Every finding on record at Envive of Indianapolis

Based on observation, interview, and record review, the facility failed to ensure the implementation of adequate and consistent nutritional interventions for a dependent resident (Resident 10) which resulted in actual harm related to significant weight loss and compromised nutritional status for 1 of 2 residents reviewed for tube feeding (TF) and the facility failed to ensure a Resident, (Resident 8) who was at high risk for malnutrition was appropriately monitored for weight loss for 1 of 8 residents reviewed for nutrition monitoring.Findings include:1. On 3/23/26 at 10:28 a.m., Resident 10 was initially observed. He was reclined in a high back wheelchair in his room. His left leg was contracted and pulled tight to his chest, his left arm was also contracted and tucked to his chest. He appeared very thin and frail. A tube feeding (TF) was hung and running at a rate of 60 milliliters (ml) and was just under 600 ml from a total of 1,000 ml. His lips were dry and cracked with a thick yellowish pasty film at the corners of his lips. On 3/24/26 at 12:50 p.m. Resident 10 was not in his room and an unidentified nursing staff member indicated he was getting a shower at that time. On 3/24/26 at 1:37 p.m., Resident 10 was observed back in his room, reclined in his wheelchair with his eyes closed. His TF was not hooked up and a lunch tray of pureed food was left untouched on the bedside table just behind his wheelchair. During an interview on 3/24/26 at 1:40 p.m., Certified Nursing Aide (CNA) 16 indicated she did not know if he was NPO (nothing by mouth) but if he was, he would probably not eat his lunch tray. He used to eat some but then started just holding the food in his mouth, so his TF was his only source of food. On 3/25/26 at 10:00 a.m., a wound treatment observation was conducted. Resident 10 was disconnected from the TF to be laid in bed for the wound treatment. On 3/25/26 at 11:14 a.m., Resident 10 remained in bed after his wound dressing, and his TF was unhooked. The TF pump alarmed and flashed inactive, has been [NAME] for 10 minutes. At that time, the feeding hung was at 700 ml and the fluids hung were at just under 600 ml. On 3/25/26 at 1:33 p.m., Resident 10 remained in bed. His TF remained unhooked. The TF pump continued to alarm and flashed inactive, has been [NAME] for 10 minutes. The feeding hung remained at 700 ml and the fluids hung were at just under 600mls. On 3/25/26 at 2:03 p.m., the Facility Social Service Director (SSD) facilitated a video phone call with Resident 10's family member. The family member expressed concern for the resident's appearance, and did not realize he had lost so much weight, or that his legs were so contracted. On 3/24/26 at 1:14 p.m., Resident 10's record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, history of a stroke which affected his left, non-dominate side and severe-protein calorie malnutrition. A quarterly Minimum Data Set (MDS) assessment, dated 3/18/26, indicated he was totally dependent on staff to meet all activity of daily living (ADL) needs including, feeding/nutrition. Before Resident 10's hospitalization on 1/21/26 he weighed 138 lbs. Upon his return from the hospital on 1/30/26 he weighed 128.4 lbs. The record lacked documentation of Interdisciplinary Team (IDT) and/or Registered Dietician (RD) follow up after his hospitalization to address this weight loss and prevent further weight loss. Upon his return from the hospital, his TF orders were discontinued from 1/29/26 – 2/2/26 with no clear alternative nutrition plan. A NP progress note, dated 1/30/26, indicated the resident had returned from the hospital and staff were requesting he be seen for pocketing of food. Evaluated to address swallowing safety and current Nothing by Mouth (NPO) status. Swallowing difficulty had been persistent and provoked by attempts at oral intake. Symptoms relieved by NPO status. Receiving enteral nutrition per G-Tube per existing feeding orders. On 2/2/26 the physician ordered for the resident to have TF at 90 ml over 12 hours daily. A Nutrition/Dietary Note, dated 2/6/26, indicated a weight warning with a weight of 128 lbs. Dietitian note indicated aware of significant weight loss and the resident was added to clinically at risk (CAR) monitoring. A Nutrition/Dietary Note, dated 2/22/26, indicated a weight warning with a weight of 128 lbs. Dietitian note indicated aware of significant weight loss and the resident was followed weekly. On 2/24/26 he was weighed at 127.8 lbs, then on 3/2/26 he was down to 117 lbs, an 8.59% loss in one week. The record lacked documentation of a re-weight following the 3/2/26 weight, and/or that nursing notified the RD of the weight loss in writing per facility policy. On 3/5/26 the tube feed order was switched from an isosorb formula to Jevity 1.5 formula at 60 ml on continuous. The record lacked documentation of rational, gradual titration, or dietician-driven plan associated with this transition. A NP progress note, dated 3/10/26, indicated the resident was seen today per nursing request for decreased appetite. Resident was observed lying in bed with meal tray at bedside and had not consumed any food or fluids. Nursing reported resident was offered assistance with feeding but did not open his mouth. On questioning, resident stated he did not like the food provided and preferred pancakes, French toast, or meatloaf. He denied nausea, vomiting, abdominal pain, choking, or odynophagia (painful swallowing). Appetite had been decreased over the past several days per nursing. Symptoms occur with each meal and were aggravated by dissatisfaction with current pureed diet. Resident remained on pureed diet due to prior aspiration noted on previous swallowing study. Recent weights show 117 lbs on 3/2/26 and 127.8 lbs on 2/24/26, indicating significant weight loss. Body Mass Index (BMI) was 15.9, consistent with severe malnutrition. Resident was currently receiving Jevity 1.5 via G-tube continuously at 60 mL/hr over 24 hours (total volume 1440 mL/day) with free water flushes at 50 mL/hr (total 1200mL/day). Given continuous enteral feeding regimen, patient may be experiencing satiety contributing to poor oral intake. He reported willingness to undergo repeat swallowing evaluation in hopes of diet advancement and agreed to consume ice cream and nutritional supplements while awaiting reassessment. Speech therapy reconsulted for repeat swallowing study. Registered Dietitian notified of significant weight loss and current tube feeding regimen for reassessment and caloric evaluation. Abdomen was soft, non-tender, nondistended. G-tube in place without erythema or drainage. Significant weight loss despite enteral nutrition raises concern for increased metabolic demand, inadequate caloric provision, malabsorption, or fluid shifts. High risk for further clinical decline.RD notified to reassess caloric needs, tube feeding rate, and timing (consider adjustment to promote oral intake if appropriate). Initiated oral supplementation (Magic Cups TID and ice cream with meals) per patient preference. Close interdisciplinary monitoring required. On 3/23/26 a new comprehensive care plan was initiated which indicated, Resident 10 had a terminal prognosis related to protein calorie malnutrition and was placed on Hospice as a result. During an interview on 3/26/26 at 1:40 p.m., with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) present, the above concerns were reviewed and discussed. The RNC indicated, Resident 10 was discussed weekly during CAR. When he first came back from the hospital, he was eating but then started to decline, so the TF were re-started. Shortly after, he started pocketing food, so he was put back to NPO and TF dependent. The dietician participated in the weekly CAR discussion over the phone, and the DON or RNC were uncertain when the last time the Dietician had been in to physically assess the resident. On 3/27/26 at 9:53 a.m., the Administrator provided a copy of current facility policy titled, Weight Assessment and Intervention, dated 8/2024. The policy indicated, Residents are weighed upon admission and at intervals established by the interdisciplinary team. any weight change of 5% or more since the last weight assessment is re-taken the next day for confirmation, if the weight is verified, nursing will immediately notify the dietician in writing. undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes. the residents target weight range. whether and to what extent weight stabilization or improvement can be anticipated. On 3/27/26 at 9:53 a.m., the Administrator provided a copy of current facility policy titled, Enteral Nutrition, dated 8/2024. The policy indicated, Adequate nutritional support through enteral nutrition is provided to residents as ordered. the dietician monitors residents who are receiving enteral nutrition, and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. the nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition, altered hydration, hypo- or hyperglycemia, and altered electrolytes. The nursing staff and provider also monitor he resident for worsening of condition that place the resident at risk for the above. 2. On 3/23/2026 at 10:03 a.m. Resident 8 was observed as she lay in bed resting with her eyes closed. She appeared to be thin and petite but not to the point of frailty. On 3/24/26 at 12:54 p.m. Resident 8's medical record was reviewed. She was a memory care Resident whose diagnoses included but were not limited to dementia and malnutrition. Resident 8 was admitted to the facility on [DATE]. A Nurse Practitioners (NP) note, dated 2/17/26, indicated Resident 8 was being admitted to the facility for nutritional monitoring, among other things. That note indicated the NP wanted the clinical staff to obtain weights weekly. The record lacked an order for weekly weights at that time. Resident 8 had a recorded weight of 79 pounds on 2/17/26. An NP note dated 2/20/26 indicated they wanted the clinical staff to continue to obtain weights weekly for Resident 8. The record lacked an order for weekly weights at that time. A Clinical at Risk (CAR) (predictive models or assessment tools used in medicine to identify patients with a higher likelihood of adverse outcomes) assessment dated [DATE] indicated the dietician added fortified foods and would follow up with a full nutritional assessment. On 2/24/26 a nutritional risk assessment was done for Resident 8. That assessment indicated Resident 8 weighed 91 pounds at the hospital on 2/5/26, which meant she had a significant weight loss of 12 pounds or 13% in less than one month. In the dietician note section the dietician indicated the plan for Resident 8 was to start offering 4-ounce mighty shakes (a nutritional supplement) once a day, clinical staff will monitor weights weekly and she would be followed weekly in CAR. The dietician considered Resident 8 to be at high risk for malnutrition. A CAR assessment, dated 2/27/26, indicated Resident 8's Body Mass Index (BMI) was very low and no weekly weights had been obtained yet. The record lacked an order for weekly weights at that time. Resident 8 had a recorded weight of 104.2 pounds on 3/5/26. A CAR assessment, dated 3/6/26, indicated the dietician had requested clinical staff reweigh Resident 8 due to a significant weight gain of 31.9% in two weeks. The note indicated the resident's eating habits had not changed since the previous assessment. A CAR assessment, dated 3/13/26, indicated there were no new weights obtained since the last assessment. The dietician requested the clinical staff reweigh Resident 8 to confirm or deny the significant weight gain. A CAR assessment, dated 3/20/26, indicated there were no new weights obtained since the last assessment. The dietician requested the clinical staff reweigh Resident 8 to confirm or deny the significant weight gain. Resident 8 had a recorded weight of 192.8 pounds on 3/22/26. Resident 8 discharged to her home from the facility on 3/26/26. The record lacked evidence of oversight and appropriate monitoring of Resident 8's weight and nutritional status. Appropriate weekly weights were never ordered, reweights to confirm or deny significant weight changes were not obtained, and discrepancies in nutritional and weight status were not resolved prior to Resident 8 discharging to her home from the facility. On 3/27/26 at 11:18 a.m. the Director of Nursing (DON) indicated she was unaware Resident 8's weights were so off. She indicated had she known she would have had the staff get a reweight immediately and reevaluate the plan for the Residents nutritional status with the dietician and provider. On 3/27/26 at 9:53 a.m., the Administrator provided a copy of current facility policy titled, Weight Assessment and Intervention, dated 8/2024. The policy indicated, Residents are weighed upon admission and at intervals established by the interdisciplinary team. any weight change of 5% or more since the last weight assessment is re-taken the next day for confirmation, if the weight is verified, nursing will immediately notify the dietician in writing. undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes. the residents target weight range. whether and to what extent weight stabilization or improvement can be anticipated. 410 IAC (Indiana Administrative Code) 16.2-3.1-46

