Immediate Jeopardy began, on 1/3/2017, when the resident reported to the Administrator she had been involved in a sexual relationship with a facility employee. The Administrator was notified of the Immediate Jeopardy on 1/19/2017 at 9:01 a.m. The immediate jeapordy was removed on 1/20/2017, but the noncompliance remained at a lower scope and severity level. Findings include: Resident #C's record was reviewed on 1/18/2017 at 9:00 a.m., Resident C's current [DIAGNOSES REDACTED]. Review of the current, Quarterly Minimum Data Set (MDS) assessment, dated 12/31/2016, indicated Resident C was cognitively intact. During an interview on 1/18/2017 at 11:45 a.m., Resident C indicated she and Employee 14 had engaged in a consensual sexual relationship. She indicated this relationship included sexual intercourse. During an interview on 1/18/2017 at 12:15 p.m., Employee #1 indicated she became ware of the relationship between Resident C and Employee #14 when she over heard the resident venting to another resident about finding out Employee #14 had a fiance'. She indicated she did not remember the exact date of the conversation, but indicated it was prior to Resident C informing the Administrator of the relationship with Employee #14. During an interview on 1/18/2017 at 12:56 p.m., Employee #2 indicated she had heard rumors about Resident C and Employee #14. She indicated she did overhear Resident C talking about dating an employee of the facility. During an interview on 1/18/2017 at 3:00 p.m., Employee #3 indicated she heard rumors from the CNA's (Certified Nursing Assistants) about a suspected inappropriate relationship between Resident C and Employee #14. She indicated she brought this to the attention of the Director of Nursing (DON) at that time. She indicated the DON did speak with Employee #14 and told him to end the relationship. She did not know if the Administrator was aware of in incident or not. During an interview on 1/18/2017 at 4:22 p.m., the Administrator indicated Resident C told him of the relationship on January 3, 2017. He indicated no staff member told him of the relationship prior to Resident C reporting the relationship to him. The day I found out, I immediately did what I needed to do. He indicated Employee #14 was suspended immediately and terminated after the investigation was completed. During an interview on 1/19/2017 at 7:09 a.m., Employee #9 indicated she had heard rumors of a conversation between Resident C and Employee #14 in which Employee #14 was discussing demonic pornography with Resident C. She indicated she did not remember who told her, but she remembered the employee coming to the nurses station to report it. Employee #9 indicated they (Employee #14 and Resident C) were both adults and if the resident wasn't having any problem with it, the conversation was none of her business. Employee #9 indicated the facility was their home and they could talk about anything they wanted to. Employee #9 indicated she did not see inappropriate interaction between Employee #14 and Resident C. She indicated she was working on the unit as a nurse and not in the role of the ADON when the report was made and she told the staff member who reported the conversation to her to take it to management if they had a problem with it. Employee #9 indicated Resident C never told her of any relationship or concerns related to Employee #14. She indicated facility staff felt as though Employee #14 was a favorite of the Director of Nursing and that bothered the staff. She was unable to remember the staff member who brought the conversation to her attention or when it occurred. Employee #9 was the Assistant Director of Nursing at that time. The former DON left the employment of the facility on 12/8/2016. During an interview on 1/19/2017 at 9:36 a.m., Employee #12 indicated she, Employee #1 and Employee #2 told the Administrator about the rumors. It was a rumor and we were telling him about the rumors. She was unable to remember the date or time of this incident, but indicated it was prior to the Resident informing him of the relationship. During an interview on 1/19/2017 at 12:17 p.m., Employee #11 indicated one time he (Employee #14) went into (Resident C's name) room to watch a movie with her. I don't think he was working at the time. One of the CNAs told him he had to leave because he couldn't be in her room. She was unable to remember the name of the other people involved or the date and time of the incident. The current policy dated 11/2016, titled, Abuse Prohibition, Reporting and Investigation was provided by the Administrator on 1/19/2017 at 9:00 a.m. The policy indicated the following: Abuse Prohibition, Reporting and Investigation Policy: This facility shall prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation . .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caregiver, of goods or services that are necessary to attain or maintain physical , mental and psychosocial well-being. Instances of abuse of a resident , irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled trough the use of technology. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Investigation, Protection and Reporting . .3. All reports of abuse must be reported to the Administrator immediately and to the resident's representative (sponsor, resident representative) per policy .5. It is the responsibility of every employee of this facility to not only report abuse situations, but also suspicion of abuse and unusual observations and/or circumstances, to his/her supervisor. If it is the employee's supervisor the employee is reporting, the employee must notify another facility supervisor or the facility Administrator. The Immediate Jeopardy that began on 1/3/2017 was removed on 1/20/2017 when the facility educated residents, staff and families on their abuse policy and interviews with both residents and staff indicated knowledge of the facility abuse policy, including when to report allegations and who to report them to, but the noncompliance remained at a lower scope and severity of isolated, no acutal harm with potential for more than minimal harm that is not immediate jeopardy. This Federal tag relates to Complaint IN 809. 3.1-28(b) 3.1-28(c)

Based on interview and record review, the facility failed to prevent the inappropriate behavior by a facility staff member toward a resident for 1 of 3 residents reviewed for abuse. This deficient practice resulted in an inappropriate sexual relationship between a facility employee and a resident. (Resident C and Employee #14) The Immediate Jeopardy began, on 1/3/2017, when the resident reported to the Administrator she had been involved in a sexual relationship with a facility employee. The Administrator was notified of the Immediate Jeopardy on 1/19/2017 at 9:01 a.m. The immediate jeapordy was removed on 1/20/2017, but the noncompliance remained at a lower scope and severity level. Findings include: Resident C's record was reviewed on 1/18/2017 at 9:00 a.m. Resident C's current [DIAGNOSES REDACTED]. Review of the current, Quarterly Minimum Data Set (MDS) assessment, dated 12/31/2016, indicated Resident C was cognitively intact. During an interview on 1/18/2017 at 11:45 a.m., Resident C indicated she and Employee #14 had engaged in a consensual sexual relationship. She indicated this relationship included sexual intercourse. She also indicated she was aware a relationship with an employee was against the facility policy. During an interview on 1/18/2017 at 12:15 p.m., Employee #1 indicated she became aware of the relationship between Resident C and Employee #14 when she overheard the resident venting to another resident about finding out Employee #14 had a fiance'. Employee #1 indicated she did not know the exact date of the conversation, but knew it was prior to Resident C reporting the relationship to the Administrator. During an interview on 1/18/2017 at 3:00 p.m., Employee #3 indicated she heard rumors from the CNA's (Certified Nursing Assistants) about a suspected inappropriate relationship between Resident C and Employee #14. She indicated she brought this to the attention of the Director of Nursing at that time. She indicated the Director of Nursing did speak with Employee #14 and told him to end the relationship. She did not know if the Administrator was made aware of in incident or not. During an interview on 1/18/2017 at 4:22 p.m., the Administrator indicated Resident C told him of the relationship on January 3, 2017. He indicated no staff member told him of the relationship prior to Resident C reporting the relationship to him. He indicated Employee #14 was suspended and terminated after the facility completed the investigation. During an interview on 1/19/2017 at 7:09 a.m., Employee #9 indicated she had heard rumors of a conversation between Resident C and Employee #14 in which Employee #14 was discussing demonic pornography with Resident C. She indicated she did not remember who told her, but she remembered the employee coming to the nurses station to report it. Employee #9 indicated they (Employee #14 and Resident C) were both adults and if the resident wasn't having any problem with it, the conversation was none of her business. Employee #9 indicated the facility was their home and they could talk about anything they wanted to. Employee #9 indicated she did not see inappropriate interaction between Employee #14 and Resident C. She indicated she was working on the unit as a nurse and not in the role of the ADON when the report was made and she told the staff member who reported the conversation to her to take it to management if they had a problem with it. Employee #9 indicated Resident C never told her of any relationship or concerns related to Employee #14. She indicated facility staff felt as though Employee #14 was a favorite of the Director of Nursing and that bothered the staff. She was unable to remember the staff member who brought the conversation to her attention or when it occurred. Employee #9 was the Assistant Director of Nursing at that time. The former DON left the employment of the facility on 12/8/2016. The Immediate Jeopardy that began on 1/3/2017 was removed on 1/20/2017 when the facility educated residents, staff and families on their abuse policy and interviews with both residents and staff indicated knowledge of the facility abuse policy, including when to report allegations and who to report them to, but the noncompliance remained at a lower scope and severity of isolated, no acutal harm with potential for more than minimal harm that is not immediate jeopardy. This Federal tag relates to Complaint IN 809. 3.1-27(a)(1)