A. Based on observations, interviews, and record reviews, the facility failed to complete a side rail assessment for 4 of 7 residents reviewed for the potential for accidents (Residents 29, 52, 54, and 20). B. Based on observations and interviews, the facility failed to ensure sliding glass doors were appropriately bolted shut in the memory care unit. This deficient practice had the potential to affect 29 of 29 Residents who resided in the memory care unit. Findings include:A1. On 3/23/26 at 10:00 a.m., Resident 29 was observed lying in bed with quarter (1/4) side rails on both sides of his bed. Resident 29 indicated he used the rails to move about in bed. On 3/26/26 at 12:17 a.m., a record review was completed for Resident 29. He had the following diagnoses which included, but were not limited to, chronic respiratory failure, low back pain, and obesity. He had a side rail assessment, dated 1/25/25, which indicated he did not have side rails on his bed. On 3/26/26 the Director of Nursing (DON) was made aware and she placed an order in his record, .per resident request, resident prefers to have the upper siderails in the up position for convenience of positioning and hanging his remote. On 3/27/26 at 10:13 a.m., the DON indicated he probably changed his mind at some point to have the rails and they just added them. 2. On 3/23/26 at 10:15 a.m., Resident 52 was observed lying in bed with 1/4 side rails on both sides of his bed. On 3/27/26 at 9:51 a.m. a record review was completed for Resident 52. He had the following diagnoses which included, but were not limited to, hypothyroidism, vitamin D deficiency, and age-related cataract. His record had an overdue side rail assessment dated [DATE]. 3. On 3/23/26 at 10:30 a.m., Resident 54 was sitting up in his bed. His bed linens were soiled with a red substance. He had 1/4 side rails on his bed. On 3/24/26 at 12:19 a.m., a record review was completed for Resident 54. He had the following diagnoses which included, but were not limited to, post-traumatic stress disorder, hypertension, seizures, and heart failure. His record had an overdue side rail assessment dated [DATE]. 4. On 3/23/26 at 10:00 a.m. Resident 20 was observed as he lay in bed resting with his eyes closed. He appeared to have limited range of motion due to contracted extremities (permanent or severe tightening of muscles, tendons, ligaments, or skin, causing rigid, bent joints and limited movement). Resident 20 had a quarter side rail on the left side of the bed. On 3/25/26 at 3:08 p.m. Resident 20's medical record was reviewed. He was a memory care resident whose diagnoses included, but were not limited to, dementia and traumatic brain injury. As part of the most recent quarterly nursing evaluation a side rail assessment was done on 3/17/26. That assessment indicated Resident 20 did not have any side rails on his bed. As part of a quarterly nursing evaluation a side rail assessment was done on 3/1/26. That assessment indicated it was recommended Resident 20 have bilateral side rails on his bed. On 3/27/26 at 10:21 a.m., the [NAME] President of Clinical Operations (VPCO) indicated they did side rail assessments quarterly. They would have done an assessment at the end of the month. The bedside nurses complete the quarterly assessments. On 3/26/26 at 2:42 p.m., a policy titled, Bed Safety and Bed Rails, was provided by the Executive Director (ED). It indicated, .Prior to the installation or the use of a side or bed rail, alternatives to the use of side or bed rails are attempted.If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the used of bed rails. B. On 3/23/26 at 11:30 a.m. the sliding glass door in room [ROOM NUMBER] on the memory care unit was observed. Upon pulling on the door handle the top of the door opened approximately 1 to 2 inches, wide enough to stick a hand or small arm through. There were multiple rooms that had sliding glass doors like the one in room [ROOM NUMBER], but they did not budge when pulled on. On 3/27/26 at 10:04 a.m. the sliding glass door in room [ROOM NUMBER] of the memory care unit was observed again. No apparent change had been made to the door. Maintenance had been observed going on and off the unit several different times across several different days. On 3/27/26 at 10:11 a.m. Licensed Practical Nurse (LPN) 10 indicated clinical staff check the main locked doors regularly but they didn't do any checks of the sliding glass doors. She believed maintenance handled checking those doors. On 3/27/26 at 10:20 a.m. the memory care Unit Manager (UM) indicated during their angel rounds they went around and looked at the doors and checked for broken blinds of cracks, but they did not check to see if they could be opened or not. She indicated the opening was wide enough for someone to get a hand in it and potentially smash it, this concerned her greatly and she immediately had clinical staff go around to check all of the doors. She indicated she planned to speak with maintenance about this issue and came up with a plan to ensure they will be checked routinely from now on. On 3/27/26 at 10:37 a.m. the Maintenance Director indicated he added a screw to the top of the door in room [ROOM NUMBER] to prevent the top corner of the door from moving. He indicated there was supposed to be a screw at the top and bottom of all the sliding glass doors to prevent them from opening, he wasn't sure what happened to the screw in the top of the door in room [ROOM NUMBER]. He also indicated because of the issue with that door they will be implementing annual checks of all sliding glass doors in the memory care unit, he indicated before this issue came up they did not have regular checks in place they only fixed things as the need arose. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure dependent residents were provided with assistance to maintain their necessary activities of daily living (ADLs) for 5 of 6 residents reviewed for ADLs (Residents 70, 73, 78, 97, and 10). Findings include:1. During an observation, on 3/23/26 at 10:22 a.m., Resident 70 was observed lying in bed. The fingernails on the resident's left hand were long and untrimmed, with dark debris underneath them. The resident had a full beard and mustache with food debris observed in the beard. During an observation, on 3/24/26 at 12:09 p.m., Resident 70 was observed lying in bed. The resident's fingernails on the left hand remained long and untrimmed, with dark debris underneath them. During an observation, on 3/25/26 at 9:18 a.m., the Resident 70 was observed lying in bed with food debris observed in his beard. During an observation, on 3/25/26 at 9:50 a.m., the Resident 70 was observed lying in bed with food debris in his beard. The resident's fingernails on the left hand remained long and untrimmed, with dark debris underneath them. Resident 70's record was reviewed on 3/25/26 at 2:26 p.m. Diagnoses on the resident's profile included, but were not limited to, personal history of traumatic brain injury. An annual Minimum Data Set (MDS) assessment, dated 2/5/26, indicated the resident had a severe cognitive impairment, required partial/moderate staff assistance for eating, substantial/maximal assistance from staff for personal hygiene, and lacked documentation the resident exhibited behaviors during the look back period, including rejection of care. A care plan, last revised on 2/9/26, indicated the resident had an ADL self-care performance deficit related to impaired mobility. Interventions included, but were not limited to, the resident required substantial/maximal staff assistance with personal hygiene and dependent on staff assistance for bathing. Progress notes, dated 2/23/26 to 3/25/26, lacked documentation the resident was offered, provided, or refused fingernail care. The progress notes lacked documentation the resident refused to have food debris removed from his beard. A treatment administration record (TAR), dated March 2026, indicated the resident was monitored for a behavior of care refusal. The TAR indicated the resident had zero occurrences of the monitored behavior. A bathing schedule was observed in the task section of the electronic record. The schedule indicated the resident was scheduled for bathing on Mondays and Thursdays on night shift. The log indicated the resident received eight baths during the last 30 days as scheduled and lacked documentation the resident refused bathing. Shower sheets indicated the resident received a bath or a shower on 3/2/26, 3/5/26, 3/9/26, 3/12/26, 3/16/26, 3/19/26, and 3/23/26. The shower sheets lacked documentation fingernail care was offered, provided, or refused with the bath. 2. During an observation, on 3/23/26 at 1:10 p.m., Resident 73 was observed up in the wheelchair, waiting in line to go outside to smoke. There was a large puddle of urine observed under the resident's wheelchair, and a foul body odor was noted. During an observation, on 3/24/26 at 12:13 p.m., Resident 73 was observed up in his wheelchair. The resident's fingernails on both hands were long and untrimmed, with dark debris underneath them. During an observation, on 3/24/26 at 1:37 p.m., Resident 73 was observed up in his wheelchair. The resident's fingernails on both hands were long and untrimmed, with dark debris underneath them. During an observation, on 3/25/26 at 9:11 a.m., Resident 73 was observed up in his wheelchair. The resident's fingernails on both hands were long and untrimmed, with dark debris underneath them. Resident 73's record was reviewed on 3/26/26 at 10:09 a.m. Diagnoses on the resident's profile included, but were not limited to, unspecified schizophrenia (a chronic, severe brain disorder that distorts how a person thinks, feels, acts, and perceives reality). A care plan, last revised on 1/16/26, indicated the resident had an ADL self-care performance deficit related to activity intolerance. Interventions included, but were not limited to, the resident was dependent on staff assistance for personal hygiene and bathing/showering. Progress notes, dated March 2026, lacked documentation the resident was offered, provided, or refused fingernail care. A behavior log, included in the task section of the electronic record, indicated the resident had not refused care during the last 30 days. A bathing log, included in the task section of the electronic record, indicated the resident was scheduled for bathing on Mondays and Thursdays on night shift. The log indicated the resident received 7 baths, and refused 1 bath, during the last 30 days. Shower sheets indicated the resident was bathed on 3/2/26, 3/5/26, 3/9/26, 3/12/26, 3/16/26, 3/19/26, and 3/23/26. The shower sheets lacked documentation the resident was offered, provided, or refused fingernail care with the baths. 3. During an observation, on 3/23/26 at 11:28 a.m., Resident 78 was observed lying in bed. The resident's fingernails on her right hand were long and untrimmed with dark debris underneath them. During an interview, on 3/23/26 at 1:55 p.m., Resident 78's family member indicated they had observed the resident's fingernails to be long and dirty at times. During an observation, on 3/24/26 at 11:43 a.m., Resident 78 was observed lying in bed. The resident's fingernails on her right hand remained long and untrimmed with dark debris underneath them. During an observation, on 3/24/26 at 1:39 p.m., Resident 78 was observed up in her wheelchair. The resident's fingernails on her right hand remained long and untrimmed with dark debris underneath them. During an observation, on 3/25/26 at 8:59 a.m., Resident 78 was observed lying in bed. The resident's fingernails on her right hand remained long and untrimmed with dark debris underneath them. Resident 78's record was reviewed on 3/26/26 at 12:15 p.m. Diagnoses on the resident's profile included, but were not limited to, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain tissue of oxygen and nutrients) unspecified severity with other behavioral disturbance. An admission Minimum Data Set (MDS) assessment, dated 1/30/26, indicated the resident had a moderate cognitive impairment, was dependent on staff assistance for showering/bathing and personal hygiene, and lacked documentation the resident refused care. A care plan, last revised on 2/2/26, indicated the resident had an ADL self-care performance deficit related to activity intolerance. Interventions included, but were not limited to, the resident was dependent on staff assistance for personal hygiene and bathing/showering. Progress notes, dated March 2026, lacked documentation the resident was offered, refused, or provided fingernail care. A shower schedule, dated 3/26/26, indicated the resident was scheduled for bathing on Tuesdays and Saturdays on night shift. Shower sheets indicated the resident was bathed on 3/3/26, 3/7/36, 3/10/26, 3/14/26, 3/17/26, 3/21/26, and 3/24/26. The shower sheets lacked documentation fingernail care was offered, provided, or refused with the baths. 4. During an observation, on 3/23/26 at 10:54 a.m., Resident 97's fingernails on both hands had dark debris underneath them. During an observation, on 3/24/26 at 12:14 p.m., Resident 97's fingernails on both hands had dark debris underneath them. During an observation, on 3/25/26 at 9:10 a.m., Resident 97's fingernails on both hands had dark debris underneath them. Resident 97's record was reviewed on 3/26/26 at 1:53 p.m. Diagnoses on the resident's profile included, but were not limited to, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain tissue of oxygen and nutrients) mild with other behavioral disturbance. A quarterly Minimum Data Set (MDS) assessment, dated 3/7/26, indicated the resident was cognitively intact, was dependent on staff assistance for showering/bathing and personal hygiene, and lacked documentation the resident refused care. A care plan, last revised on 12/9/25, indicated the resident had an ADL self-care performance deficit related to decreased mobility. Progress notes, dated March 2026, lacked documentation the resident was offered, provided, or refused fingernail care. Interventions included, but were not limited to, the resident was dependent for personal hygiene and showering/bathing. A shower log, included in the task section of the electronic record, indicated the resident was scheduled for bathing on Tuesdays and Fridays on night shift. The log indicated the resident received 8 baths in the last 30 days and lacked documentation the resident refused bathing. During an interview, on 3/26/26 at 10:46 a.m., the Director of Nursing (DON) indicated fingernail care should have been done with showers and as needed. Food should have been cleaned from a resident's beard after they were done eating. If a resident refused care, the aides should have notified the nurse, and the nurse should have documented it in the notes. During an interview, on 3/26/26 at 1:30 p.m., Qualified Medication Aide (QMA) 9 indicated fingernail care should have been provided with showers and as needed. If a resident was diabetic, the nurse had to do fingernail care, but it still should have been done on scheduled shower days. If a resident refused care they re-attempted three times and notified the nurse. The aides were able to document refusals in the task section, and the nurse should have documented refusals in their notes. 5. On 3/23/26 at 10:28 a.m., Resident 10 was initially observed. He was reclined in a high back wheelchair in his room. His left leg was contracted and pulled tight to his chest, his left arm was also contracted and tucked to his chest. He appeared very thin and frail. He was unable to answer questions and just stared blankly. He was dressed in only a hospital gown, he had a bushy beard, and long thick fingernails with debris under them. On 3/24/26 at 12:58 p.m., Resident 10 received a shower. On 3/24/26 at 1:37 p.m., Resident 10 was observed back in his room after his shower. His bear remained overgrown and bushy, his fingernails remained long and had debris under them. On 3/25/26 at 2:03 p.m., the Facility Social Service Director (SSD) facilitated a video phone call with Resident 10's family member. She expressed concern for his appearance, and did not realize he had lost so much weight, or that his legs were so contracted. On 3/24/26 at 1:14 p.m., Resident 10's record was reviewed. He was a long-term care resident with diagnoses which included, history of a stroke that affected his left non-dominate side. A quarterly Minimum Data Set (MDS) assessment, dated 3/18/26, indicated he was totally dependent on staff for all ADLs, including personal hygiene and grooming. He had a comprehensive care plan, revised 3/6/26, which indicated he had an ADL self-care performance deficit related to his diagnoses and was dependent on staff for all ADL care. On 3/26/26 at 2:50 p.m., the Administrator provided a copy of current facility policy titled, Activities of Daily Living (ADLs), Supporting, dated 8/2024. The policy indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3).

Based on observations, interview and record review, the facility failed to ensure orders were in place and implemented to properly monitor, flush, and secure a resident's G-tube, for 1 of 2 residnets reviewed for tube feeding, (Residnet 95)Findings include:On 3/23/26 at 10:30 a.m. Resident 95 was observed in bed wearing a hospital gown. She indicated she had a G-tube but expressed a desire to have it removed due to irritation and pain. She reported the tube was no longer used.On 3/26/26 at 10:57 a.m., Resident 95's g-tube and incersion cite was observed with Licensed Practical Nurse (LPN) 17. Insertion site noted to have cut gauze; resident reported discomfort, bloating, and pain. LPN 17 indicated, the only order related to the g-tube was to put [NAME] Oxide at the insertion cite. She did not know why the tube was so long, and indicated nurses had not been flushing the tube because there were no orders. She observed the tube and indicated she was not sure why it was clouded, or what could be in the tube.On 3/26/26 at 11:15 a.m., Resident 95's G-tube was observed with the Regional Nurse Consultant. He indicated the tube was excessively long and he had to pull it out from between her thighs. He observed the insertion cite and acknowledged that the site appeared irritated and raw, likely from tugging and exposure to gastric contents. He indicated the need for orders for aspiration, flushing, and anchoring.On 3/26/26 at 9:59 a.m., Resident 95's record was reviewed.Her record lacked physician orders routine or as needed g-tube cite care such as, flushes, spirations, anchoring and monitoring for sign/symptoms of infection.Her comprehensive care plans lacked revision to indicated the g-tube was not longer in use, and or how to provide care for the equipment until it could be removed.During an interview on 3/26/26 at 12:00 p.m., The Director of Nursing indicated, nursing staff should review orders and recognize there were no standing orders for her g-tub after her return from the hospital, and called the physician to obtain appropriate orders to prevent the risk for complications and infections.On 3/27/26 at 9:53 a.m., the Administrator provided a copy of current facility policy, titled, Enteral Nutrition, dated 8/2024. The policy indicated, Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as: aspiration, tube misplacement or migration, skin breakdown around insertion site, perforation of the stomach or small intestine leading to peritonitis, esophageal swelling, strictures, fistulas; and clogging of the tube. Staff caring for residents with feeding tubes are trained on how to recognize complications relating to the administration of enteral nutrition products, such as: nausea, vomiting, diarrhea and abdominal cramping, inadequate nutrition, metabolic abnormalities, interactions between feeding formula and medications; and aspiration. Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments are documented and any changes are made to the care plan. Input from the resident or legal representative is included in the assessment.410 IAC (Indiana Administrative Code) 16.2-3.1.44.

Based on record review and interview, the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASRR) (a federal Medicaid requirement ensuring individuals with serious mental illness or intellectual disabilities are not inappropriately placed in nursing homes) was re-evaluated when a psychiatric diagnosis was added for 1 of 2 residents reviewed for PASRR (Residents 78 and 11). Findings include:1. Resident 78's record was reviewed on 3/26/26 at 12:15 p.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, psychotic disorder (a mental health condition characterized by a loss of contact with reality, where individuals struggle to distinguish what is real from what is not) with delusions (firm, fixed, and false beliefs that persist despite clear evidence to the contrary and are not explained by a person's cultural or religious background) due to a known physiological condition, dated 1/23/26, and psychotic disorder with hallucinations (a false perception of objects or events involving the senses) due to a known physiological condition, dated 1/30/26. A PASRR Level One Screening Outcome, dated 10/18/21, was completed at another nursing facility. The screening indicated the resident did not have a serious mental illness, and level two PASRR an in-depth, person-centered assessment required when a Level I screen indicates a person applying to a Medicaid-certified nursing facility may have a serious mental illness, intellectual disability, or related condition was not required). The resident's record lacked documentation the resident was referred for a new PASRR assessment when the psychotic disorder diagnoses were added. Physician's orders indicated the resident received psychotropic medications including Depakote (mood stabilizer), trazodone (antidepressant), and buspirone (anti-anxiety medication). During an interview, on 3/26/26 at 12:55 p.m., the [NAME] President (VP) of Life Enrichment indicated she reviewed the resident's record, and the resident needed reassessed for the consideration of a level two PASRR. The resident had a new psychotic disorder diagnosis which required reassessment. During an interview, on 3/27/26 at 11:04 a.m., the Social Services Director (SSD) indicated she thought the psychotic disorder diagnosis was on the resident's record when she was admitted to the facility from another nursing facility. The resident was on the list to be referred for a new PASRR assessment due to the diagnosis, but it had not been completed yet. The SSD was not sure how long from the time of admission they had to complete the referral.

Based on record review the facility failed to ensure a fall care plan was appropriately revised to reflect new fall interventions to be in place after several falls. This deficient practice had the potential to affect 1 of 7 Residents (Resident 12) reviewed for care plan revision.Findings include:On 3/25/26 at 12:01 p.m. Resident 12's medical record was reviewed. He was a memory care resident whose diagnoses included, but were not limited to, dementia and schizoaffective disorder (a chronic mental health condition combining schizophrenia symptoms with major mood episodes).An Interdisciplinary Team (IDT) note, dated 8/27/25, indicated on that day Resident 12 had fallen out of bed while he was changing positions. The new intervention to be put in place to prevent future falls was to refer the Resident to Occupational Therapy (OT) for an evaluation on his bed mobility. The note indicated Resident 12's care plan had been reviewed and updated.Resident 12's current fall care plan lacked the new fall intervention from his fall on 8/27/25.An IDT note, dated 10/13/25, indicated on 10/11/25 Resident 12 had fallen in the bathroom. The new intervention to be put in place to prevent future falls was to have Physical Therapy (PT) work with the Resident on dynamic functional transfers to improve safety awareness. The note indicated Resident 12's care plan had been reviewed and updated.Resident 12's current fall care plan lacked the new fall intervention from his fall on 10/11/25.An IDT note, dated 10/16/25, indicated on 10/15/25 Resident 12 had fallen in the activity room. The new intervention to be put in place to prevent future falls was to have PT work with the resident on lower extremity strength. The note indicated Resident 12's care plan had been reviewed and updated.Resident 12's current fall care plan lacked the new fall intervention from his fall on 10/15/25.An IDT note, dated 10/29/25, indicated on that day Resident 12 had fallen in his room trying to go to the bathroom. The new intervention to be put in place to prevent future falls was to have PT work with the Resident on bed mobility. The note indicated Resident 12's care plan had been reviewed and updated.Resident 12's current fall care plan lacked the new fall intervention from his fall on 10/29/25.On 3/27/26 at 12:00 p.m. a copy of a current facility policy titled, Care Plans, Comprehensive Person-Centered, dated 8/2024, was provided. That policy indicated, .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.410 IAC (Indiana Administrative Code) 16.2-3.1-35(c)(1)

Based on observation, record review, and interview, the facility failed to ensure call lights were kept within the residents' reach for 3 of 3 residents reviewed for call lights (Residents 70, 78, and 6). Findings include:1. During an observation, on 3/23/26 at 10:24 a.m., Resident 70 was observed lying in bed. The resident's call light was on the floor behind the head of the bed. There was no call light within the resident's reach. Resident 70's record was reviewed on 3/25/26 at 2:26 p.m. Diagnoses on the resident's profile included, but were not limited to, personal history of traumatic brain injury and aphasia (a communication disorder resulting from brain damage that impairs a person's ability to speak, understand, read, and write). An annual Minimum Data Set (MDS) assessment, dated 2/5/26, indicated the resident had a severe cognitive impairment and was dependent on staff assistance for most activities of daily living (ADLs). A care plan, last revised on 11/20/25, indicated the resident had a communication speech/language deficit related to aphasia and spoke non-sensical sentences and statements. Interventions included, but were not limited to, ensure and provide a safe environment including the resident's call light being kept within reach. A care plan, last revised on 2/9/26, indicated the resident was at risk for falls related to impaired mobility. Interventions included, but were not limited to, keep the resident's call light within reach. 2. During an observation, on 3/23/26 at 11:28 a.m., Resident 78 was lying in bed. The resident's call light was on the floor, between the bed and the wall. At the same time, the resident indicated she was not sure how she would call for help if needed because she was not sure where her call light was. During an observation, on 3/24/26 at 11:43 a.m., Resident 78 was lying in bed. The resident's call light was draped across the foot of the bed, hanging over the side approximately eight inches, and was not within the resident's reach. At the same time, the resident indicated she did not know where her call light was and did not think the staff had given it to her yet. During an observation, on 3/25/26 at 8:59 a.m., Resident 78 was observed lying in bed. The resident's call light was hanging over the foot of the bed and not within the resident's reach. At the same time, the resident indicated she was not sure where her call light was, and no one had given her the call light today. The resident indicated it bothered her not to have her call light within reach because without it, she had to yell for help when she needed it. Resident 78's record was reviewed on 3/26/26 at 12:15 p.m. Diagnoses on the resident's profile included, but were not limited to, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain tissue of oxygen and nutrients) unspecified severity with other behavioral disturbance. An admission Minimum Data Set (MDS) assessment, dated 1/30/26, indicated the resident had a moderate cognitive impairment and was dependent on staff assistance for showering/bathing and personal hygiene. A care plan, last revised on 2/2/26, indicated the resident was at risk for falls and fall related injuries. Interventions included, but were not limited to, keep the resident's call light within reach and encourage the resident to use it. 3. During an observation, on 3/23/26 at 12:52 p.m., Resident 6 was observed lying on a mattress next to the bed. The resident's call light was between the bed and the wall, and not within the resident's reach. Resident 6's record was reviewed on 3/24/26 at 11:33 a.m. Diagnoses on the resident's profile included, but were not limited to, unspecified altered mental status. A quarterly Minimum Data Set (MDS) assessment, dated 3/11/26, indicated the resident was cognitively intact. A care plan, last revised on 1/16/26, indicated the resident was at risk for falls and injury related to decreased mobility. Interventions included, but were not limited to, keep the resident's call light within reach. During an interview, on 3/26/26 at 1:30 p.m., Qualified Medication Aide (QMA) 9 indicated residents should have always had their call lights within their reach in their rooms. Staff should have made sure the call lights were within the residents' reach before the staff left the residents' room. During an interview, on 3/26/26 at 2:04 p.m., the Director of Nursing (DON) indicated call lights should have been placed within the residents' reach before staff left their room. On 3/27/26 at 9:11 a.m., the Administrator provided a document titled, .Answering the Call Light, last revised in August 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .General Guidelines.5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(v)(1)

Based on interviews and record reviews, the facility failed to ensure residents had orders for desired advance directives for two residents (Residents 75 and 113) and failed to ensure a Physician Order for Scope of Treatment (POST) form was appropriately filled out for a resident (Resident 3) for 3 of 5 residents reviewed for advanced directives.Findings include:1. On 3/26/26 at 11:43 a.m., a record review was completed for Resident 75. He had the following diagnoses which included, but were not limited to, cerebral infarction (stroke), aphasia (difficulty speaking), dementia, major depressive disorder, anxiety disorder and insomnia. His record lacked an order indicating he desired to have a full code status in the event of a cardiac arrest. He had a care plan, dated 3/4/26, indicating he wished to be a full code. The goal, dated 3/4/26, indicated that his wishes would be honored. 2. On 3/23/26 at 11:57 a.m., a record review was completed for Resident 113. She had the following diagnoses which included, but were not limited to, multiple fractures of the ribs, essential hypertension (HTN), hyperlipidemia (high cholesterol), generalized anxiety disorder, depression, insomnia, and muscle weakness. Her record lacked an order indicating she desired to have a full code status in the event of a cardiac arrest. She had a care plan, dated 3/3/26, indicating she wished to be a full code. The goal, dated 3/4/26, indicated her wishes would be honored. On 3/27/26 at 10:05 a.m., the Director of Nursing (DON) indicated she added orders for the two residents. 3. On 3/26/26 at 10:39 a.m. Resident 3's medical record was reviewed. She was a memory care resident whose diagnoses included, but were not limited to, dementia. Resident 3's medical record indicated her daughter was her Power of Attorney (POA). Resident 3 had a POST form that had been uploaded to her medical record. Upon review of this form, it was found that the form was filled out incorrectly. At the top of the form in the section labeled Patient Last Name, Patient First Name and Middle Initial Resident 3's daughter's name had been written which would have indicated the POST form was for the Resident 3's daughter not the Resident. On 3/27/26 at 11:18 a.m. the Director of Nursing (DON) indicated the POST form was more than likely filled out in error by Resident 3's daughter and it wasn't caught before being uploaded. She indicated they would reach out to the Resident's daughter to have her sign a new POST form immediately. A policy titled, Advanced Directives revised on 8/24 was provided by the Executive Director (ED) on 3/26/26 at 2:42 p.m. It indicated, .The resident has the right to formulate an advance directive, including the right to accept of refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. 410 IAC (Indiana Administrative Code) 16.2-3.1-4(1)

Based on record review and interview, the facility failed to complete a medication disposition for residents' medications when discharged from the facility for 2 of 2 records reviewed for discharge (Residents 120 and 119).Findings include:1. On 3/24/26 at 11:37 a.m., a record review was completed for Resident 120. She was discharged from the facility on 2/27/26. The resident's record lacked documentation upon discharge of the disposition of the following medications:magnesium oxide (a supplement) 400 milligram (mg)Trintellex (used to treat depression) 20 mgferrous sulfate (a supplement) 325 mgnaloxone (a lifesaving non-controlled opioid antagonist) 0.4 mgmethocarbamol (a muscle relaxer)1000 mgpantoprazole (used to treat acid reflux) 40 mgglycolax powder (use to treat constipation)acetaminophen (used to treat pain) 500 mgsenna-docusate (used to treat constipation) 8.6-50 mggabapentin (used to treat pain) 600 mgtorsemide (a diuretic)10 mgondansetron (used to treat nausea and vomiting) 4 mgloperamide (used to treat diarrhea) 2 mgdulcolax (used to treat constipation) 10 mgMilk of Magnesia (used to treat constipation) 30 ml2. On 3/24/26 at 12:36 a.m., a record review was completed for Resident 119. He was discharged from the facility on 2/28/26.The resident's record lacked documentation upon discharge of the disposition of the following medications:Risperdal (an antipsychotic) 0.5 milligram (mg)vitamin (a supplement) B12 1000mcg (microgram)metoprolol 12.5 mg (used for high blood pressure)lisinopril (used for high blood pressure) 10mgMilk of Magnesia 30 ml (used to treat constipation)methimazole (used to treat hypothyroidism) 5 mgfurosemide (a diuretic) 20 mgamlodipine (used to treat high blood pressure) 10 mgsennosides-docusate (used for constipation) 8.6 mg-50 mgacetaminophen (pain reliever) 325 mgEliquis (a blood thinner) 5 mgomega 3 [NAME] oil (a supplement) 500 mgcholecalciferol (a supplement)1000 u (unit)mirtazepine (an antidepressant) 7.5 mgDuring an interview with the [NAME] President of Clinical Services (VPCS) on 3/27/26 at 11:13 a.m., he indicated the resident's medications were sent back to the pharmacy and they were destroyed. He indicated he had no record of the destruction.On 3/26/26 at 9:51 a.m., the Director of Nursing (DON) received an email from the pharmacy indicating they could not find where the two residents had any of their medications returned to the pharmacy.A policy titled, Discarding and Destroying Medications, with a revision date of 8/24 was provided by the Executive Director (ED) on 3/26/26 at 2:14 p.m. It indicated, .non-controlled and schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guideline regarding disposition of non-hazardous medications.The medication disposition record contains, at a minimum, the following information: h. the resident's name, i. the name and strength of the medication, j. the prescription number, k. the name of the dispensing pharmacy, l. date medication destroyed, m. the quantity destroyed, n. the method destroyed, o. reason for destruction, p. signature of witnesses.

Based on observation, record review, and interview, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurate for 1 of 18 residents' MDS assessments reviewed (Resident 78). Findings include:During an observation, on 3/23/26 at 11:28 a.m., Resident 78 was lying in bed. The resident's left hand was closed, and she was unable to open or move it. Resident 78's record was reviewed on 3/26/26 at 12:15 p.m. Diagnoses on the resident's profile included, but were not limited to, hemiplegia (near paralysis on one side) and hemiparesis (weakness or limitation in movement on one side) following a nontraumatic subarachnoid hemorrhage (a type of stroke caused by bleeding into the space surrounding the brain) affecting the left non-dominant side. An admission MDS assessment, dated 1/30/26, indicated the resident did not have a limitation in range of motion to the upper or lower extremities. During an interview, on 3/26/26 at 12:57 p.m., the MDS Coordinator indicated the resident's admission MDS assessment, dated 1/30/26, was not coded correctly. The assessment should have indicated the resident had an impairment on one side of the upper extremities. The MDS Coordinator indicated the facility used the Resident Assessment Instrument (RAI) manual as their facility policy for completing MDS assessments. The Centers for Medicare and Medicaid [NAME] (CMS) RAI manual 3.0, dated October 2025, indicated, .GG0115: Functional Limitation in Range of Motion.Coding Instructions for GG0115A, Upper Extremity (Shoulder, Elbow, Wrist, Hand).Code 1, impairment on one side: if resident has an upper.extremity impairment on one side that interferes with daily functioning or places the resident at risk of injury. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(c)(4)

Based on observation and interview, the facility failed to ensure medications were properly stored and dated on medication carts for 2 of 2 medication carts observed for medication storage (Residents 58, 65, 64, 92, 51, 47, 63, and 83).Findings include:On 3/24/26 at 11:35 a.m. B hall medication cart was reviewed with Licensed Practical Nurse (LPN) 7. Findings were as follows:Resident 58 had an open Fluticasone inhaler that had no open date on the box or the inhaler itself.Resident 65 had an open Albuterol inhaler that had no open date on the box or the inhaler itself.Resident 65 had a second open Albuterol inhaler that had no open date on the box or the inhaler itself.Resident 64 had an open Albuterol inhaler that had no open date on the box or the inhaler itself.Resident 92 had an open Incruse Elipta inhaler that had no open date on the box or the inhaler itself.Resident 51 had an open Albuterol inhaler that had no open date on the box or the inhaler itself.Resident 47 had an Anoro Ellipta inhaler that had no open date on the box or the inhaler itself.Resident 63 had a bottle of Amoxicillin (an antibiotic) that indicated it should be taken for 7 days. The bottle indicated it was filled on 2/5/26. LPN 7 indicated Resident 63 stopped taking the Amoxicillin a while ago, it just hadn't been thrown out yet. The LPN indicated she did not know there was a separate expiration date for some medications, such as inhalers, once they were opened. On 3/24/26 at 12:15 a.m. A hall medication cart was reviewed with LPN 8. Findings were as follows:Resident 83 had a bottle of Moxifloxacin (an antibiotic) eye drops that indicated it should be given for only 7 days. The bottle indicated it had been filled on 2/10/26.Bisacodyl (a stool softener) suppositories were being stored in the same compartments as eye drops and nasal sprays.There was an open glass vial of lidocaine (a local numbing agent) in one of the compartments of the drawer. There was no bag or box for this medication and there was no prescription label on the bottle to indicate who the medication was for or what the order was.On 3/27/26 at 1:05 p.m. a copy of a current facility policy titled, Medication Storage in the Facility, dated 2020 was provided. That policy indicated .3. Orally administered medications are kept separate from externally used medications (e.g. suppositories, liquids, lotions and tablets. 13. Outdated. medications.are immediately removed from stock.On 3/27/26 at 1:05 p.m. a copy of a current, undated facility guideline titled, Expiration Dates, was provided. That policy indicated .Anoro Ellipta [expiration] 6 weeks after foil opened.Fluticisone [expiration] 6 weeks after foil opened.Incruse Ellipta [expiration] 6 weeks after foil opened.Albuterol [expiration] 3 months at room temperature.Symbicort [expiration] 3 months after foil opened.410 IAC (Indiana Administrative Code) 16.2-3.1-25(j)410 IAC (Indiana Administrative Code) 16.2-3.1-25(m)410 IAC (Indiana Administrative Code) 16.2-3.1-25(n)

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity during interactions with staff and dining for 2 of 2 residents reviewed for dignity (Resident 87 and 112). Findings include: 1. During an observation, on 3/23/26 at 11:34 a.m., Resident 87 was repetitively and loudly yelling in the hallway. Licensed Practical Nurse (LPN) 6 sternly told the resident, I'm going to assist you, but you're still yelling in the hallway for no reason. Resident 87 continued to yell. The staff was not observed to attempt to find out why the resident was yelling or provide a targeted intervention. During an observation, on 3/23/26 at 11:50 a.m., Resident 87 was observed repeatedly calling out for help for several minutes. The Administrator had approached the resident, and then indicated the resident had been incontinent and was wet. Two nurse aides were present at the nurses' station but did not approach the resident or address the resident's calls for help. At the same time, the resident indicated he was upset, kicked a soiled shirt, and indicated he was wet. The resident was observed to have a wet spot on the front of his sweatpants. During an interview, on 3/23/26 at 1:04 p.m., Resident 87 indicated the staff did not treat him with respect and dignity, and they did not follow his instructions. The resident indicated earlier, when he started yelling, he needed assistance to get to his urinal, but the staff was not helping. He was frustrated because they were not helping him. When he was unable to access his urinal, he peed his pants, because he was not able to wait. He was then yelling because he wanted to get help getting changed. The resident indicated the nurse was not nice to him when he was yelling, and this was not unusual. The resident indicated it made him feel bad when the staff spoke to him that way. Resident 87's record was reviewed on 3/27/26 at 9:27 a.m. Diagnoses on the resident's profile included, but were not limited to, dementia (progressive decline in memory, thinking, and cognitive skills severe enough to interfere with daily life). A quarterly Minimum Data Set (MDS) assessment, dated 2/12/26, indicated the resident was cognitively intact, dependent on staff assistance for personal hygiene, and frequently incontinent of bladder. A care plan, last revised on 11/4/25, indicated the resident had behaviors of becoming physically and verbally aggressive, urinating on the floor, and verbal aggression towards staff. Interventions included, but were not limited to, assess and anticipate the resident's needs including toileting and redirect the resident with non-pharmacological interventions to enhance his quality of life including offering to converse about him working in a hotel, used to play tennis, ride bikes, going outdoors, chess, offering the resident to watch television, attend church services, and socialization. A care plan, last revised on 2/13/26, indicated the resident had an activities of daily living (ADL) self-care performance deficit related to decreased mobility. Interventions included, but were not limited to, dependent for toileting hygiene and personal hygiene. A care plan, last revised on 2/13/26, indicated the resident had bladder incontinence related to decreased mobility. Interventions included, but were not limited to, supply resident with toileting devices as appropriate including a urinal and check routinely for incontinence and change clothing as needed after incontinence episodes. During an interview, on 3/27/26 at 11:04 a.m., the Social Services Director (SSD) indicated if a resident was approached by the staff in a negative manner, the resident was more likely to respond in a negative way. The approaches used by staff affected the resident's response. The SSD indicated for this resident, the nurse speaking to him in the way she did was not likely to help the resident calm down or de-escalate the situation. The staff should have used interventions included on the resident's care plans when he was yelling. The SSD indicated the resident was very religious and talking with him about his religion was helpful. The resident could also be re-approached at a later time, or the Director of Nursing (DON) or SSD could have been asked to help with the resident if needed. On 3/27/26 at 12:15 p.m., the Administrator provided a document titled, .Dignity, last revised in August 2024, and indicated it was the policy currently being used by the facility. The policy indicated, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 2. On 3/23/26 from 12:00 p.m. until 12:30 p.m. the following was observed during a dining observation. At 12:00 p.m. staff began to pass lunch trays in random order to the residents gathered in the dining room, so that some residents were left waiting while their tablemates ate. At one table, where four residents sat, two residents were served, while the other two waited. By the time they were served their other two tablemates had already eaten and left the table. At 12:09 p.m., Resident 112's lunch plate was set in front of her. She was reclined in a Broda chair, had slid down, was leaning to her left side, and her head nearly resting on the armrest of the chair. Two unidentified staff members, pulled her away from the table, and attempted to reposition her by using the hoyer pad that was under her. The Assistant Director of Nursing and one of the nursing aides, removed her from the dining room, leaving her lunch plate at the table. At 12:18 p.m., Resident 112 was returned to the dining room at her place at the table where her plate remained. When staff attempted to help feed her, she refused to take bites. No one offered to warm the plate up, or offer her an alternative. An unidentified nursing aide, attempted to help Resident 112 eat, by standing and leaning over her and resting her forearms on the table. She talked to another aide and did not engage or look at the Resident. She did not make meaningful attempts to encourage Resident 112 to eat. After a few quick attempts, she left the resident to gather discarded meal tickets. At 12:30 p.m., Resident 112 was removed from the dining room, after not eating or being offered alternatives. On 3/24/26 at 10:13 a.m., Resident 112's record was briefly reviewed. She had diagnoses which included, but were not limited to, cerebral palsy. She had a quarterly Minimum Data Set (MDS) assessment, dated 3/13/26, indicated she was totally dependent on staff for all activities of daily living (ADLs) including nutrition and eating. On 3/27/26 at 12:15 p.m., the Administrator provided a copy of current facility policy titled, Dignity, dated 8/2024. The policy indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. allowed to choose when to sleep, eat and conduct activities of daily living; and. provided with a dignified dining experience. 410 IAC (Indiana Administrative Code) 16.2-3.1-3.