Based on record review and interview, the facility failed to implement and follow their policy regarding abuse and reporting of abuse, resulting in a delay in investigation of reported sexual abuse by a facility employee toward a resident. This deficient practice resulted in an inappropriate sexual relationship between a facility employee and a resident. (Resident C) The Immediate Jeopardy began, on 1/3/2017, when the resident reported to the Administrator she had been involved in a sexual relationship with a facility employee. The Administrator was notified of the Immediate Jeopardy on 1/19/2017 at 9:01 a.m. The immediate jeopardy was removed on 1/20/2017, but the noncompliance remained at a lower scope and severity level. Findings include: Resident #C's record was reviewed, on 1/18/2017 at 9:00 a.m. Resident #C's current [DIAGNOSES REDACTED]. Review of the current, Quarterly Minimum Data Set (MDS) assessment, dated 12/31/2016, indicated Resident C was cognitively intact. During an interview on 1/18/2017 at 11:45 a.m., Resident C indicated she and Employee 14 had engaged in a consensual sexual relationship. She indicated this relationship included sexual intercourse. During an interview on 1/18/2017 at 12:15 p.m., Employee #1 indicated she became aware of the relationship between Resident C and Employee #14 when she over heard the resident venting to another resident about finding out Employee #14 had a fiance'. She indicated she did not know the exact date of the conversation, but indicated it was prior to Resident C informing the Administrator of the relationship. During an interview on 1/18/2017 at 12:56 p.m., Employee #2 indicated she heard rumors about Resident C and Employee #14. She indicated she did overhear Resident C talking about dating a facility employee. During an interview on 1/18/2017 at 3:00 p.m., Employee #3 indicated she had heard rumors from the CNA's (Certified Nursing Assistants) about a suspected inappropriate relationship between Resident C and Employee #14. She indicated she brought this to the attention of the Director of Nursing at that time. She indicated the Director of Nursing did speak with Employee #14 and told him to end the relationship. She did not know if the Administrator was aware of in incident or not. During an interview on 1/18/2017 at 4:22 p.m., the Administrator indicated Resident C told him of the relationship on January 3, 2017. He indicated no staff member told him of the relationship prior to Resident C reporting the relationship to him. The day I found out, I immediately did what I needed to do. He indicated Employee #14 was suspended immediately and terminated after the investigation was completed. During an interview on 1/19/2017 at 7:09 a.m., Employee #9 indicated she had heard rumors of a conversation between Resident C and Employee #14 in which Employee #14 was discussing demonic pornography with Resident C. She indicated she did not remember who told her, but she remembered the employee coming to the nurses station to report it. Employee #9 indicated they (Employee #14 and Resident C) were both adults and if the resident wasn't having any problem with it, the conversation was none of her business. Employee #9 indicated the facility was their home and they could talk about anything they wanted to. Employee #9 indicated she did not see inappropriate interaction between Employee #14 and Resident C. She indicated she was working on the unit as a nurse and not in the role of the ADON when the report was made and she told the staff member who reported the conversation to her to take it to management if they had a problem with it. Employee #9 indicated Resident C never told her of any relationship or concerns related to Employee #14. She indicated facility staff felt as though Employee #14 was a favorite of the Director of Nursing and that bothered the staff. She was unable to remember the staff member who brought the conversation to her attention or when it occurred. Employee #9 was the Assistant Director of Nursing at that time. The former DON left the employment of the facility on 12/8/2016. During an interview on 1/19/2017 at 9:36 a.m., Employee #12 indicated she, Employee #1 and Employee #2 told the Administrator about the rumors. It was a rumor and we were telling him about the rumors. She was unable to remember the date or time of this incident, she indicated it was prior to the resident informing the Administrator of her relationship with Employee #14. During an interview on 1/19/2017 at 12:17 p.m., Employee #11 indicated one time he (Employee #14) went into (Resident C's name) room to watch a movie with her. I don't think he was working at the time. One of the CNA's told him he had to leave because he couldn't be in the room. She was unable to remember the name of the other people involved or the date and time of the incident. The current policy, dated 11/2016, titled, Abuse Prohibition, Reporting and Investigation was provided by the Administrator on 1/19/2017 at 9:00 a.m. The policy indicated the following: Abuse Prohibition, Reporting and Investigation Policy: This facility shall prohibit and prevent abuse, neglect, misappropriation of resident property, and exploitation . .