Based on interview and record review, the facility failed to protect a resident's right to be free from verbal abuse by a Certified Nursing Assistant (CNA 6) who engaged in a verbal altercation with the resident that included profane language for 1 of 3 residents reviewed for abuse (Resident C). This deficient practice was corrected by 2/16/26 prior to the start of the survey and was therefore Past Noncompliance. Findings include:A Facility Reported Incident (FRI), dated 2/14/26 at 11:01 a.m., indicated Resident C and CNA 6 had a verbal altercation. CNA 6 stated the resident had hit her in the face and called her several names, and in return CNA 6 became upset and called Resident C names. CNA 6 was initially sent to another part of the building, then suspended pending investigation. The investigation was completed and CNA 6 subsequently terminated on 2/16/26. Resident C's clinical record was reviewed on 3/2/26 at 12:45 p.m. Diagnoses on Resident C's profile included hemiplegia (severe paralysis of one side) and hemiparesis (mild paralysis of one side) following a cerebral infarction affecting the left non-dominant side, intermittent explosive disorder, post-traumatic stress disorder (PTSD), and adjustment disorder with mixed anxiety and depressed mood. A quarterly MDS (Minimum Data Set) assessment, completed on 12/13/25, indicated Resident C was cognitively intact, and was documented during the assessment period as having both physical and verbal behaviors towards others. The resident was dependent on staff for transfers for toileting and shower/bathing. Resident C was wheelchair dependent. A current care plan for Resident C indicated he had an ADL (activities of daily living) self-care deficit related to decreased mobility secondary to hemiplegia, and a right above the knee amputation. He was dependent on staff for tub/shower transfers and bathing/showering. The resident used an electric wheelchair for mobility. A current care plan for Resident C indicated he had extensive behaviors of attention seeking and making false statements and accusations towards staff and others. Interventions included staff providing care in pairs. A current care plan for Resident C indicated he was at risk for falls/injury due to hemiplegia, a right above the knee amputation, and a history of non-compliance with self-transfers. Interventions included anticipate and meet the resident's needs, and call light was to be within reach. Resident C's clinical record lacked documentation on 2/14/26 regarding an altercation with a staff member. A witness statement from Nurse Supervisor 8, dated 2/14/26, indicated she had been walking towards A-Wing from the connecting hallway. As she got closer to the unit, she heard yelling and cursing from CNA 6 and Resident C. CNA 6 ran out of the shower room stating Resident C hit her in the face. Nurse Supervisor 8 asked CNA 6 to explain to the charge nurse what was going on as she went to check on the resident. CNA 6 stated she was going home and did not want to give any statements. Nurse Supervisor 8 indicated she had called the Director of Nursing (DON) after separating the resident and aide and gave report on what had happened as she saw at the time. This supervisor along with the charge nurse took patient in confidence, and made sure he had no immediate needs, and asked him what happened in the shower room. Resident stated that he was cursing at the CNA and that she was cursing back at him as they were both yelling, and she lunged at him in a threatening manner like a boxer, saying no one got hit. We asked him if he hit her and he denied touching her. At this time CNA 6 refused to give the supervisor or charge nurse report stating she would e-mail her statement. CNA 6 was relieved of her assignment and sent home for the safety of the residents pending further investigation. A witness statement from Registered Nurse (RN) 9, dated 2/14/26, indicated she had heard both Resident C and CNA 6 cursing each other out from the hallway. The voices were coming out of the A-hall shower room. The writer tried to understand what triggered the noise, but the only thing she could hear at that time was the two cursing each other back and forth. A nurse witness statement (signature illegible), dated 2/14/26, indicated the nurse had been coming from B-hall and heard CNA 6 yelling and cursing along with Resident C. CNA 6 then ran out of the shower room saying Resident C had hit her in the face. CNA 6 would not calm down enough to explain what happened in detail and refused to write a statement when asked. Review of CNA 6's staff file, indicated she was hired on 1/30/25, and had signed as having received education on abuse, resident rights, and dementia training. An Employee Termination Form, dated 2/16/26, indicated CNA 6 had been suspended on 2/14/26 at 11:30 a.m., and then involuntarily terminated for verbal abuse, after positive conclusion to an investigation on 2/14/26. A FRI follow-up, dated 2/20/26, indicated the investigation was completed and substantiated.CNA 5 and CNA 6 had been providing a shower to Resident C. When the shower was completed, CNA 5 went to get a male staff member to assist with the transfer of the resident. While CNA 5 was gone, CNA 6 stepped out of the shower room and stood by the door. Resident C, who was care planned for care in pairs, became upset and began banging and yelling. When CNA 6 and other staff members responded to the noise, Resident C started cussing and allegedly called CNA 6 the N word. CNA 6 was sent away from the area, then instructed to clock out by the weekend supervisor. CNA 6's employment with the company was subsequently terminated. During an interview on 3/2/26 at 2:01 p.m., the DON indicated on the morning of Saturday 2/14/26, female CNA 5 and male CNA 10 had lifted Resident C in the shower room, as it took 2 persons to safely transfer him. CNA 10 then left and CNA 5 proceeded to give the resident his shower. When the shower was finished, CNA 5 left the shower room to get assistance to again lift the resident. At some point, Resident C started banging on things, and CNA 6, who had been standing outside of the shower room to provide oversight and privacy, entered the shower room, and Resident C and CNA 6 got into a verbal confrontation. Staff nurses 9 and 12 overheard the resident and aide cursing each other but did not witness any physical altercation. The DON indicated after that the calls and messages between her and staff happened quickly and some simultaneously. Around 11:05 a.m., before the nurses could call her, CNA 6 called her to report Resident C had hit her. The DON instructed CNA 6 to get off the hallway and to provide a written statement. The DON then spoke to the weekend supervisor, who had been attempting to contact her, and was told there was more to the story. After hearing there had been a verbal altercation to include the use of profane language from both the resident and aide, the DON gave instructions for CNA 6 to be clocked out and sent home, and the aide was suspended after she left the facility. The weekend supervisor started gathering statements from the staff who had overheard the altercation. At 11:22 a.m., CNA 6 texted the DON asking if she was fired. The DON responded by again requesting a written statement, the aide responded, yes ma'am, but never provided a statement. The DON notified the Executive Director (ED) and all necessary parties of the incident. Abuse education to staff was initiated by Weekend Supervisor 8 on 2/14/26. On Monday, 2/16/26, the DON called CNA 6 and terminated her employment. During an interview on 3/3/26 at 11:55 a.m., CNA 5 indicated one weekend Resident C had been complaining about not getting showers and she told him she would give him one. CNA 5 had left the shower room while the resident washed himself and to get the male CNA 10 to help lift the resident into his chair. When coming back down the hall, CNA 5 heard a lot of screaming, and Resident C repeated yelling for CNA 6 to get out. There had not been anyone in the shower room with Resident C, and when CNA 5 heard him yelling, she thought he had fallen and she began to run. When she rounded the hall, she saw CNA 6 at the door threshold and heard her say, OMG I thought you fell. Resident C began yelling at CNA 6, asking why she did not get in there and put him in his chair. Why don't you get your fat black African ass over here and put me in my chair. When CNA 5 told the resident that CNA 10 was on his way because he could lift him, the resident pointed at CNA 6 and stated, Her fat black ass can do it. Resident C then turned the shower head back on and sprayed CNA 6. After Resident C had been lifted back into his chair, he moved down the hall in his power chair to the nurse's station where CNA 6 was and began to berate her by repeating similar insults to her. CNA 6 did not respond to the resident, and CNA 10 got him to move on. CNA 5 indicated she did not hear CNA 6 engage with the resident at all. During an interview on 3/3/26 at 1:49 p.m., RN 9 indicated she was there the day Resident C and CNA 6 got into it. She had been in the middle of the hallway and heard loud voices coming from the shower room. She heard both cussing each other out but could not remember what was said. CNA 6 went away from the shower room and sat at nurse's station, and a few minutes later, Resident C went to the station on his power chair. They began to yell at each other again, and were both using bad words, going back and forth. CNA 10 was able to talk the resident into moving on down the hall. During an interview on 3/4/26 at 11:20 a.m., the DON indicated the subject of resident abuse, what it was and to who it needed to be reported to, was always discussed during monthly staff meetings. The DON indicated she and other supervisors, including the weekend supervisor, tried to interact with the floor staff frequently, monitor them for signs of burnout, and would encourage them to take a short break when needed. In her opinion, staff were communicative and watched out for each other. The DON indicated she knew there were monthly resident council meetings scheduled, but did not know if the Social Service Director discussed abuse with the residents or not. She did know that residents had been educated on using the grievance process for concerns. Nursing concerns were placed on Quality Assurance and Performance Improvement (QAPI) plans, and as of January 2026, QAPI meetings would be scheduled quarterly. Abuse had not been a topic at the January 2026 QAPI meeting as there had not been a pattern of concerns at that time. During an interview on 3/4/26 at 11:32 a.m., the SSD indicated she did not routinely plan or participate in Resident Council Meetings, that was usually the responsibility of the Activity Director. But, on 2/23/26, the SSD facilitated the February meeting, and the agenda included how the resident could submit a grievance, where to find the contact phone number for the local Ombudsman, and where to locate the State Annual Survey binder. The discussion included what could be considered abuse, how and who to report to, i.e. to the nurse who reported it to the ED immediately, and then what the follow-up investigation would include. During an interview on 3/3/26 at 3:28 p.m., Resident C indicated on 2/14/26 he had been in the shower room by himself, washing his body where he could reach. His bottom slipped into the hole of the shower chair, and it was a little uncomfortable. He started banging on the wall with the shower wand and yelling to get some help. CNA 5 came in and they got into little argument, but it was nothing big. CNA 6 then came into the room and started yelling at him, cursing and calling him names, although he could not remember what was said specifically. He was yelling back at her and then told her to get the f--- out of here. CNA 6 stood outside the door, and when he said something to her, she came back into the shower room, and he thought she was going to hit him. CNA 6 continued to yell and approached him, and he was yelling back at her, although he could not recall what he was yelling. Nurse 12 came into the room and told everyone to calm down. CNA 6 left the room, and he finished getting dressed and went to his room. When he passed the nurse's station, CNA 6 was there and began to yell at him again. He did yell back until CNA 10 helped to push him to his room. On 3/2/26 at 2:32 p.m., the ED provided an Abuse and Neglect clinical protocol, dated 8/2024, and indicated the protocol was the one currently being used by the facility. The protocol indicated, instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse. This deficient practice was corrected by 2/16/26 prior to the start of the survey and was therefore Past Noncompliance. The facility reviewed their current practices and had a plan in place for resident and staff education regarding policy and procedures for monitoring, reporting, and documenting abuse, and would have ongoing monitoring by Quality Assurance and Performance Improvement (QAPI). This citation relates to Intake 2744070. 410 IAC (Indiana Administrative Code) 16.2-3.1-27(b)

Based on interview and record review, the facility failed to complete a thorough investigation of a resident-to-resident allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident D)Findings include:Review of a facility reported incident, dated 8/24/25, indicated Resident D and Resident E were outside in the smoking area. There was a disagreement between them, and Resident E made contact with Resident D's cheek. The two residents were separated. Resident D was assessed with no injuries observed by the nurse. Resident D indicated he had moderate pain to the area and was treated for pain management. Both residents returned to their rooms. The physician, Director of Nursing, Administrator and resident's representatives were notified. A follow-up report was added on 8/19/25 and indicated Resident E and Resident D were doing well. During the interview process, Resident E indicated he had been upset with Resident D because he felt he was making fun of another resident. Resident D believed he had not said anything and did not know why it happened. Resident E indicated he was wrong to behave that way. Both residents had made up their differences and have interacted with each other. No other issues between residents had occurred and no psychosocial concerns had been noted.1. The clinical record for Resident D was reviewed on 9/5/25 at 10:28 a.m. Diagnoses included left-sided hemiplegia and hemiparesis following a stroke, anxiety disorder, and right above knee amputation. A quarterly Minimum Data Set (MDS) assessment, dated 6/19/25, indicated the resident was cognitively intact. The resident had no hallucinations or delusions, rejection of care, and had no physical or verbal behaviors. A nursing progress note, dated 8/23/25 at 10:15 p.m., indicated Resident D reported that another resident had punched him with a closed fist on the left cheek while not facing him, after having a small disagreement. The resident reported pain to his left cheek where he was punched. The resident was assessed for pain, skin injury and vital signs. He reported his pain as 5 out of 10. No injuries were noted. Vitals signs were within normal limits. The residents were separated and reminded to maintain distance. The Administrator was notified immediately.During an interview on 9/5/25 at 10:28 p.m., Resident D indicated the incident was embarrassing for him, to be hit over a misunderstanding. He was left with swelling on the left side of his face and felt like he could not see as well out of his left eye. He felt the staff were unconcerned about his feelings following the incident. The Administrator and Social Services Director had asked him how he was doing, but only in common areas where there was no privacy. He had been smoking in his truck following the incident because he was concerned the resident might misunderstand him again. He was just not comfortable. Resident E had apologized to him, but he remains uncomfortable around him.2. The clinical record for Resident E was reviewed on 9/5/25 at 10:25 a.m. Diagnoses included paranoid schizophrenia, antisocial personality disorder, and hypertensive heart disease with heart failure. A quarterly MDS assessment, dated 7/2/25, indicated the resident was cognitively intact. The resident had no hallucinations or delusions, rejection of care, and had no physical or verbal behaviors.A nursing progress note, dated 8/23/25 at 6:38 p.m., indicated Resident E was observed walking back to his room from the smoking area when a few seconds later, Resident D was observed coming down the hallway on his electric wheelchair, yelling, and accusing Resident E to have bashed me in my face. Resident E exited his room into the hallway and started to argue with Resident D. Staff members intervened and de-escalated the incident, directing residents to their rooms.During an interview on 9/5/25 at 10:25 a.m., Resident E indicated he made a mistake during the incident and apologized to Resident D. He had misunderstood what Resident D had said and had hit him. He felt the two were fine to be around each other now.During an interview on 9/5/25 at 11:45 a.m., the Nurse Practitioner (NP) indicated she had seen Resident D on 8/25/25 and observed no swelling, redness or bruising to the left side of his face. He had not mentioned he was fearful or concerned about Resident E or feeling in danger. She had observed him in the common areas and outside smoking with residents. She was confident Resident D would have talked to her about any discomfort in being around Resident E.During an interview on 9/5/25 at 10:52 a.m., the Administrator indicated Resident E was protective of other residents and staff. He indicated Resident E had heard Resident D say something inappropriate about someone and had slapped Resident D on the left side of his face. He was on the phone with the nurse when Resident D was at the nurses' station and had requested to call the police. He had instructed the nurse to call the police if that was what Resident D requested. However, Resident D changed his mind and indicated to the nurse he did not want the police called. He observed Resident D the following day and could not see any redness or swelling to the left side of his face.The Administrator provided the incident investigation information on 9/5/25 at 11:15 a.m., containing a written statement by an LPN 4 and a document signed by the Administrator.The written statement was signed by LPN 5, who had not witnessed or observed the residents on the date of the incident. The statement indicated she had been notified by other residents that Resident E had made physical contact with Resident D due to Resident D picking and calling other residents names. Resident E was protecting other residents and became defensive on or about 8/23/25.Another document contained in the investigation file, signed by the Administrator, and dated 8/29/25, included the following:a. 8/25 I (Administrator) spoke with [Resident D] about incident with [Resident E]. [Resident D] didn't know why he was hit by [Resident E].b. 8/25 I spoke with Resident E about incident. Resident E said he was upset about Resident D talking bad about other residents.c. 8/28 [Resident D] stated he did not say anything wrong about other residentsd. 8/29 [Resident E] informed staff member, LPN 5 that they had apologized and there were no issues between them.During an interview on 9/5/25 at 2:00 p.m., the Administrator indicated the residents were both cognitively intact and he felt the investigation was as thorough as it needed to be and that the resident's had worked things out. He was unaware that Resident D remained uncomfortable around Resident E. He had not interviewed other residents or staff regarding the incident/behavior.A current facility policy, dated 8/2024, titled, Accidents and Incidents - Investigating and Reporting, provided by the Administrator on 9/5/25 at 2:03 p.m., included the following: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.The Administrator indicated on 9/5/25 at 2:28 p.m., the policy provided was the only policy regarding resident-to-resident or resident-to-staff incidents. The facility follows the Indiana Department of Health guidelines.This citation relates to Incident 2600099.3.1-28(d)