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caregiver, of goods or services that are necessary to attain or maintain physical , mental and psychosocial well-being. Instances of abuse of a resident , irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled trough the use of technology. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Investigation, Protection and Reporting . .3. All reports of abuse must be reported to the Administrator immediately and to the resident's representative (sponsor, resident representative) per policy. .5. It is the responsibility of every employee of this facility to not only report abuse situations, but also suspicion of abuse and unusual observations and/or circumstances, to his/her supervisor. If it is the employee's supervisor the employee is reporting, the employee must notify another facility supervisor or the facility Administrator. The Immediate Jeopardy that began on 1/3/2017 was removed on 1/20/2017 when the facility educated residents, staff and families on their abuse policy and interviews with both residents and staff indicated knowledge of the facility abuse policy, including when to report allegations and who to report them to, but the noncompliance remained at a lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This Federal tag relates to Complaint IN 809. 3.1-28(a)

Based on interview and record review, the facility failed to ensure a referral appointment was made following a physician's order for 1 of 3 residents reviewed. This failure resulted in a hospitalization for acute [MEDICAL CONDITION] (Resident B). The facility also failed to ensure a resident received a pre-[MEDICAL TREATMENT] assessment and fistula monitoring for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. (Resident C) Findings include: 1. The clinical record for Resident B was reviewed on 6/30/15 at 10:10 a.m. [DIAGNOSES REDACTED]. Review of the laboratory results obtained on 4/20/15 indicated Resident B had a recorded Basic Urea Nitrogen (BUN) of 37 mg/dL. The normal range for BUN was 7-25 mg/dL. He also had a creatinine result of 2.3 mg/dL The normal range for creatinine was 0.6-1.3 mg/dL. A note on the laboratory test indicated for the facility was to obtain a nephrology consult for Resident B. Review of a Physician's order, dated 4/21/15, indicated a signed order for a nephrology consult. A Nursing note, dated 6/5/15 at 9:25 a.m., indicated Resident B was found in his room, pale and confused. Resident B had a pulse rate of 30 beats per minute. Other vital signs included; blood pressure 90/46, respiratory rate 22 and oxygen saturation 88%. Resident B was complaining of chest pain and nausea. 911 was called and Resident B was transferred to a local hospital. A Nursing note, dated 6/5/15 at 10:45 a.m., indicated a family member called the facility and stated Resident B's kidney were not functioning properly and he was sent to another hospital. During an interview on 6/30/15 at 1:45 p.m., the Director of Nursing (DON) indicated the staff person who receives a physician ' s order, is the person who schedules the appointment. She indicated the nurse who took the order for the nephrology consult for Resident B no longer worked at the facility. She indicated the facility did not have a just one person who schedules all the appointments. Resident B returned to the facility on [DATE]. 2. Resident #C's record was reviewed on 6/30/15 at 9:00 a.m. Resident #C's current [DIAGNOSES REDACTED]. The record indicated Resident #C went out for [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays, order dated 3/16/13. The Post [MEDICAL TREATMENT] Assessment, dated from 4/1/15 through 6/30/15, indicated the following: The Post [MEDICAL TREATMENT] Assessment was not documented for 4/3/15, 4/10/15, 4/17/15 and 4/24/15. No Post [MEDICAL TREATMENT] Assessments for March, May and June 2015 documented. The Post [MEDICAL TREATMENT] Assessment did not provide for assessment of the fistula site. Refusal by the resident documented on the Post [MEDICAL TREATMENT] Assessment for 4/1/15, 4/8/15, 4/13/15, 4/15/15, 4/20/15, 4/22/14, 4/24/15 and 4/29/15. No Post [MEDICAL TREATMENT] Assessments for March, May, and June 2015 During an interview on 6/30/15 at 11:15 a.m., the Director of Nursing indicated the fistula assessment should have been ordered for all residents receiving [MEDICAL TREATMENT]. She indicated she did not know when the order for assessment fell off the re-writes. Review of the Medication Administration Records for March, April, May and June 2015 