Based on interview and record review, the facility failed to protect a resident during care resulting in actual harm when the resident sustained a full thickness burn to his left foot requiring surgical interventions for 1 of 4 reviewed for accidents (Resident B). The deficient practice was corrected on 5/23/25, prior to the start of the survey, and was therefore past noncompliance. Findings include: A review of Resident B's clinical record was completed on 6/2/25 at 10:53 a.m. Diagnoses included burn of unspecified degree of left foot, diabetes mellitus type II, and degenerative disease of the nervous system. A quarterly Minimum Data Set (MDS) assessment, dated 4/11/25, indicated the resident was cognitively intact, used a wheelchair for mobility, required partial to moderate assistance of staff to put on and remove footwear, complete lower body dressing, transfer from chair to bed, and had a diabetic foot ulcer and received dressings to his feet. A health care plan, initiated 2/4/25, indicated Resident B had diabetes mellitus with neuropathy. Interventions included to avoid exposure to extreme heat or cold. A nurse practitioner progress note completed by Nurse Practitioner (NP) 2, dated 5/19/25 at 3:30 p.m., included Resident B was seen at the request of nursing for a blister to his left foot. The resident was found seated with both feet resting on a towel and a wash basin visibly placed in front of the patient. Nursing indicated that foot washing was initiated as a preparatory measure before the administration of previous treatment .for an unrelated skin condition. Nurse reports that she facilitated foot washing by preparing water and directing the patient to immerse his feet. Subsequently, the patient raised concerns regarding the water temperature. Nurse reports, the water temperature was found to be within an acceptable range.' Following this, the nurse advised the patient to 'hold on' while she retrieved treatment supplies. Nurse reports, upon her return to the room, the patient presented with a fluid-filled blister on the top of left foot, after removing his foot from the water. Notable clinical findings included the presence of loose skin and mild erythema on the affected foot A nursing progress note by LPN 7, dated 5/21/25 at 5:06 p.m., indicated the dressing to Resident B's left foot was hard to get off and had blisters noted to top of all five toes, sloughing, copious amount of serous drainage, skin peeling, and very painful to touch. The wound NP was notified, and treatment was completed as ordered. A NP progress note completed by NP 2, dated 5/21/25 at 7:46 p.m., included Resident B was seen at the request of nursing for pain to his left foot. The patient seen for a follow-up visit concerning their left foot pain, which presented with new symptoms during recent care. The patient has a significant history of diabetes and frequent cellulitis episodes, necessitating careful management of skin integrity and related complications. The patient reports new onset pain in the affected area (Left foot). The patient describes the pain as moderate but constant, located specifically to the left foot where he has a previous blister .The treatment plan includes continued monitoring and education, with an emphasis on prompt notification of any acute changes, underscoring the need for vigilance given the patient's predisposition to complications due to his underlying conditions. Nursing staff have been briefed on these updates and are prepared to report any further developments promptly .Derm: Dressing intact to left foot A nursing progress note completed by RN 3, dated 5/21/25 at 10:03 p.m., indicated the resident had complained of excruciating pain to his left foot. The resident indicated his foot was submerged in hot water prior to the scheduled treatment on 5/19/25. RN 3 had changed the dressing and indicated the foot appears to be a 3rd degree burn, yellow slough, red, draining & toes matted. RN 3 contacted 911 and the resident was taken to an acute care burn unit for further evaluation and treatment. During an interview on 6/2/25 at 11:33 a.m., the DON indicated there was no order as part of Resident B's wound care to soak his foot. LPN 4 wanted to make sure the area was clean prior to completing the ordered treatment to the diabetic ulcer on the bottom of his left foot. She should not have soaked his foot as this was not part of his wound care treatment orders. During an interview on 6/2/25 at 11:46 a.m., LPN 4 indicated she was preparing to complete Resident B's wound care orders, and she wanted to complete foot care prior to his left foot treatment. As she was running the water into the basin for the resident to soak his foot, she ran her hand under the running water, and it felt warm. She finished filling the basin. She had not checked the temperature of the water in the basin after it was filled. She instructed the resident to put his left foot in the water. Resident B placed his foot in the water and indicated the water was hot and removed his foot. She indicated to him that she had just checked the water and told him to hang on and she would go get his wound care supplies. She was gone for about five minutes and when she returned to his room his foot was in the basin. She noticed his skin had developed a small lemon sized blister on the top of his foot. She had not intended for the resident to put his foot in the basin when she left the room. He indicated to her his foot hurt and she administered an as needed dose of pain medication. She informed NP2 and the unit manager and both came to the resident's room. During an interview on 6/2/25 at 12:07 p.m., Resident B indicated his left foot was burned when LPN 4 was providing wound care. He indicated the nurse brought over a basin of water for him to soak his foot in prior to applying a treatment to the sore on the bottom of his left foot. When he put his foot into the water, he felt like it was too hot, and he pulled his foot out. The nurse told him she had felt the water, and it was not too hot, but to hold on and she would go get some supplies. She had been out of the room for a couple of minutes when she passed by his door and told him to go ahead and try again. She had not checked the water temperature. He put his foot into the water, it felt hot but tolerable. When she returned about five minutes later, she was surprised to see a blister on the top of his foot. His feet were numb a lot because of his diabetes, and he had not realized the water was still hot. During an interview on 6/2/25 at 12:40 p.m., NP 2 indicated she had been called to Resident B's room on 5/19/25. She had not noticed a blister, but the resident's left foot was sorta red with a small open area. She had visualized the resident's foot following the incident, but had not had staff remove the resident's dressing during her follow up visit on 5/21/25 due to increased pain. The physician was completing rounds the following day (5/22/25), and she wanted the physician to look at the left foot at that time. During a telephone interview on 6/2/25 at 2:41 p.m., RN 3 indicated Resident B had been in so much pain and his wound looked bad on 5/21/25. He had not been in a lot of pain the night before. When she had completed his wound treatment on 5/21/25, she had been unaware the resident had sustained a burn to his left foot. She had prepared to complete his treatment for his diabetic ulcer to the bottom of his left foot. The resident had a hard time tolerating the treatment. She had called the DON and received approval to send him to the emergency room for treatment. A Burn Service Team History and Physical Note, dated 5/22/25, from the acute burn unit provider, indicated the resident had presented with scald burns to his left foot, sustained three days ago. The Assessment/Plan indicated the patient had a three day old full thickness scald burn to the left foot. An Inpatient Discharge summary, dated [DATE], from the acute burn care provider, indicated the resident had two surgical procedures on 5/22/25 and 5/27/25 for debridement of left foot and skin graft application. A current facility policy, dated 8/2024, titled, Change in a Resident's Condition or Status, provided by the Corporate Nurse on 6/3/25 at 12:06 p.m., included the following: .Policy Interpretation and Implementation .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The deficient practice was corrected by 5/23/25 after the facility implemented a systemic plan that included the following actions: water temperature adjustments and monitoring, resident interviews, staff interviews, resident skin assessments, education of staff, and continued monitoring. Cross reference F684. This citation relates to Complaint IN00460578. 3.1-45(a)

Based on interview and record review, the facility failed to obtain timely treatment and assessments of a full thickness burn to a resident's left foot resulting in actual harm when the resident required hospitalization and surgical interventions at an acute care hospital for 1 of 4 reviewed for timely care and treatment (Resident B). Findings include: During an interview on 6/2/25 at 12:07 p.m., Resident B indicated on 5/19/25 his left foot was burned when the nurse was providing wound care. He indicated the nurse brought over a basin of water for him to soak his foot in prior to applying a treatment to the sore on the bottom of his left foot. When he put his foot into the water, he felt like it was too hot and pulled his foot out. The nurse told him she had felt the water, and it was not too hot, but to hold on and she would go get some supplies. She had been out of the room for a couple of minutes when she passed by his door and told him to go ahead and try again. She had not checked the water temperature. When he returned his foot into the water, it felt hot but tolerable. When she returned about five minutes later, she was surprised to see a blister on the top of his foot. His feet were numb a lot because of his diabetes, and he had not realized the water was still hot. Cross reference F689. A review of Resident B's clinical record was completed on 6/2/25 at 10:53 a.m. Diagnoses included burn of unspecified degree of left foot, diabetes mellitus type II, and degenerative disease of the nervous system. A nurse practitioner progress note completed by Nurse Practitioner (NP) 2, dated 5/19/25 at 3:30 p.m. and created on 5/24/25 at 8:18 p.m., included Resident B was seen at the request of nursing for a blister to his left foot. The resident .was found seated with both feet resting on a towel and a wash basin visibly placed in front of the patient. Nursing indicated that foot washing was initiated as a preparatory measure before the administration of previous treatment .for an unrelated skin condition. Nurse reports that she facilitated foot washing by preparing water and directing the patient to immerse his feet. Subsequently, the patient raised concerns regarding the water temperature. Nurse reports, 'the water temperature was found to be within an acceptable range.' Following this, the nurse advised the patient to 'hold on' while she retrieved treatment supplies. Nurse reports, upon her return to the room, the patient presented with a fluid-filled blister on the top of left foot, after removing his foot from the water. Notable clinical findings included the presence of loose skin and mild erythema on the affected foot. A Weekly Skin Assessment, dated 5/19/25 at 6:58 p.m., indicated the resident had a new impairment of skin integrity. The description indicated a fluid filled blister to the top of the left foot. Wound interventions indicated the NP/physician was notified, a treatment as ordered, and monitor for signs or symptoms of infection. A current physician's order, dated 5/19/25 at 7:00 p.m., indicated to cleanse left foot with sterile water, pat dry, and apply a non-adherent dressing. Staff were to wrap foot with gauze and secure with tape. Treatment was to be completed every day and night shift. A Weekly Skin Assessment, dated 5/20/25 at 6:01 a.m., indicated the resident had a new impairment of skin integrity. The description indicated left toes. Wound interventions indicated the NP/physician was notified and treatment as ordered. The clinical record lacked documentation regarding an assessment and description of the resident's burn wound on 5/20/25. A nursing progress note by LPN 7, dated 5/21/25 at 5:06 p.m., indicated the dressing to Resident B's left foot was hard to get off and had blisters noted to top of all five toes, sloughing, copious amount of serous drainage, skin peeling, and very painful to touch. The wound NP was notified, and treatment was completed as ordered. A NP progress note completed by NP 2, dated 5/21/25 at 7:46 p.m. and created on 5/25/25 at 9:15 p.m., included Resident B was seen at the request of nursing for pain to his left foot. The patient seen for a follow-up visit concerning their left foot pain, which presented with new symptoms during recent care. The patient has a significant history of diabetes and frequent cellulitis episodes, necessitating careful management of skin integrity and related complications. The patient reports new onset pain in the affected area (Left foot). The patient describes the pain as moderate but constant, located specifically to the left foot where he has a previous blister .The treatment plan includes continued monitoring and education, with an emphasis on prompt notification of any acute changes, underscoring the need for vigilance given the patient's predisposition to complications due to his underlying conditions. Nursing staff have been briefed on these updates and are prepared to report any further developments promptly .Derm: Dressing intact to left foot A nursing progress note completed by RN 3, dated 5/21/25 at 10:03 p.m., indicated the resident had complained of excruciating pain to his left foot. The resident indicated his foot was submerged in hot water prior to the scheduled treatment on 5/19/25. RN 3 had changed the dressing and indicated the foot appears to be a 3rd degree burn, yellow slough, red, draining & toes matted. RN 3 contacted 911 and the resident was taken to an acute care burn unit for further evaluation and treatment. A Clinically at Risk report, dated 5/23/25 at 12:51 p.m., indicated the reason for review was for a chronic wound. Team members in attendance were listed as the DON and registered dietician. The comment included that the resident had been admitted to the hospital on [DATE] for a diabetic foot ulcer. Under the Skin/Wounds section of the report, concerns were listed regarding left foot plantar, diabetic foot ulcer. Cleanse with wound cleanser, apply hydrogel and bordered gauze. The report indicated the care plan had been updated and was signed on 5/25/25. The report lacked indication of the resident sustaining and being hospitalized due to a burn sustained during care at the facility. During an interview on 6/2/25 at 11:46 a.m., LPN 4 indicated she was preparing to complete Resident B's wound care orders, and she wanted to complete foot care prior to his left foot treatment. As she was running the water into the basin for the resident to soak his foot, she ran her hand under the running water and felt it was warm and finished filling the basin. She had not checked the temperature of the water in the basin after it was filled. She instructed the resident to put his left foot in the water. Resident B placed his foot in the water and indicated the water was hot and removed his foot. She indicated to him that she had just checked the water and told him to hang on and she would go get his wound care supplies. She was gone for about five minutes and when she returned to his room his foot was in the basin. She noticed his skin had developed a small lemon sized blister on the top of his foot. She had not intended for the resident to put his foot in the basin when she left the room. He indicated to her his foot hurt and she administered an as needed dose of pain medication. She requested another staff member inform NP 2, and she called the unit's manager who both came to the resident's room. She had not documented in a progress note, as the NP was going to document. During an interview on 6/2/25 at 12:40 p.m., NP 2 indicated she had been called to Resident B's room. She had not noticed a blister, but the resident's left foot was sorta red with a small open area. She had visualized the resident's foot following the incident, but had not had staff remove the resident's dressing during her follow-up visits. She had not examined the wound during her 5/21/25 visit with the resident for increased pain. The physician was completing rounds the following day (5/22/25), and she wanted the physician to look at the left foot at that time. During a telephone interview on 6/2/25 at 2:41 p.m., RN 3 indicated Resident B had been in so much pain and his wound looked bad. He had not been in a lot of pain the night before. When she had completed his wound treatment on 5/21/25, she had been unaware the resident had sustained a burn to his left foot. She had prepared to complete his treatment for his diabetic ulcer to the bottom of his left foot. The resident had a hard time tolerating the treatment. She had called the DON and received approval to send him to the emergency room for treatment. A Burn Service Team History and Physical Note, dated 5/22/25, from the acute care provider, indicated the resident had presented with scald burns to his left foot, sustained three days ago. The Assessment/Plan indicated the patient had a three day old full thickness scald burn to the left foot. An Inpatient Discharge summary, dated [DATE], from the acute care provider, indicated the resident had two surgical procedures on 5/22/25 and 5/27/25 for debridement of left foot and skin graft application. A current facility policy, dated 8/2024, titled, Change in a Resident's Condition or Status, provided by the Corporate Nurse on 6/3/25 at 12:06 p.m., included the following: .Policy Interpretation and Implementation .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status This citation relates to Complaint IN00460578. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was able to appeal a facility initiated discharge and failed to document why the facility was discharging the resident instead of allowing them to return to the facility after a hospital stay for 1 of 3 residents reviewed for discharges (Resident D). Findings include: On 2/18/25 at 11:32 a.m., a record review was completed for Resident D. He had the following diagnoses which included but were not limited to antisocial personality disorder (a mental health condition characterized by a persistent pattern of disregard for and violation of the rights of others, often leading to problems in relationships, work, and legal issues), bipolar disorder (a chronic mental health condition characterized by extreme shifts in mood, energy, and behavior, alternating between periods of mania and depression), pseudobulbar affect (a neurological disorder characterized by uncontrollable episodes of laughing or crying that are often inappropriate or exaggerated), insomnia, attention-hyperactivity disorder (a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and/or impulsivity that interfere with daily functioning in multiple areas), and traumatic brain injury (an injury to the brain caused by an external physical force, such as a blow, bump, fall, or car accident). During a review of his hospital note, dated 10/27/24, prior to admission to the Skilled Nursing Facility, indicated Resident D became aggressive in the emergency department and threw his colostomy bag. Also, he had spent time at another hospital and had some issues with social work and placement issues. He was banned from that hospital due to bad behaviors and history of being abusive to staff. A Brief Interview for Mental Status (BIMS) assessment score, completed on 12/10/24, indicated he scored 15 out of 15, and was cognitively intact. A care plan, dated 11/20/24, indicated Resident D had a diagnosis of anti-social personality disorder (ASHD). A care plan, dated 11/21/24, indicated Resident D had a diagnosis of bipolar disorder. A care plan, dated 11/21/24, indicated Resident D had a diagnosis of mild intellectual disabilities. A care plan, dated 11/20/24, indicated Resident D had a mood problem related to diagnosis of paranoid schizophrenia. A care plan, dated 12/5/24, indicated Resident D had made sexually inappropriate behaviors such as asking staff to have sex with him. A care plan, dated 12/5/24, indicated Resident D was physically aggressive as evidenced by throwing his colostomy bag at staff, throwing the remote control at staff related to poor impulse control, antisocial personality disorder, schizophrenia, autism, cursing at staff, places himself on the floor, spitting at staff, throwing bowls and plates on the floor causing them to shatter, and manipulative behaviors towards staff. A care plan, dated 12/5/24, indicated Resident D was verbally aggressive as evidenced by yelling out frequently when he wants something related to mental, emotional illness, poor impulse control and had made false allegations toward staff. A care plan, dated 12/11/24, indicated Resident D had behaviors of refusal of care, medications, wound treatment, non-compliant with wound treatment, digging and picking into his wound repetitively removing his dressing. Resident D was observed poking a fork into his wound and a straw to his stoma. He was non-compliant with the smoking policy and was found smoking cigarettes in his room. A care plan, dated 12/24/24, indicated Resident D had a history of making false allegations against staff. A care plan, dated 12/26/24, indicated Resident D exhibited restlessness, nervousness, and/or anxiety symptoms, agitation, attention and concentration deficit due to diagnosis of ASHD. A progress note, dated 2/2/25, indicated Resident D used another resident's cell phone to call 911, paramedics arrived and stated resident want to be transferred to a local hospital, and it was his right to transfer. There was no indication of why Resident D wanted to transfer as his needs were being met at the facility. A progress note, dated 2/3/25, indicated a nurse from the local hospital call and indicated Resident D had been admitted with swollen testicles. A hospital progress note, dated 2/3/25, indicated Resident D had numerous hospitalization s at multiple systems over the last 6 months. He was seen in the emergency room . The resident's record lacked documentation of a reason for the discharge of the resident by the physician. The resident's record lacked documentation of how the resident was a danger to other residents or himself. The resident's record lacked documentation of why the facility was not honoring the resident's right to return to the facility pending an appeal of any facility-initiated discharge. During an interview with the Social Services Director (SSD) on 2/18/25 at 10:53 a.m., she indicated Resident D did not have a discharge assessment completed because he was leaving 911. She indicated the company decided not to take him back because of his behaviors. They were worried about the overall safety of other residents and staff. On 2/18/25 at 10:55 a.m., during an interview with the Executive Director (ED), he indicated they admitted Resident D to administer some antibiotics. He was aware that residents would not always be accepting to care. He threw his colostomy bag at the staff. He hit a staff member in the face. He called the police around 36 times. Resident D finally handed his phone off to management to lock up. The police did not want to arrest him due to the wounds he had on his buttocks. He dug in his wounds with silver ware. He destroyed his room and pulled a handrail off the wall. They attempted 1 on 1 supervision because he was consuming so much time with his call light and hollering at staff. It took 2 to 3 staff members to care for him at a time due to safety concerns. He indicated when he reviewed Resident D's admission documentation prior to admission at the facility, it did not indicate the resident had these behaviors. There were no specific incidents causing a denial to readmit Resident D. The ED was unaware of the resident's current condition at the hospital. On 2/18/25 at 12:40 p.m., during an interview with the ombudsman, she indicated she witnessed Resident D's behaviors herself. He dug in his colostomy bag and acted like he was going to throw feces on her. She told the facility they would have to give a 30-day notice of intent to discharge. On 2/18/25 at 1:03 p.m., an interview by phone was attempted but Resident D did not answer his phone. On 2/18/25 at 1:03 p.m., during an interview, Resident D's mother indicated she was unaware of the reason why Resident D was not allowed to return to the facility. She worried about his belongings and cell phone. On 2/19/25 at 10:31 a.m., a policy titled, Transfer or Discharge, Facility Initiated was provided by the Special Projects and Interim Administrator. It indicated, .Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy This deficiency relates to Complaint IN00453734.