indicated no order for assessment of fistula pre or post [MEDICAL TREATMENT]. The Director of Nursing indicated she could not provide documentation that the fistula assessment had ever been done. No further information provided. The 10/2014, policy titled [MEDICAL TREATMENT] Coordination/Facility Services was provided by the Director of Nursing on 6/30/15 at 10:55 a.m. Purpose: To ensure effective communication between the facility and [MEDICAL TREATMENT] center providing service to the resident. Policy: Facility personnel will communicate with the outpatient [MEDICAL TREATMENT] center in an effort to ensure the resident is rendered necessary care and services for the provision and maintenance of [MEDICAL TREATMENT] services. Facility personnel will monitor the status of the resident receiving [MEDICAL TREATMENT] for potential complications. Review physician's orders for the resident receiving [MEDICAL TREATMENT] to confirm: Type of access site and location Orders for care or access site, if any specified [MEDICAL TREATMENT] days Order for provision of medications (meds (medications) to be held on [MEDICAL TREATMENT] days, provision of medications that will be missed during [MEDICAL TREATMENT] and meds to be given with meals) Frequency resident weight to be obtained If fluid restriction is ordered, ensure to follow policy regarding Fluid restrictions addressing fluids to be provided by nursing and by dietary. Procedure: . 3. If [MEDICAL TREATMENT] facility requires form(s) to be filled out and sent with resident , complete and send with resident. Review of a current facility policy dated 10/20/14, titled PHYSICIAN ORDERS, which was provided by the Director of Nursing on 7/1/15 at 11:42 a.m., included, but was not limited to, the following: PURPOSE: Physician's orders are administered upon the clear, complete and signed order of an individual lawfully authorized to prescribe. POLICY: Facility nursing personnel will ensure clear, accurate and complete physician's orders. PROCEDURE: TELEPHONE OR VERBAL ORDERS: .4. Notify the resident/legal representative of the new order and document notification in the clinical record. 5. Transcribe new order onto the MAR indicated [REDACTED]. This Federal tag relates to Complaint IN 047. 3.1-37(a)

Based on record review, observation and interview, the facility failed to ensure resident's with pressure ulcers received preventative measures and treatment to prevent the worsening of the pressure ulcer or the possibility of worsening for 4 of 5 residents reviewed with pressure ulcers in a sample of 15. (Resident H, B, G, and OO) When a pressure reducing back wheelchair cushion was indicated and not in place, Resident H's stage II pressure ulcer on her spine progressed to a Stage IV wound with necrotic tissue and slough. Findings include: 1. An undated policy titled "Interventions to reduce the risk of pressure ulcer development & pressure ulcer management" was provided by the administrator on 2/4/11 at 8 a.m. The policy indicated: "Review this list of interventions when determining what to put in place to reduce the risk of pressure ulcer development and pressure ulcer management. This list contains many appropriate interventions but is not all inclusive. RESIDENTS AT RISK: Equipment...Pressure reducing chair cushion-filled with foam, static air, gel or water. Initiate OT referral for wheelchair management...Routine Skin Care Interventions ...Provide incontinent care timely...Positioning Interventions Avoid positioning directly on a current pressure ulcers...Lift heels totally off bed surface with pillow or other device under the calves/ankles...Refer to OT to evaluate postural alignment, distribution of weight, balance and stability when positioning resident in a wheelchair...." 2. The record for Resident H was reviewed on 1/31/11 at 8:20 a.m. Current [DIAGNOSES REDACTED]. A plan of care dated 11/2/10 and updated 2/2/11 indicated a problem of an open area on the resident's spine. Approaches to the plan of care included, but were not limited to, provide pressure relieving devices to reduce pressure to affected area. A "Pressure Ulcer Flowsheet" dated 1/27/11 indicated the resident had a stage II pressure ulcer on her spine that was 3 centimeters (cm) by 3 cm with a 0.1 cm depth. The wound bed was pink and beefy red with serosanguinous drainage. The additional comment section indicated "Spoke (c with a line over it) with therapy (name of therapist) about cushion for back of w/c (wheelchair)." On 1/31/11 at 8:15 a.m., the resident was observed sitting in her wheelchair in her room, no cushion was observed to the back of her wheelchair. A "Pressure Ulcer Flowsheet" dated 2/2/11 indicated the resident had a stage IV pressure ulcer on her spine that was 3 cm by 3 cm. The depth could not be determined. The wound bed had slough and black/brown eschar. The sheet indicated the wound had deteriorated. There was no mention of a need for a cushion to the back of her wheelchair. During observations of the resident on 2/3/11 at 9:40 a.m., she received wound care and no cushion was present for the back of her wheelchair. The wound was observed at this time. The wound was located on the lower spine. The wound was approximately 3 cm circular with a yellow wound bed with black edges around the bottom of the wound. The peri-wound be was red. On 2/4/11 at 10:30 a.m., the resident was observed sitting in her wheelchair in her room, no cushion was observed to the back of her wheelchair. An Occupational Therapy evaluation was completed on 2/4/11 by Occupational Therapist (OT) # 12. This evaluation indicated the resident was referred to therapy due to increased problem with wheelchair positioning and mobility. The evaluation indicated the resident was leaning to the right. The evaluation failed to mention the resident had a stage IV pressure ulcer on her spine. During a telephone interview with OT # 12 on 2/4/11 at 1:30 p.m., the therapist indicated he was unaware the resident had a pressure ulcer. He indicated his evaluation did not address the need for a cushion for the back of Resident H's wheelchair. During an interview with the Physical Therapy Assistant (PTA) # 13 on 2/8/11 at 10:55 a.m., she indicated wound RN # 15 spoke to her regarding the need for a back cushion to the resident's wheelchair. PTA # 13 indicated she had informed the Certified Occupation Therapy Assistant (COTA) # 14 of the need for a cushion to the back of the resident's wheelchair. During an interview with COTA # 14 on 2/8/11 at 2:30 p.m., she indicated she was unaware the resident had a pressure ulcer on her back. She indicated she was informed on 1/26/11 the resident was leaning in her wheelchair and she had informed nursing to document on the leaning for at least 3 days so therapy could see the resident. She indicated a pressure reducing cushion had been ordered on [DATE] for the back of the resident's wheelchair, ten days after the resident's first assessed need for a pressure reducing cushion to the back of her wheelchair. 3. On 2/07/11 from 9:40 a.m. to 9:55 a.m., as Resident #B's personal care was begun, the resident was uncovered. The resident's heels were not floated off the mattress but were observed lying on top of the mattress. After personal care was completed, the resident was repositioned in her bed with the heels resting on the mattress with no attempt to float her heel off of the bed as CNA #29 and CNA #30 indicated they had completed her care. On 2/07/11 at 1:45 p.m., as LPN #26 prepared to do Resident #B's dressing change to her lower back, the resident was uncovered and observed in her bed with no floatation of her heels observed. Her heels were resting on the bed mattress. On 2/07/11 at 2:10 p.m. during an interview, LPN #26 indicated one of the resident's heels had some small dark hard areas on her heel. Resident #B's record was reviewed on 1/31/11. The resident' [DIAGNOSES REDACTED]. The physician order, dated 2/06/11, was to float the heels. 4. On 2/07/11 from 1:55 p.m. to 2:35 p.m., Resident #G's personal care was observed. After CNA #32 and CNA #33 checked the resident, they indicated the resident had been incontinent of urine with his incontinent pads and top sheet wet. CNA #32 and CNA #33 were observed to change the resident's linen and reposition him in his bed. No incontinent care was completed on this resident during this observation. Resident #G's record was reviewed on 1/31/11 at 2:55 p.m. The resident's [DIAGNOSES REDACTED]. The resident's care plan, dated 1/16/11, indicated the problem was the resident was at high risk for alteration in skin integrity. The interventions included, but were not limited to, peri care after each incontinent episode. The "PRESSURE ULCER FLOWSHEET," dated 2/02/11, indicated a stage III area on the resident's coccyx and a stage II on the right gluteal and a stage II on the left gluteal. 5.) Resident OO's record was reviewed on 2/7/11 at 9:00 a.m. Resident OO's current [DIAGNOSES REDACTED]. Resident OO had a "PRESSURE ULCER FLOWSHEET" which indicated she was first noted to have a stage II pressure area in her left posterior heel, ankle and tendon area on 11/10/10. The form indicated the area was 3 by 3 cm with a depth of less than 0.1 cm. The form also indicated the resident believed the area was causes from an orthotic boot she received form the orthopedic doctor 2 days prior. The "PRESSURE AREA FLOW SHEET" indicated Resident OO continued to have a stage II pressure area which required treatment on 11/18/10, 11/26/10, 11/29/10, 12/6/10, 12/13/10, and 12/21/10. The flow sheet indicated the area became unstageable on 12/28/11 and later became a stage III pressure area on 1/5/11. The flow sheet indicated the stage III pressure area continued to require treatment on 1/11/11, 1/18/11, 1/27/11, and 1/31/11. The 1/31/11 documentation indicated the would measured .5 by .5 cm and was less that 0.1 cm depth with scant brown exudate and was currently a healing stage III pressure area. Through the course of the wound treatment Resident OO has had physician's orders [REDACTED]. a.)12/12/11-santyl daily to ankle wound b.) 1/5/11-Santyl daily to ankle wound for 14 days. c.) undated when ordered and signed on 