Based on interview and record review, the facility failed to follow the policy by not allowing the resident to return to the facility after a hospitalization for 1 of 3 resident reviewed for discharged (Resident D). Findings include: On 2/18/25 at 11:32 a.m., a record review was completed for Resident D. He had the following diagnoses which included but were not limited to antisocial personality disorder (a mental health condition characterized by a persistent pattern of disregard for and violation of the rights of others, often leading to problems in relationships, work, and legal issues), bipolar disorder (a chronic mental health condition characterized by extreme shifts in mood, energy, and behavior, alternating between periods of mania and depression), pseudobulbar affect (a neurological disorder characterized by uncontrollable episodes of laughing or crying that are often inappropriate or exaggerated), insomnia, attention-hyperactivity disorder (a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and/or impulsivity that interfere with daily functioning in multiple areas), and traumatic brain injury (an injury to the brain caused by an external physical force, such as a blow, bump, fall, or car accident). . A progress note, dated 2/2/25, indicated Resident D used another resident's cell phone to call 911, paramedics arrived, stated resident want to be transferred to a local hospital, and it was his right to transfer. There was no indication of why Resident D wanted to transfer as his needs were being met at the facility. A progress note, dated 2/3/25, indicated a nurse from the local hospital call and indicated Resident D had been admitted with swollen testicles. A hospital progress note, dated 2/3/25, indicated Resident D had numerous hospitalization s at multiple systems over the last 6 months. The resident's record lacked documentation of how the resident was a danger to other residents or himself. The resident's record lacked documentation of why the facility was not honoring the resident's right to return to the facility pending an appeal of any facility-initiated discharge. During an interview with the Social Services Director (SSD) on 2/18/25 at 10:53 a.m., she indicated Resident D did not have a discharge assessment completed because he was leaving 911. She indicated the company decided not to take him back because of his behaviors. They were worried about the overall safety of other residents and staff. On 2/18/25 at 10:55 a.m., during an interview, the Executive Director (ED) indicated they admitted Resident D to administer some antibiotics. He was aware that the resident would not always be accepting to care. He threw his colostomy bag at the staff. He hit a staff member in the face. He called the police around 36 times. Resident D finally handed his phone off to management to lock up. The police did not want to arrest him due to the wounds he had on his buttocks. He dug in his wounds with silver ware. He destroyed his room and pulled a handrail off the wall. They attempted 1 on 1 supervision because he was consuming so much time with his call light and hollering at staff. It took 2 to 3 staff members to care for him at a time due to safety concerns. He indicated when he reviewed Resident D's admission documentation prior to his admission at the facility, it did not indicate the resident had these behaviors. There were no specific incidents causing a denial to readmit Resident D. The ED was unaware of the resident's condition at the hospital. On 2/18/25 at 12:40 p.m., during an interview, the ombudsman indicated she witnessed his behavior herself. He dug in his bag and acted like he was going to throw feces on her. She told the facility they would have to give a 30-day notice of intent to discharge. On 2/18/25 at 1:03 p.m., an interview by phone was attempted but Resident D did not answer his phone. On 2/18/25 at 1:03 p.m., during an interview, Resident D's mother indicated she was unaware of the reason why Resident D was not allowed to return to the facility. She worried about his belongings and cell phone. On 2/19/25 at 10:31 a.m., a policy titled, Transfer or Discharge, Facility Initiated was provided by the Special Projects and Interim Administrator. It indicated, .Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy This deficiency relates to Complaint IN00453734.

Based on observation, interview, and record review, the facility failed to ensure the Facility Assessment Tool was updated in a timely manner to reflect the specific nursing needs, care and treatments services for the identified resident population. This deficient practice had the potential to affect 102 of 102 residents who resided in and received nursing care, services and treatments in the facility. Findings include: The Facility Assessment Tool is used to identify, quantify, and outline the resident population in order to effectively provide materials, equipment, care and services in order to attain or maintain the highest practicable physical, mental and psychosocial well-being of the residents who reside in the facility. During the survey entrance conference on 2/6/25 at 10:06 a.m., a copy of the facility's Assessment Tool was requested and provided by the Administrator (ADM). On 2/6/24 at 11:07 a.m., the ADM provided a Facility Assessment, dated November 2023, which reflected data and assessment for the year 2023. On 2/14/25 at 1:00 p.m., the most recent Facility Assessment tool, reflective of the year 2024 was requested. On 2/14/25 at 1:15 p.m., the ADM provided a Facility assessment dated for November 2024, but the information was identical. During an interview on 2/14/25 at 1:22 p.m., the ADM indicated, he used the previous 2023 as a template and updated the date, therefore the data might not be a direct reflect of the current population and resident needs. The following discrepancies were reviewed with the Administrator: In general, the facility's average daily census ranged from 105-115. Common diagnoses of the resident population included, but were not limited to, psychosis, impaired cognition, mental disorder, depression, bipolar disorder, schizophrenia, post-traumatic stress disorder and anxiety. a. The Facility Assessment tool used the Resource Utilization Group (RUG) Version IV, (which is a system used to classify long-term care residents into groups based on their care needs,) to identify the acuity of care required based on population averages. One area of identified acuity needs was for Behavioral Symptoms and Cognitive Performance, which was quantified as, 6. However, the facility identified Special Treatment and Conditions which included, but was not limited to Mental Health, listed 0 active or current substance use disorders, and Behavioral Health Needs, was left blank. b. The Facility Assessment Tool Part 2: Services and Care we Offer Based on our Resident Needs, indicated, .Mental Health and Behavior- Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities . However the Facility Assessment did not document or specify who the Psychiatric provider was. How often they were available to the residents, or how/who determined a residents needs for psychiatric services and what provisions would/could be made if the provider was unavailable. c. The Facility Assessment Tool Part 3: Facility Resources Needed to Provide Competent Support and Care for Our Resident Population Every Day and During Emergencies, identified the following types of staff members and/or other health professionals needed to care for the residents, (included, but not limited to) Behavioral and mental health providers, but again, lacked specification/identification of those staff members designated and or other contracted rounding providers. It lacked specification of how often these staff members would be available to the residents and to what degree of serves could/should be provided. In order to provide person-centered/directed care: Psycho/social/spiritual support the Facility Assessment indicated, .identify hazards and risks for residents . However during the QAPI interview, identification of cited concerns related to infection control practices and accident hazards related to resident's smoking procedures had not been identified and/or discussed. Cross Reference F880 and F689.

Based on record review and interview, the facility failed to code Minimum Data Set (MDS) correctly for residents who required a level II according to Pre-admission screening and resident review (PASRR) for 4 of 5 residents reviewed for MDS accuracy (Residents 52, 49, 9, and 14). Findings include: 1. On 2/11/25 at 10:58 a.m., a record review was completed for Resident 52. He had the following diagnoses which included but were not limited to schizophrenia, muscle weakness, and hyperlipidemia (high cholesterol). Resident 52 had a level II PASRR dated 8/8/23. His Minimum Data Set (MDS) assessment, dated 4/4/24, indicated he did not require a level II PASRR. Resident 52 had a care plan, dated 7/26/23, indicated he required a level II PASRR. 2. On 2/11/24 at 11:04 a.m., a record review was completed for Resident 49. He had the following diagnoses which included but were not limited to schizophrenia, bipolar disorder, and arthritis. Resident 49 had a level II PASRR, dated 8/11/22. His MDS, dated [DATE], indicated he did not require level II PASRR. Resident 49 had a care plan, dated 7/26/23, that indicated he required level II PASRR. 3. On 2/11/24 at 11:01 a.m., a record review was completed for Resident 9. He had the following diagnoses which included but were not limited to hyperlipidemia, delusional disorder, psychotic disorder, generalized anxiety, and major depressive disorder. Resident 9 had a level II PASRR, dated 9/12/23. His MDS, dated [DATE], indicated he did not require level II. Resident 9 had a care plan, dated 12/11/23, indicating he required a level II PASRR. On 2/11/25 at 11:07 a.m., a record review was completed for Resident 14. He had the following diagnoses which included but were not limited to mood disorder with major depressive-like episode, anxiety disorder, adjustment disorder, psychotic symptoms, and asthma. Resident 14 had a level II PASRR dated 3/7/24. His MDS, dated [DATE], indicated he did not require a level II. Resident 14 had a care plan, dated 4/5/24, that indicated he required a level II PASRR. On 2/14/25 at 11:00 a.m., during an interview, the MDS Coordinator indicated she was new to the facility and could not explain why the level IIs were not coded accurately. A policy titled, Resident Assessments dated 8/24 was provided by the [NAME] President of Clinical Services (VPCS). It indicated, .Information in the MDS assessments will consistently reflect information in the progress notes, plan of care, and resident observations/interviews

Based on observation, interview, and record review, the facility failed to ensure a resident received treatment that was in accordance with professional standards of practice when they failed to assess, document, provide timely diagnostic testing after a fall with severe injury, withhold blood thinning medication, and update the care plan with individualized interventions, for 1 of 2 residents reviewed for falls with severe injury (Resident B). Findings include, On 1/3/23 at 2:33 p.m., Resident B's responsible party indicated, on 12/25/22, she came to take the resident home for the holiday and found the resident to have a black and blue eye and a white bandage beside her right eye. Staff told her Resident B had fallen the night before, but staff had not contacted her about the fall, and she had doubts about the date and time of the fall due to the extent of the injury. The Responsible Party called the Executive Director (ED) at home and demanded details of the fall and why staff had not contacted her. The ED indicated she was unaware of the fall but would contact the facility immediately. Resident B told her staff would not answer her call light, and she fell out of bed while attempting to self-transfer hitting her head and side on an oxygen concentrator. Complainant did not know at that time but later found out the resident had a large and to her disturbing bruise on her right side. To her knowledge the physician was not immediately notified of the fall or injuries, and there were no immediate orders for x-rays or a CT scan to rule out a concussion or broken ribs until after the holidays. The resident did not have a CT scan scheduled until 1/5/23 almost 2 weeks after her fall. A Report of Concern/Grievance Log, dated 12/26/22, indicated documentation Resident B's daughter was concerned the resident's call light was not being answered or not being answered timely. On 1/3/23 at 3:40 p.m., Resident B was observed sitting in a wheelchair at bedside receiving oxygen per nasal cannula from a soft sided pack on the back of the wheelchair. An oxygen concentrator was sitting near the top of the bed turned off. The resident was alert, talkative and soft spoken. A bandaid was positioned vertically beside the right eye, dark discoloration and edema was observed around the top and bottom of the right eye. Resident B indicated she had attempted to get up alone and fell hitting the oxygen concentrator. They don't pay any attention to me. They don't answer my call light when I call. When asked if she had any other injury, pointed down to the right side of her torso and indicated, somewhere down there. During an observation of Resident B with the Regional [NAME] President of Nursing Services, on 1/4/23 at 2:45 p.m., resident was sitting in her wheelchair near the nurse's desk with her coat on preparing to leave for an outside nephrology appointment unrelated to her fall and injuries. The Regional VP of Nursing Services observed a bandaid on right side of resident's face near the eye extending across and stuck to the eyebrow, and with permission from the resident removed the bandaid revealing a half inch horizonal scab at the outer end of the eyebrow. When questioned by the Regional VP of Nursing Services, Resident B indicated she had fallen due to waiting on staff to answer her call light and they kept walking by and ignoring her, so she attempted to self-transfer and fell . She got a black eye and hurt her side, and staff immediately put a bandaid on her eye so her daughter would not get mad. She had blurred right eye vision since the fall. When the Regional VP of Nursing Services asked Resident B if it would be okay with her to move up the CT scan by a day, Resident B got visibly upset and indicated what made her mad was nobody did anything when she fell and now they were asking to treat her. Resident B's record was reviewed on 1/4/23 at 10:54 a.m. Diagnoses on Resident B's profile included, but were not limited to, end stage renal disease, vascular dementia moderate with agitation and anxiety, restlessness and agitation, repeated falls, and dependence on supplemental oxygen. A quarterly Minimum Data Set (MDS) assessment, completed on 10/26/22, assessed Resident B as having the ability to make herself understood and to understand others. A Brief Interview for Mental Status (BIMS) score of 9 indicated moderately impaired cognition. Extensive assistance of one person physical assist for bed mobility, transfers, dressing, and eating. No physical help from staff for walking in room. Limited assistance of one person physical assist for locomotion on or off the unit, and personal hygiene. Supervision of one person physical assist for toilet use. 1 fall since admission/readmission or prior assessment with no injury. A care plan for Resident B dated 3/29/22 indicated, the resident was at risk for falls/injury due to a history of falls, impaired cognition/safety awareness, incontinence, and weakness/disability. The goal was for the resident to not sustain serious injuries. Interventions included dycem to the wheelchair, maintenance to elevate refrigerator to safer height to prevent resident from bending over, re-educate resident to use call light and request assistance for transfers, anticipate and meet the resident needs, call light within reach, keep personal items in reach, anti-rollbacks to wheelchair, and non-skid/gripper socks. 12/28/22 revision: PT/OT/ST to evaluate and treat. A care plan for Resident B dated 10/20/22 indicated, resident is on anticoagulant therapy related to blood clot prevention. The goal was for the resident to be free from discomfort or adverse reactions related to anticoagulant use. Interventions included administer anticoagulant medications as ordered by physician and monitor for side effects and effectiveness every shift. Daily skin inspection and report abnormalities to the nurse. Labs as ordered and report abnormal labs to the physician. Monitor/document/report adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden change in mental status, significant or sudden changes in vital signs. A Physician's order, dated 5/10/22, indicated oxygen at 2 liters (L) via nasal cannula, resident may remove at times. A Physician's order, dated 5/10/22, indicated Clopidogrel Bisulfate Tablet (Plavix a blood thinner) 75 milligrams (MG) give 1 tablet by mouth one time a day for blood clot. A Physician's order, dated 12/27/22 at 9:51 a.m., indicated obtain facial/skull x-ray. A physician's script, dated 12/29/22, indicated no contrast CT of the head, recent fall, hit head, patient on Plavix. Radiology Report Results, dated 12/28/22 at 9:30 a.m., indicated no acute findings considering the inherent limitations of skull radiology. If there was persistent clinical concern, consider CT. The resident record lacked documentation staff timely alerted the physician to Plavix use after the resident fell on [DATE] and developed extensive facial and torso bruising, or held the medication related to the extensive bruising or potential for internal bleeding. Pictures of Resident B, dated 12/25/22, indicated varying shades of purple and black discoloration and swelling to the right eye and eyebrow extending from top of the eyebrow, around the entire eye, down past the right cheekbone, and towards the right ear, white gauze taped on the right side of the face near the eye and over part of the eyebrow. Varying shades of dark to lighter purple bruising on the right side/flank area extending from bottom of the bra line down past the waistline, on the back and around towards the front of the torso. A skin assessment, dated 1/24/22, indicated some new discoloration or impaired skin integrity. Face small bruising on side of head. A fall risk assessment, dated 12/24/2022, indicated low risk for falls. Alert and oriented, 1-2 falls in the past 3 months. Ambulatory, continent, and gait normal. The resident record lacked documentation to describe the extent of Resident B's injures, treatment of the injuries, on-going monitoring of the injuries, or resident tolerance of injuries. Additional pain medication was documented in December as administered 1 time on 12/26/22. A Nurse's Note, dated 12/24/22 at 7:34 a.m., indicated Resident B had an unwitnessed fall. The nurse found the resident on the floor in room during hourly rounding, resident stated I was trying to get my robe. Full head to toe assessment done, resident had small bruising to head. Called family but no answer. Resident educated on the importance of the use of call light for anything. A Nurse's Note, dated 12/24/22 at 8:15 a.m., indicated no injures noted. A Nurse's Note, dated 12/26/22 at 12:01 a.m., indicated noticed right side of patients face and black eye bruised from recent fall. A Nurse's Note, dated 12/26/22 at 8:51 a.m., indicated observed pinpoint laceration to eyebrow and bruising to right eye and to right side. MD aware and was to put in a new order for X-ray, will notify family. A Nurse Practitioner's Note, dated 12/26/22 at 11:36 a.m., indicated resident seen today for follow up to a fall with injury. Resident complaint of right eye being sore. Resident reports she fell over the oxygen tank in her room trying to go to the bathroom. Resident reports hitting her head on the oxygen tank and hitting her side. Will order a stat chest X ray. Bruise around the right eye and right flank. An Interdisciplinary Note, dated 12/27/2022 at 10:41 a.m., indicated review of fall on 12/24/22. Patient reported fall while attempting to dress self, sustaining minor injuries. Nursing staff provided care for the resident upon notification and notified provider, family, and updated plan of care accordingly. Occupational Therapy/Physical Therapy/Speech Therapy (OT/PT/ST) will screen patient for any deficits and treat accordingly as intervention. A Psychotherapy Note, dated 12/27/22 at 3:55 p.m., indicated resident presented as fatigued, tearful, and depressed. She had a black eye and cut above her eye, which she reported that she fell and hit her oxygen tank. Speech rate slow and less talkative than usual. A Nurse Practitioner progress note, dated 12/28/22 at 11:58 a.m., indicated resident seen today for follow up to diagnostics. Resident denies any pain to the right eye, reports that the right eye was sore. Resident reported that her right flank continued to be sore, no fracture noted, bruise remains. On 12/28/22 a chest x-ray conclusion indicated modest cardiomegaly with mild congestive heart failure worse than 9/19/2022, fluid noted in minor fissure. Plan: repeated falls, continue to monitor. A Nurse's Note, dated 12/29/22 at 8:30 a.m., indicated small laceration remains to right brow area and bruising remains to right eye and right side. Discomfort noted with some movement but normal for baseline. A note on a calendar at nurse's desk indicated 1/6/23 at 10:10 a.m., Resident B had an appointment at a nearby radiology center for a CT scan of the head due to complaint of a fall. A Risk Management Report, dated 12/24/22 at 4:30 a.m., indicated Resident B was found on the floor by nurse during hourly rounding. Resident stated she was trying to go get her robe. Head to toe assessment completed. Resident educated on importance of using the call light whenever she needed anything. Bruise and laceration to face, bruise to right trochanter (hip). Resident alert and oriented to person, place, and time. Injury observed post fall. Notes: pinpoint 2 centimeter (cm) x 2 cm laceration right eyebrow. 5.5 cm x 8 cm dark purple bruising around eye. 7 cm x 9 cm dark purple bruising to right side. Director of Nursing (DON) notified 12/24/22 at 4:45 a.m., on-call MD notified 12/24/22 at 7:30 a.m. A radiology electronic ordering system report indicated, on 12/26/22 at 8:49 a.m., the DON ordered skull x-rays, and on 12/26/22 at 11:40 a.m. ordered chest x-rays. Reason for portability: patient weak/non-ambulatory (altered mental status/behavior issues). MRI results for Resident B, dated 1/4/23, indicated, there were compression fractures at thoracic (T)11, lumbar (L)3, L4, L5, age of these compression fractures was indeterminate. During an interview on 1/4/23 at 9:54 a.m., Qualified Medication Aide (QMA) 7 indicated, Resident B had skin discoloration due to a fall about a week ago. The resident required assistance for transfers, would put on her call light most of the time, but would get up alone. During an interview on 1/4/23 at 9:57 a.m., Registered Nurse (RN) 5 indicated, Resident B was fairly proficient in transfers, needed assist with dressing due to limited range of motion in her shoulders, and was one of the few that would use the bathroom call light. During an interview on 1/4/23 at 10:26 a.m., Certified Nursing Assistant (CNA) 6 indicated, he could not say when Resident B fell , he worked Christmas Eve and when he came back, she had bruises. The resident had told him she was reaching for a robe on her chair and fell out of bed. During an interview on 1/5/23 at 10:08 a.m., Licensed Practical Nurse (LPN) 18 indicated, on 12/24/22 when she arrived to work at 7:00 a.m., she was informed Resident B had fallen around 4:00 a.m. When the resident was assessed and left the facility that morning for dialysis, the resident had no injury to her face or dressing to her eye. When LPN 18 returned to work on 12/26/22 Resident B was observed to have extensive dark purple bruising on her right eyebrow with edema and bruising around the eye. LPN 18 asked the NP to exam the resident. LPN 18 indicated, there was no documentation of the resident's condition in the medical record on 12/25/22. Indicated, she could not answer if Resident B had another fall between 12/24 and 12/26 but knew there had been no injury found on 12/24/22. LPN 18 indicated, Resident B's right eye looked to have dark deep purple bruising in a circle approximately 1-2 inches around the entire eye, with edema. The right eyebrow was raised and sticking out due to edema with a white dressing. A pinpoint open area on outer right brow area, all swollen. During the eye exam Resident B was grimacing, moaning, and guarding her right side as she was being moved around, and her right side was found to have dark deep purple bruising raised with edema from under her right arm extending to torso and around her back, down towards her waistline. Measurements at the time for her right eye started above brow down to cheek bone then over toward ear. Her right side/rib area darker bruising approx. 8 in diameter x 3 length, and purple bruising fading around it. The NP was supposed to put in orders for skull and chest x-rays. During an interview on 1/6/23 at 12:33 p.m., CNA 14 indicated, she had worked on 12/23 and 12/24 7:00 a.m. - 7:00 p.m. and Resident B was not injured. When she arrived at work on 12/25/22 at 7:00 a.m., the resident was observed to have injuries on her face. On 1/5/23 at 1:01 p.m., the Executive Director (ED) provided a Fall Program Guidelines, dated 12/2022, and indicated the policy was the one currently being used by the facility. The policy indicated, To screen all residents to identify possible risk factors that could place a resident at risk for falls, evaluate those risks, implement interventions to reduce the risk and monitor the interventions for effectiveness .1. The resident will be assessed for fall risk upon admission and quarterly. 2. Interventions will be implemented if resident is determined to be at risk. 3. Should a fall occur, the nurse shall complete an assessment of the resident and circumstances surrounding the fall incident. The interdisciplinary team [IDT] should determine root cause and evaluate to ensure appropriate interventions are implemented. 4. The attending physician or medical director in the absence of the attending physician and the responsible party should be notified. 5. The resident care plan should be revised to reflect any new or change in interventions. 6. Effectiveness of interventions will be monitored through the Clinically At-Risk program . On 1/5/23 at 1:01 p.m., the ED provided a Call Lights policy and indicated the policy was the one currently being used by the facility. The policy indicated, Purpose: To respond to resident's requests and needs in a timely manner .All staff should assist in answering call lights. Nursing staff members shall go to resident's room to respond to call system and promptly cancel the call light when the room is entered . This Federal tag relates to Complaint IN00393356. 3.1-37(a) 3.1-37(b)

Based on observation, interview, and record review, the facility failed to follow professional standards of practice to prevent potential for accidents while using a mechanical lift, resulting in a fall with fracture, delay of diagnosis of a fracture despite resident continued complaints of severe pain, and ensuring individualized care plan interventions were implemented for 1 of 3 residents reviewed for accidents (Resident G). Findings include: An Indiana State Department of Health Survey Report System report, dated 11/16/22 at 5:01 p.m., indicated Resident G had a change in condition/shortness of breath so was transferred to the emergency room where they found a fracture of the distal femoral metadiaphysis (end of the bone near the growth plate, commonly caused by a fall from a height). On 1/5/23 at 10:30 a.m., Resident G indicated, on 11/3/22 around 7:00 p.m., Certified Nursing Assistants (CNA) 8 and 9 had come into her room with the Hoyer (a mechanical lift) to transfer her from the bed to a shower chair. She was placed on a lift pad, the pad hooked to the lift, and as they swung her around in front of the TV, she suddenly fell from the lift pad and landed on the metal feet of the Hoyer lift and bounced onto the floor. Resident G indicated, she was approximately 4 - 5 feet in the air at the time of the fall as her bed was in high position when they lifted her off it, and it happened so fast she only started to yell out when she hit the floor. It was her opinion the aides did not check the Hoyer pad to make sure it was in good working order before transferring her, and upon inspection the broken strap was dry rotted, the pad ripped, and it came apart causing the strap to break. Resident G indicated the lift pad should never have been in use since it was rotten. Observation of Resident G's Hoyer pad showed it to have frayed and missing binding around the perimeter, the strap material was frayed, and there was one broken strap the resident indicated had caused her fall. Resident G indicated, when she was dropped, she instantly felt pain from her mid upper right arm down through her right leg stump. Initially staff only gave her a mild pain medicine which did nothing for the pain and they ordered an x-ray of her upper body but not her lower body. The resident indicated, she would scream out every time staff touched her for care and refused dialysis due to not being about to stand the pain of being transferred. They let me suffer for 2 weeks, kept telling me nothing was wrong. Resident G indicated, she finally saw the Nurse Practitioner (NP) walking past her door one day and asked to be seen at the hospital, where she was diagnosed with a hairline fracture and kept for several days. The resident indicated, the NP said she was not told the resident had fallen from a Hoyer lift. Resident G indicated, she reported to the hospital staff the nursing home had ignored her complaints that something was wrong. Resident G's record was reviewed on 1/5/23 at 11:01 a.m. Diagnoses on Resident G's profile included, but were not limited to, acquired absence of right and left leg below the knee (amputation), end stage renal disease with dependence on renal dialysis, hemiplegia and hemiparesis (paralysis) following cerebral infarction affecting left non-dominant side, and chronic pain. A Physician's order, dated 11/4/22, indicated Ibuprofen tablet (anti-inflammatory/analgesic) 600 milligrams (mg) give 600 mg by mouth one time only for pain. A Physician's order, dated 11/4/22, indicated Hydrocodone -Acetaminophen (narcotic pain medication) tablet 5-325 mg give 1 tablet by mouth three times a day for 7 days related to pain to right leg. A Physician's order from the hospital, dated 11/15/22, indicated oxycodone HCl (narcotic pain medication) tablet 5 mg give 0.5 tablet by mouth three times a day for pain. A fall assessment for Resident G, dated 11/3/22, indicate the resident was a low risk for falls. She was alert and oriented and required assistive devices with transfers. A Nurse's Note, dated 11/3/22 at 8:29 p.m., indicated Resident G had a witnessed fall. Resident fell while aides were in the process of transferring her from the bed to the shower chair via Hoyer lift. No injury, denied hitting head, complained of right-side pain, took PRN (as needed or requested) Tylenol (analgesic). New X-ray order per the NP for right upper extremities, hip, and pelvis. Director of Nursing (DON) notified. A Nurse's Note, dated 11/4/22 at 6:11 a.m., indicated resident complained of right hip pain due to earlier fall, she refused hospital visit and requested for stronger pain medication than Tylenol. NP gave order for ibuprofen 600 mg one (1) time now then follow up by NP in the morning. An Interdisciplinary (IDT) note, dated 11/4/22 at 9:21 a.m., indicated recent fall on 11/3/22. Resident was being transferred from bed to shower chair and fell . No injuries noted. X-rays ordered. Discussed intervention of staff education on safe transfers. Family/MD notified. Assessments and care plans updated. A late entry NP note, dated 11/4/22 at 12:42 p.m., indicated the resident was seen today for follow up fall without injury, reports fall during transfer from bed to chair. Right lower extremity slightly swollen related to fall. A NP note, dated 11/7/22 at 3: 35 p.m., indicated patient being seen today to follow-up to right hip, arm and knee pain after a fall. Resident receiving Norco (narcotic) 5/325 mg. Resident is having breakthrough pain. Norco will be increased and Tylenol for breakthrough pain. Resident is crying today and stated, I am really hurting, and I need something stronger for the pain. Resident encouraged to move in bed as she is complaining on being stiff. Patient will be referred to Physical Therapy (PT). A NP note, dated 11/9/22 at 11:08 a.m., indicated resident seen today for follow-up to a fall without injury. Right lower extremity swelling resolving. Assessment/Plan for pain, Biofreeze (topical pain relief) to right hip, knee and arm. A Nurse's Note, dated 11/10/22 at 1:03 p.m., indicated slight edema to face and arm. Refused blood pressure and has been refusing dialysis. A Nurse's Note, dated 11/16/22 at 8:08 a.m., indicated resident seen today for follow-up to hospitalization . Patient discharge diagnosis was fluid overload and a commuted fracture involving the distal femoral metadiaphysis. Refer to Ortho within 1 to 2 weeks. Oxycodone (narcotic pain medication) discussed with nursing. The resident record lacks documentation of the resident being sent to the hospital on 11/11/22 or reason for the transfer. A hospital History and Physical, dated 11/14/22, indicated resident resented to the emergency department with over one (1) week of right and hip pain, being admitted for hyperkalemia and a right distal femur fracture. Right hip/leg pain due to a distal femur fracture. Complaining that current pain regimen ineffective. Orthopedic surgery was consulted and recommended posterior splint and clinic follow up. Patient will need outpatient with follow up and supportive care for pain control and bowel regimen. Pain control with scheduled low dose Percocet (narcotic) 2.5 mg three times daily (TID) and PRN, oxycodone 5-325 mg for breakthrough pain. Hospital In-Patent Discharge Summary indicated, in house 1-11-22 - 11/15/22, diagnosis fracture of distal end of right femur. A hospital instructions for care x-ray report, dated 11/11/22 at 10:40 a.m., indicated fell out of Hoyer lift 9 days ago, via emergency medical service (EMS) from facility, was dropped out of Hoyer lift last week. X-rays done by facility last week were unremarkable. Bilateral below the knee (BTK) amputee. On 1/6/23 at 10:45 a.m., the ED provided documentation of education she indicated was presented to the nursing staff due to prior citation related to Hoyer use to include, a. On 1/20/22 mechanical lift education. The policy was presented and verbal direction on use. CNA 9 signed as having received the education. b. On 5/9/22 mechanical lift education. Use of the Hoyer lift was presented. CNA's 8 and 9 signed as having received the education. A quarterly Minimum Data Set (MDS) assessment completed 10/21/22, assessed Resident G as having the ability to make herself understood and to understand others. A Brief Interview for Mental Status (BIMS) score of 15/15 indicated cognitively intact. Extensive assistance of 2+ persons physical assistance for bed mobility. Total dependence of 2+ persons physical assist for transfers. Mobility devices included a wheelchair. No history of falls. A care plan for Resident G indicated the resident had an assistance with daily living (ADL) deficit related to diabetes mellitus, osteoarthritis, and hemiplegia or hemiparesis of the left side. The goal was for the resident to remain clean and well groomed. Interventions included, but were not limited to, the resident required a mechanical lift with 2 staff assistance for transfers. A care plan for Resident G, dated 10/21/22, indicated the resident was at risk for falls/injury due to bilateral amputee, diabetes mellitus, and hemiplegia or hemiparesis of the left side. The goal was for the resident to be free from falls. Interventions included, anticipate and meet the resident's needs, call light within reach, and ensure pathways were free of clutter. Revision dated 11/4/22 staff education provided related to safe transfer techniques. Resident record lacked documentation the care plan was updated with individualized interventions to include, but not limited to, use of a right leg splint. During an interview on 1/4/23 at 10:05 a.m., Qualified Medication Aide (QMA) 7 indicated, staff would go in every morning at 7:00 a.m. to set the resident up for am care, she required ADL assistance for bathing, dressing, and transfers due to being a double amputee. During an interview on 1/5/22 at 12:02 p.m., the DON and Regional VP of Nursing Services indicted, Resident G had fell during a transfer with staff and a Hoyer (mechanical lift).The Regional VP of Nursing Services indicated, during her investigation the resident had told them she fell from the Hoyer due to a frayed Hoyer pad but would not give staff the pad or show it to them. On-going staff education on Hoyer lift use was presented on 11/5/22 to include how to use the lift, only keeping the Hoyer pads for one (1) year and dating the pad when they were put out for use. Indicated, the housekeeping/laundry supervisor was responsible for the monitoring and replacing of Hoyer pads. During an interview on 1/5/23 at 12:18 p.m., the housekeeping/laundry supervisor indicated, she ordered Hoyer pads when told to by the DON or when the pads were outdated. When new Hoyer pads were received they were initially kept in her office, where she dated them before they went to the floor for resident use. Laundry staff checked the dates on the pads when laundering, and at 12 months threw them away. She was hired in February 2022, from that date she knew she dated new Hoyer pads and the 2 or 3 that had been in the laundry room, she was not sure about the pads that were already in use on the floor. Indicated she could guess the number of Hoyer pads in use on the wings, but there was no system currently in place to track the Hoyer pads. Ultimately laundry and nursing were responsible for the residents having usable, safe Hoyer pads. During an interview on 1/5/23 at 12:25 p.m., CNA 8 indicated, she had worked in the facility for a year. On 11/3/22 she and CNA 9 had gone to give Resident G a shower. They placed a Hoyer pad under the resident, hooked her up to the mechanical lift, and when they went the lift without warning the pad broke and the resident fell hitting the metal feet of the lift. At the time of the fall the resident was about four (4) feet off the floor. Observation of the Hoyer pad indicated it had a broken strap. CNA 8 indicated, she did not remember paying an attention to the condition of the Hoyer pad prior to the fall. As for prior education on mechanical lift transfers, she had been told to always use 2 persons for transfers per Hoyer but thought the actual training for Hoyer use and examining pads started after the fall on 11/3/22 during an in-service. When Resident G fell , she complained of her legs/hips being sore, but she did not want to go out to the doctor. It was the responsibility of laundry to make sure Hoyer pads were inspected and someone went in there and got rid of those that were not safe. During an interview on 1/5/23 at 2:30 p.m., the Executive Director (ED) indicated, her understanding was that Resident G fell from the Hoyer pad onto the bed, so she had not questioned staff regarding the incident. The housekeeping supervisor was responsible for ordering and monitoring Hoyer pads and replacing them. The ED indicated she had followed up with the resident the day after the fall due to being told it involved a fall from a Hoyer, but she was not told the resident fell to the floor. Resident G had not shown or given the ED the Hoyer pad that supposedly broke. The ED indicated, she was not sure how long Hoyer pads were to be kept, but she approved to replace them anytime needed. On 11/5/22 the ED presented a staff in-service regarding customer service and phone use, and the DON added Hoyer use to the in-service. The DON told her she had spoken to the aides, but she was not sure which ones. Checking the Hoyer pad should be the first thing the aides did before using the mechanical lift, safety should always come first. It was the responsibility of the CNA's using the Hoyer lifts to report when the lift pads were ripped or no longer safe. During an interview on 1/6/23 at 12:07 p.m., the DON indicated on 11/3/22 a nurse (she did not remember the name) called and reported Resident G had fallen from a Hoyer lift due to a problem with the sling (Hoyer pad). CNA 8 had told her the sling broke. Resident G indicated the staff turned her when up in the lift going towards the shower chair and the sling broke. On 11/4/22 she and Resident G spoke with the Regional VP of Nursing Services on the phone, and the resident told them the same story about the sling breaking and how she fell on the floor. The resident would not show the sling to the staff. Upon inspection of the Hoyer slings currently in use on the floor some had been dated and some not. Nurse documentation of a fall was to be entered in the electronic medical record to include in a risk management form, fall assessment, and Skin assessment. Once the risk management form was done, the IDT notes were made and populates into the progress notes for others to see. The MDS nurse was responsible for updates to the care plan. During an interview on 1/6/23 at 12:12 p.m., the ED indicated, the details of Resident G's fall from a Hoyer lift had not been put on the state reportable incident as she was not aware she had to put all detail on the report. Reportable incidents were sent to corporate for approval before being sent. On 1/5/23 at 1:01 p.m., the ED provided a Fall Program Guidelines, dated 12/2022, and indicated the policy was the one currently being used by the facility. The policy indicated, To screen all residents to identify possible risk factors that could place a resident at risk for falls, evaluate those risks, implement interventions to reduce the risk and monitor the interventions for effectiveness .1. The resident will be assessed for fall risk upon admission and quarterly. 2. Interventions will be implemented if resident is determined to be at risk. 3. Should a fall occur, the nurse shall complete an assessment of the resident and circumstances surrounding the fall incident. The interdisciplinary team [IDT] should determine root cause and evaluate to ensure appropriate interventions are implemented. 4. The attending physician or medical director in the absence of the attending physician and the responsible party should be notified. 5. The resident care plan should be revised to reflect any new or change in interventions. 6. Effectiveness of interventions will be monitored through the Clinically At-Risk program . On 1/6/22 at 11:30 a.m., ED provided Invacare Patient Sling Owner's Manual, revised 7/99, and indicated this was the Hoyer manual currently being used in the facility. The manual indicated, warning: after each laundering, inspect sling(s) for wear, tears, and loose stitching. Warranty 1 year. Dawn Regional indicated to her this meant to replace after one year. On 1/6/23 at 11:55 p.m., the ED provided a Mechanical Lift Policy, dated 8/2022, and indicated it was the policy currently being used by the facility. The policy indicated, A mechanical lift is to be utilized for residents who are too heavy to be moved by one person, or who are disabled to the point of inability to assist with transfers. Two [2] personnel members must be present when a mechanical lift is utilized .1. Inspect the mechanical lift before each use . The policy lacked documentation for mechanical lift sling monitoring and maintenance. This Federal tag relates to Complaint IN00393356. 3.1-45(a)(2)