1/9/11-cleans with wound cleans prior to santyl, [MEDICATION NAME] rap with Kerlix daily for 14 days d.) 1/12/11-apply Poly-Santyl mix-daily and as needed for soilage or slippage. e.) 1/28/11-[MEDICATION NAME] to left heel tow times daily and cover and secure with [MEDICATION NAME] and Kerlix. Resident OO's treatment records for 12/10, 1/11 and 2/1-3/11 were reviewed. The treatment records contained multiple circles indicating the treatment was not completed on the following dates and times. The treatment records also lacked documentation as to why the nursing staff were unable to complete the treatment: 6:00 a.m. to 2:00 p.m. shift: 1/5/11, 1/15/11 2 to 10 p.m. shift: 1/1/11, 1/2/11, 1/3/11, 1/4/11, 1/11/11, 1/13/11, 1/15/11, 1/16/11. During a 2/7/11, 1:30 p.m., interview the Director of Nursing indicated a circle on the treatment administration record indicated a treatment was not done. She additionally indicated the nurses should have documented why the treatment was not done. She indicated if the resident's [MEDICAL TREATMENT] or therapy were causing difficulty in completing treatments this information should be documented on the treatment record to allow for future changes and adjustments to the resident's treatment schedule. This Federal deficiency relates to Complaint IN 237. 3.1-40(a)(2)

BASED ON RECORD REVIEW AND INTERVIEW, THE FACILITY FAILED TO ASSURE THE URINARY OUTPUTS WERE MEASURED, DAILY CATHETER CARE WAS PERFORMED, AND THE LOWER ABDOMINAL PAIN, SEDIMENTATION IN THE CATHETER TUBING, AND INCREASED [MEDICAL CONDITION] WERE RECOGNIZED AND ASSESSED, FOR 1 (RESIDENT A) OF 3 RESIDENTS REVIEWED FOR INDWELLING CATHETER CARE AMONG THE SAMPLE OF 10. THIS FAILURE RESULTED IN A HOSPITAL EVALUATION OF RESIDENT (A) WITH VOIDING AROUND A PLUGGED CATHETER AND A RETURN OF 1250 MILLILITERS OF AMBER URINE, HEAVY WITH SEDIMENTATION, ON RE-CATHETERIZATION. RESIDENT (A) WAS admitted to the hospital with [REDACTED]. FINDINGS INCLUDE: RESIDENT (A) WAS INTERVIEWED BY TELEPHONE AT 4:30 P.M., 9/8/10, AND INDICATED HER CATHETER HAD BEEN PLUGGED DURING A JUNE 2010, ADMISSION TO THE NURSING FACILITY (NF). RESIDENT (A) INDICATED THE KIDNEYS HAD SHUT DOWN AND IT HAD ALMOST KILLED HER. THE RECORD OF RESIDENT (A) WAS REVIEWED AT 4:45 P.M., 9/8/10, AND INDICATED A 6/15/10 ADMISSION WITH [DIAGNOSES REDACTED]. THE 6/15/10, 3:30 P.M., ADMISSION NURSING NOTES INDICATED 3 PLUS PITTING [MEDICAL CONDITION] TO THE BILATERAL LOWER EXTREMITIES AND THE PRESENCE OF A FOLEY CATHETER DRAINING AMBER COLORED URINE. NURSING NOTE DOCUMENTATION DID NOT INDICATE THE PRESENCE OF A FOLEY CATHETER AGAIN UNTIL 3:20 P.M., 6/24/10, ( 9 DAYS LATER) WHEN NEW ORDERS WERE RECEIVED FROM THE PHYSICIAN FOR CARE AS DIRECTED BY FACILITY PROTOCOLS. THE 6/24/10, DOCUMENTATION DID NOT INDICATE THE CHARACTERISTICS OF THE URINE NOR ASSESSMENT OF THE CATHETER PLACEMENT. NURSING NOTE DOCUMENTATION FROM 6/25/10, THROUGH THE 7/2/10, 3:00 P.M., TRANSFER TO THE HOSPITAL, DID NOT INDICATE THE PRESENCE OF THE FOLEY CATHETER, CHARACTERISTICS OF THE URINE, THE [MEDICAL CONDITION], OR ASSESSMENT OF THE LOWER ABDOMEN. A 7/1/10, 7:00 P.M., NURSING NOTE INDICATED A PHYSICIan order for [REDACTED]. THE NEXT NURSING NOTE DOCUMENTATION WAS AT 3:00 P.M., 7/2/10, INDICATING RESIDENT (A) HAD BEEN SENT TO A LOCAL HOSPITAL DUE TO A CHANGE IN THE HEALTH STATUS. A 7/2/10, 10:00 P.M., NURSING NOTE INDICATED RESIDENT (A) HAD BEEN admitted WITH [DIAGNOSES REDACTED]. A 7/3/10, 10:00 P.M., NURSING NOTE INDICATED THE RESULTS OF THE 7/1/10, URINALYSIS AND CULTURE HAD RETURNED WITH 4 PLUS BACTERIA. DOCUMENTATION INDICATED 6/15/10, PHYSICIAN ORDERS [REDACTED].M., AND 8:00 P.M., AND [MEDICATION NAME] (A POTASSIUM SPARING DIURETIC) 100 MG EVERY DAY). A 6/24/10, PHYSICIAN ORDER [REDACTED]. THE PHYSICIAN ORDERED THE CATHETER AND DRAINAGE BAG TO BE CHANGED MONTHLY. THE ONLY DOCUMENTED ASSESSMENT OF THE NEED FOR THE FOLEY CATHETER WAS A 6/23/10, CARE PLAN CONCERN. THE INDICATED USE FOR AN INDWELLING CATHETER WAS [MEDICAL CONDITION], MULTIPLE DIURETICS, PITTING [MEDICAL CONDITION] SECONDARY TO [MEDICAL CONDITION], AND PRESSURE AREAS. A VISIT WAS MADE TO THE HOSPITAL AT 2:15 P.M., 9/9/10, AND THE 7/2/10 TO 7/6/10, hospitalization RECORD WAS REVIEWED. THE INITIAL 7/2/10, 3:06 P.M., emergency room (ER) PHYSICIAN ASSESSMENT INDICATED RESIDENT (A) HAD INCREASED [MEDICAL CONDITION]. THE ER PHYSICIAN ALSO DOCUMENTED THE FOLEY CATHETER HAD DRIED SEDIMENT IN THE TUBING AND (RESIDENT A) WAS VOIDING VERY ODOROUS URINE AROUND THE TUBING. THE ER PHYSICIAN INDICATED (RESIDENT A) HAD BEEN COMPLAINING OF LOWER ABDOMINAL PAIN FOR 5 DAYS. LABORATORY WORK INCLUDING A BLOOD CULTURE WAS DONE. AT 3:31 P.M., ER REGISTERED NURSE (RN #1) ANCHORED A FOLEY CATHETER. RN #1 DOCUMENTED 1250 MILLILITERS (MLS) OF DARK AMBER URINE, HEAVY WITH SEDIMENT, HAD RETURNED AND A SPECIMEN WAS SENT FOR CULTURE. THE ER PHYSICIAN INDICATED [DIAGNOSES REDACTED]. FOLLOWING THE RE-CATHETERIZATION, INTRAVENOUS (IV) ANTI BIOTICS WERE STARTED. AT 6:09 P.M., 2000 ML OF CLOUDY, AMBER URINE WAS EMPTIED FROM THE CATHETER. LICENSED PRACTICAL NURSE (LPN #1), WHO HAD DONE CARE FOR RESIDENT (A) DURING THE 6/10-7/2/10, FACILITY STAY, WAS INTERVIEWED AT 3:15 P.M., 9/9/10. LPN #1 INDICATED SHE DID NOT RECALL RESIDENT (A) HAVING A FOLEY CATHETER. LPN #1 INDICATED SHE RECALLED RESIDENT (A) HAD PRN (AS NEEDED ) ORDERS FOR PAIN MEDICATION. LPN #1 INDICATED RESIDENT (A) COULD LET THE NURSES KNOW IF SHE HAD PAIN. CERTIFIED NURSING ASSISTANT (CNA #1) WAS INTERVIEWED AT 3:20 P.M., 9/9/10, AND INDICATED SHE HAD PROVIDED PERSONAL CARE FOR RESIDENT (A), DURING THE 6/10-7/10, ADMISSION. CNA #1 INDICATED SHE REMEMBERED RESIDENT (A) HAD A FOLEY CATHETER FROM THE DAY OF ADMISSION AND HAD ALSO USED A BEDPAN. CNA #1 INDICATED SHE HAD DONE CATHETER AND PERI CARE FOR RESIDENT (A). CNA #1 INDICATED INITIALLY, THE URINE HAD BEEN CLEAR. CNA #1 INDICATED SHE REMEMBERED BLOOD IN THE URINE SOME TIME LATER, AFTER THE ADMISSION. AT 3:50 P.M., 9/9/10, THE FACILITY RECORD OF RESIDENT (A) WAS REVIEWED WITH RN CONSULTANT #1. THE 9/9/10, 3:50 P.M., RECORD REVIEW DID NOT INDICATE DOCUMENTATION OF URINARY OUTPUTS FROM THE 6/15/10 ADMISSION THROUGH THE 7/2/10 HOSPITAL TRANSFER. DOCUMENTATION ON THE 6/10, TREATMENT RECORD INDICATED THE FOLEY CATHETER CARE WAS FIRST PERFORMED 6/24/10, ON THE SECOND SHIFT (9 DAYS FOLLOWING THE ADMISSION). CATHETER CARE WAS DOCUMENTED EACH SHIFT FROM 6/25-6/28/10. CATHETER CARE WAS ALSO DOCUMENTED AS PERFORMED ON THE NIGHT SHIFT, ONLY, ON 6/29, AND 6/30/10. THE FOLEY CATHETER CARE WAS NOT TRANSCRIBED ONTO THE 7/10, MEDICATION, TREATMENT RECORD. DURING THE 9/9/10, 3:50 P.M., REVIEW, RN CONSULTANT #1 INDICATED THE URINE OUTPUT WAS TO BE DOCUMENTED EVERY SHIFT. RN CONSULTANT #1 ALSO INDICATED A DESCRIPTION OF THE URINE CHARACTERISTICS WOULD BE DOCUMENTED IN THE NURSING NOTES ONLY IF THERE WERE ABNORMALITIES. RN CONSULTANT #1 INDICATED THE CNA(S) WERE TO DO CATHETER CARE EVERY SHIFT AND TO DOCUMENT THE URINE OUTPUTS ON THE (CNA) CARE SHEETS. AT 10:00 A.M., 9/10/10, RN CONSULTANT #1 PROVIDED A COPY OF THE 7/2/10, MEDICARE WORKSHEET DOCUMENTATION FOR RESIDENT (A) WHICH SHE INDICATED HAD BEEN FOUND IN THE OVERFLOW MEDICAL RECORDS. A 7/2/10, 10:30 A.M., MEDICARE NURSING NOTE, DOCUMENTED BY LPN #3, INDICATED RESIDENT (A) HAD COMPLAINED OF GENERAL DISCOMFORT AND THE PRN MEDICATION HAD BEEN GIVEN. THE MEDICARE DOCUMENTATION ALSO INDICATED THE FOLEY CATHETER WAS PATENT AND DRAINING 900 CUBIC CENTIMETERS (CCS) OF CLEAR YELLOW URINE, WITHOUT LEAKAGE OR DISCHARGE AT THE INSERTION SITE. THE 7/2/10, 1:30 P.M., MEDICARE NURSING NOTE INDICATED LPN #2 WAS CALLED TO THE ROOM OF RESIDENT (A). LPN #2 DOCUMENTED RESIDENT (A) WAS CONFUSED AND THE SKIN WAS COOL AND CLAMMY. LPN #2 DOCUMENTED FAMILY MEMBERS WERE AT THE BEDSIDE, BECAME BELLIGERENT, AND REFUSED A COMPLETE EVALUATION OF RESIDENT (A). LPN #2 INDICATED THE FAMILY REQUESTED A TRANSFER TO THE HOSPITAL AND 911 WAS CALLED. LPN #2 INDICATED THE EMERGENCY MEDICAL TECHNICIANS (EMT) ARRIVED TO TRANSPORT RESIDENT (A) AT 1:47 P.M., 7/2/10. LPN #2 WAS NOT AVAILABLE FOR INTERVIEW 9/10, NOR 9/13/10. LPN #3 WAS INTERVIEWED AT 10:30 A.M., 9/10/10, AND INDICATED THE CATHETER OUTPUT WAS TO BE MEASURED BY THE ASSIGNED CNA EACH SHIFT. LPN #3 INDICATED THE CNA REPORTED THE AMOUNT TO THE LICENSED NURSE WHO WAS RESPONSIBLE TO DOCUMENT IT IN THE TREATMENT RECORD. CNA #2 WAS INTERVIEWED AT 11;10 A.M.,9/10/10, AND INDICATED CATHETERS WERE TO BE EMPTIED EACH SHIFT AND THE AMOUNT REPORTED TO THE NURSE TO DOCUMENT. CNA #2 INDICATED IF BLOOD OR SEDIMENT WAS OBSERVED, THE LICENSED NURSE WAS TO BE NOTIFIED. LPN #4, WHO WAS ASSIGNED THE UNIT RESIDENT (A) HAD STAYED DURING THE 6/10-7/10, ADMISSION, WAS INTERVIEWED AT 3:15 P.M., 9/10/10. LPN #4 INDICATED SHE THOUGHT THE CNA(S) WERE RESPONSIBLE FOR MEASURING AND DOCUMENTING THE CATHETER OUTPUTS IN THE ACTIVITY OF DAILY LIVING (ADL) BOOKS. LPN #4 INDICATED SHE DID NOT DOCUMENT AN OUTPUT IN THE RECORD UNLESS SPECIFICALLY ORDERED BY THE PHYSICIAN. THE FACILITY'S 9/05, POLICY FOR FOLEY CATHETER MAINTENANCE WAS PROVIDED BY CONSULTANT RN #1 ON 9/10/10. THE PURPOSE WAS TO MAINTAIN URINARY DRAINAGE AND MONITOR RENAL FUNCTION. POINT #1 UNDER CATHETER CARE INDICATED IT WAS TO BE DONE TWICE DAILY. POINT #10 UNDER EMPTYING DRAINAGE INDICATED THE MEASUREMENT WAS TO BE RECORDED ON THE DESIGNATED FORM. THE 9/05, POLICY FOR CATHETERIZATION WAS ALSO PROVIDED BY CONSULTANT RN #1 ON 9/10/10. THE PURPOSE WAS TO RELIEVE BLADDER DISTENTION, OBTAIN SPECIMENS FOR DIAGNOSTIC PURPOSES, DETERMINE THE AMOUNT OF RESIDUAL URINE, INSTILL MEDICATION, OR TO PROVIDE COMFORT AND SUPPORT TO RESIDENTS WHOSE INCONTINENCE CAUSED OBSTRUCTION AND FOR WHOM OTHER INTERVENTIONS WERE NOT FEASIBLE. THE FACILITY'S 5/06, CATHETER ASSESSMENT PROCEDURE, HAD BEEN PROVIDED BY CONSULTANT RN #1 ON 9/10/10. POINT #1 INDICATED IF A CATHETER WAS IN PLACE, ASSESSMENTS WERE TO BE COMPLETED UPON ADMISSION, QUARTERLY, ANNUALLY, AND WITH A SIGNIFICANT CHANGE IN CONDITION. POINT #2 INDICATED THE ASSESSMENT WAS TO INCLUDE THE TYPE OF CATHETER IN USE AND HOW OFTEN, THE SIZE AND BULB (IN CCS), DATE ANCHORED, WRITTEN ORDER, RATIONAL AND [DIAGNOSES REDACTED]. THIS FEDERAL TAG RELATES TO COMPLAINT NUMBER IN 729. 3.1-41(a)(2)