A. Based on observation, interview, and record review, the facility failed to ensure dishes, trays, and pots and pans (serving- ware) were cleaned and sanitized as directed by the dishwasher instructions and dried according to regulation which resulted in 82 of 83 residents who received food from the kitchen being at risk of contamination from improperly cleaned serving-ware including the potential of exposure from kitchen serving trays being cleaned from isolation rooms. The immediate jeopardy began on 9/12/22 when the facility's industrial dishwashing machine was observed to only reach a wash temperature of 80 degrees Fahrenheit (F). When asked, the kitchen staff were unaware if the machine was a high or low temperature machine and were unaware they should test the chemical concentration of the dishwasher water to ensure proper sanitation was attained. The kitchen staff indicated cloth dish towels were used to wipe off and dry dishes as they came out of the dishwasher because the serving-ware took too long to air dry due to the cool water temperatures. The 3-compartment wash sink was observed to be missing the chemical disinfectant solution and lacked the tubing hook-up which should connect to a pump to dispense the sanitizing solution. The 3-compartment sink was not observed to be utilized, despite the dishwasher being too cold. A blank dishwashing monitor log was observed posted on the front of the machine for the month of September. Dishwashing logs from June-August were reviewed and lacked documentation that the chemical concentration had been monitored and there were multiple days with low temperature readings. Large serving trays were observed to be in use in transmission-based precaution (TBP) isolation rooms which were returned to the kitchen to be cleaned in the dishwasher. During a follow up observation on 9/13/22, the dishwashing machine was observed to not reach the required temperature. The 3-compartment sink was observed to be filled and in use with dishes soaking but was not at the proper concentration of sanitizing solution. The Administrator, Regional Director of Clinical Operations, and Chief Operations Office were notified of the immediate jeopardy at 2:33 p.m. on 9/13/22. The immediate jeopardy was removed on 9/14/22, but noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. B. Based on observation, interview, and record review, the facility failed to ensure the employee handwashing sink in the kitchen was supplied with soap, bulk items in food storage were labeled and dated to be easily identified and failed to ensure long-handled scoops were not left in bulk storage bins which had the potential to effect 82 of 83 residents who were served from the kitchen. Finding include: A. During an initial kitchen tour on 9/12/22 from 9:15 a.m., until 9:45 a.m., the following was observed: There was a standing puddle of water near the dishwashing area. The Dietary Manager (DM) indicated the water was leaking from the dishwasher, which had been giving them problems on and off again for several months. A dishwasher monitoring log for the month of September was posted on the front of the machine but was observed to be blank. The DM indicated the log had not been filled out because the dishwasher had not been getting up to temperature and the temperatures varied too widely. She was unsure if the dishwasher was a high or low temperature machine. The DM ran several wash cycles back-to-back. The wash temperature was monitored by an external thermometer that never read more than 80 degrees Fahrenheit (F). No dishes were in the wash cycle for the observation, so the water tested by physical touch was lukewarm. The water ran clear. No detergent, or disinfectant was observed to be dispensed from the tubing into the front drain compartment which allowed it to be cycled through the machine. When asked how the dishes were sanitized if the dish machine did not get up to temperature, the DM indicated the 3-compartment sink was rarely used and the sanitizer was not even hooked up. She did not know what parts per million (PPM) (a measurement of the mass of a chemical or contaminate per unit volume of water) was or how to check the concentration. The DM indicated because the water was too cold during the wash cycle the dishes took too long to air dry, so the staff used cloth towels to wipe off and dry any equipment out of the machine as needed. After the dishwasher cycles were observed, Cook 12 loaded the dishwasher with serving-ware to include a large cooking pot and several burgundy trays. As he ran the dishes through the cycle, the machine did not reach temperature. Cook 12 indicated the dish machine had been having problems since he started in March, specifically that the water was always cold, and they had to use cloth towels to dry the serving-ware. He did not know what PPM was or how to check the concentration. On 9/12/22 at 9:50 a.m., a rolling cart with breakfast trays was observed on the A-hall. All food items and beverages were observed to be plated on regular, reusable serving-ware and set on top of large plastic burgundy food trays. Meal tickets which remained on the trays included the names of residents in isolation as new admission for COVID-19 precautions. During an interview on 9/12/22 at 9:50 a.m., Qualified Medication Aide (QMA) 14 indicated there was one resident who had admitted and was COVID-19 positive (Resident 286) but he was out of the facility at that time for [CONDITION(S)]. When asked how he was served meals, she indicated all his food was prepared and served in Styrofoam containers but brought in on a burgundy tray. The tray was returned to the kitchen like all the others. During an interview on 9/12/22 at 9:55 a.m., QMA 15 indicated there was one resident who was COVID-19 positive on the D-hall (Resident 4). Her food was served in all paper containers but taken into the room on a regular tray. At this time, she donned the appropriate PPE (personal protective equipment) and entered the room. Through the open door, Resident 4 was observed sitting in a chair, with her over-bed table in front of here where she ate her breakfast off a Styrofoam plate that rested on one of the burgundy food trays. During a follow up visit to the kitchen on 9/12/22 from 11:53 a.m., until 12:15 p.m., the following was observed: Dietary Aide (DA) 16 was observed at the dishwasher running equipment and serving-ware through. She indicated the dishwasher had been broken for a while, and because it did not dry the dishes well, the staff used cloth towels to wipe off and dry dishes after the wash. The dishwasher was observed for several more cycles. There was an instructional panel on the top right corner of the machine which indicated the dish washer was a low temperature machine and should reach a minimum of 120 degrees F for both the wash and rinse cycles. Additionally, the wash water should be tested to ensure a minimum of 50 PPM of chlorine sanitizer was concentrated into the water. The DM indicated she had not been testing for PPM. She was observed to get a small container of test strips and dip the strip into the water reserve as the dishwasher was running. She removed the strip and compared it to the guide on the side of the strip container. The side of the testing strips had PPM concentrations to match the testing strip with, but 50 PPM was not listed on the side of the bottle. The strip was not observed to change colors. The DM indicated she may need to prime the tubing and she held the control on the machine to prime the tubing. No liquid was observed to be dispensed into the dishwasher water reservoir. The DM attempted to the prime the machine multiple times without liquid being dispensed. She retested the concentration of the water, and the strip did not change colors. During an interview on 9/12/22 at 12:05 p.m., the dish washing machine logs from June through August of 2022 were reviewed with the DM. At this time, she indicated the logs were temperature recordings, even though the log was for PPM monitoring. She did not know the staff should be checking the PPM ,so she has instructed them to record temperatures only. Upon review of the logs, the following days were recorded below the required minimum of 120 F. a. June 12, 13, 14, 16, 18, 19, 21, 22, 23 and 31, 2022. b. July 1, 3, 5, 7, 9, 11, 12, 17, 18, 24, 25, 26, 27, 29 and 30, 2022. c. August 2, 3, 4, 5, 7, 8, 10, 16, 17, 18, 20, 28 and 29, 2022. During an interview on 9/12/22 at 12:09 p.m., the Maintenance Director indicated the kitchen staff had let him know that the dishwasher was not getting up to temperature. He suspected the hot water heater was the problem. They had previously had other issues with the dishwasher related to plumbing and leaking so they had a contracted company come out for repairs. Other than small, simple technical repairs, the Maintenance Director was not qualified or certified to service the dishwasher when it broke which was why he needed to call someone else to come look at it. When he went to assess the machine after the DM let him know it was not up to the correct temperature, he observed that the temperature did not get over 80 degrees F. During an interview on 9/12/22 at 12:17 p.m., the Administrator indicated she had been informed of concerns with the dishwasher from earlier that morning. The dishwasher had issues that come and go, and were repaired as needed. During an interview on 9/12/22 at 12:33 p.m., the DM indicated she had repeatedly reported concerns about the disrepair of the dishwasher to the Administrator and knew that the Administrator had contacted cooperate about the issues. She had even witnessed the Administrator calling corporate and had not been given a final answer on repairs. When asked about the burgundy trays serving trays that meals were sent out on, the DM indicated every room received their meals on the serving trays except the two COVID-19 positive rooms. On 9/12/22 at 12:56 p.m., a rolling cart with lunch trays was observed on the A-hall. All food items and beverages were observed to be plated on Styrofoam or plastic disposable serving-ware but were placed on top of large plastic burgundy food trays. Meal tickets which remained on the trays included the names of residents in isolation as new admission for COVID-19 precautions. On 9/12/22 at 1:00 p.m., an unidentified Certified Nursing Assistant (CNA) delivered a Styrofoam lunch box to Resident 4, who was COVID-19 positive. After she donned the appropriate PPE, she entered the room, and through the open door, she was observed to set the lunch box on top of a burgundy serving tray that was on Resident 4's over-bed table. During an interview on 9/12/22 at 1:25 p.m., the Administrator indicated staff had been instructed to wipe off the burgundy serving trays before taking them out of the COVID-19 positive rooms. During an interview on 9/12/22 at 3:07 p.m., the Maintenance Director indicated he had determined that the kitchen staff had accidently turned off a switch under the dishwashing sink, that turned the hot water off. He had already called and gotten someone out to check the hot water heater which was being repaired as well. Additionally, he identified the tubing on the dish machine was not properly dispensing chemicals into the tank, so he needed to contact someone else to come and get that fixed. There was no way to determine how long the tubing had been compromised and not properly dispensing the dishwashing chemicals. During a follow-up observation of the dish washing machine on 9/12/22 at 4:47 p.m., a Contracted Technician was observed as he put final pieces of a repair on the dishwashing machine. At this time, he indicated the squeeze tubes for the chloride and rinse solutions had worn to disrepair and needed to be replaced. Upon replacement, the dish washer cycle was observed. Steaming hot water poured into the water basin, and bubbles gathered on the top of the water which indicated soapy water was present. The technician had tested the water and it was coming out to the correct PPM. He indicated he replaced the pump and chemical disinfectant solution for the 3 compartment sink as well as it had been missing. The DM who was present at that time, indicated she had no idea the squeeze tubes were able to be replaced, who, or how often they should be replaced. On 9/13/22 from 9:14 a.m., until 9:40 a.m., a return visit was conducted in the kitchen to observe the dishwashing machine. The DM indicated she had been instructed to let the machine run 5-6 times to ensure it got up to temperature before running dishes through it. She began the machine. After 10 back-to-back cycles, the machine only reached 112 degrees F. The DM indicated she did not know why it was acting up again. It had been fixed the previous night. While the dish machine ran, the DM used a purple PPM test strip to dip in the wash water. The test strip turned to indicate the appropriate amount of disinfectant had been dispensed into the dish machine wash water and it was 50 PPM. The DM indicated someone from corporate had come in and explained the repairs, but she had gone home and Googled some research on PPM testing and figured it out on her own. She had used the incorrect test strips on 9/12/22. While still waiting for the dish machine to get up to temperature, it was requested to test the PPM of the 3-compartment sink, as dishes were observed in the wash sink soaking. The DM used several of the same purple test strips she had used for the dishwasher. The strip did not turn colors. The DM indicated she needed to add the disinfectant and explained that two new hoses had needed to be installed last night to hook the pump back up properly. She pressed a button which started the pump to dispense the chemical sanitizer. She dipped a purple strip in the water several more times, but the strip did not turn colors. When prompted to test the water with a different type of test strip that the PPM strip registered and changed color to indicate the water was 100 PPM. The Dietary Manager was unaware this PPM was not appropriate for the 3 compartment sink. During an interview on 9/13/22 at 9:29 a.m., DA 18 indicated she had not received any new education or in-service the day before. The DM added at this time, she was in the process of getting her DAs re-educated. The DM indicated she had not signed any in-service material either, but she had been present for the repairs and had been told by the technicians what to do. On 9/13/22 at 9:46 a.m., the Administrator was notified that the dishwashing machine was still not getting to the correct temperature. Copies of the in-service and/or education that was provided the day before were requested at this time. During an interview on 9/13/22 at 10:11 a.m., the DM indicated the Administrator had just asked her to have the kitchen staff sign an in-service sheet and to provide education on the dishwasher temperatures, so she had called all her kitchen staff to come in to receive the education. On 9/13/22 at 10:37 a.m., the DM provided a copy of an in-service sign-in and a current policy titled, Cleaning Dishes and Dish Machine. She was in the process of educating her staff. A corporate consultant came last night and educated her and the staff that were present. On 9/13/22 at 10:40 a.m., the above policy was reviewed [and detailed below] and lacked information/instruction on low versus high temperature dish machines, PPM sanitizing procedure, and referred to the dish washing manufacture's recommendations, but no manufacture's recommendations were included. On 9/13/22 at 11:12 a.m., the dish washer was observed with the DM, the Regional Director of Maintenance (RDM) and two other technicians. During the wash and rinse cycle the internal thermometer registered 130 degrees F. The RDM indicated an electric valve to the hot water tank had gone bad and was replaced, which was different than the repair the Maintenance Director had completed the previous day. On 9/13/22 at 12:13 p.m., the previously mentioned policy was reviewed with the Administrator. She was notified at this time, that the policy lacked information/instruction related to the sanitation intent/specifications/requirements. Additionally, as the provided policy referred to the dish machine manufacture's recommendations and the dish washing manual, those documents were requested at this time as well. The Administrator indicated she had looked for the manual, but the machine was so old, and had had so many repairs, they did not have a copy of the manual so she would look online. On 9/13/22 at 1:50 p.m., the Administrator provided typed instructions, which were noted to have been copied onto a policy template, titled, Kitchen Culinary Sanitation Facts. The Administrator also provided a copy of the dishwashing manual and indicated she had printed a copy from online. The Kitchen Culinary Sanitation Facts, dated 8/2021, indicated, .to test a sanitation bucket OR to test the 3-compartment sink, use the Hydrion Quat strips. Peel off a strip and immerse it in the sanitizer being tested for ten (10) seconds. Compare the strip to the key on the outside of the strip container while wet. Sanitizer concentration is read in parts per million (ppm). Ideal concentration is 200 ppm, but concentration is acceptable between 150-400 ppm . low temperature dish machines should have a chemical chlorine concentration of 50 ppm The dishwashing manual provided by the ADMINISTRATOR on 9/13/22 at 1:50 p.m. was titled, American Dish Service [ADS] Low Temperature Dishwasher Model: 5-AG-S Parts Manual, dated 7/2013. The manual indicated, .NOTICE: before you begin . keep all instructions for future reference . should you desire to make sure that you have the most up-to-date information, we would direct you to the appropriate document on our website: www.americadish.com . it is your obligation as the customer to ensure that the replacement parts for the machine are installed safely and properly, and when completed, the machine is left in proper and safe working order . failure to provide adequate water quantity, pressure and temperature to the machine will cause the machine to function improperly . On 9/14/22 at 7:50 a.m., additional recommendations for the 5-AG-S dish machine model were reviewed on the manufactures' website at: https://www.americandish.com/WhatsNew/Installation%20Manual%205-AGS.pdf. A document titled, American Dish Service, INSTALLATION INSTRUCTIONS Model 5-AGS or 5-AG, dated 5/2017 indicated, .Water heaters or boilers must provide the minimum temperature of 120F for this model of machine, which demands an hourly minimum of 118.4 GPH. Temperatures above 150F degrees exceed the operational design limits for this model. While the supply water must have a minimum of 120F degrees, 130/140F degrees is recommended for best results. CHEMICAL FEEDER PUMPS ADS provides three (3) peristaltic pumps to dispense liquid chemicals Chemical feed lines are color coded Red Detergent , Green Sanitizer, Blue Rinse aid .Pick up tubes are provided for chemical product containers Sanitizer (chlorine) concentrations should be set at 50 parts per million. Inspect the transfer tubing for any cuts or holes, keep them protected and secured . CHEMICAL LINES - Squeeze tubes should be replaced at least every six months On 9/13/22 at 10:35 a.m., the DM provided a copy of the in-service material and sign-in sheet she had provided to her staff. A current facility policy titled, Cleaning Dishes and Dish Machines, dated 8/2022. The policy indicated, Dishes and cookware will be washed and sanitized after each meal . make sure detergent and sanitizers are properly loaded . check temperatures and pressure. Follow manufactures' recommendations . air dry all items . Keep your ware washing machine in good repair The immediate jeopardy that began on 9/12/22 was removed on 9/14/22 when the facility had the water heater and dishwasher repaired by outside companies, the Dietary Manager and dietary staff were educated on how to use and monitor the temperature and chemical concentration of the dishwasher and the chemical concentration of the 3 compartment sink, and a process to monitor the dishwasher was implemented, but the noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because the need for additional monitoring of dishwasher temperatures, chemical concentrations of the dishwasher and 3 compartment sink, and ongoing training of kitchen staff. B. Upon entrance into the kitchen, for an initial kitchen tour on 9/12/22 at 9:15 a.m., the employee handwashing station was observed. The soap dispenser was out of soap, and the paper towels were set horizontally on top of the paper towel dispensing box. The Dietary Manager (DM) came over and indicated she was unaware that the station was out of soap. She did not have a replacement and would call Housekeeping to replace it. Instead, the DM grabbed a bottled of alcohol-based hand rub from her office desk, used it, and placed it on the sink for employee use. The DM indicated all the staff had hand gel as needed. The dry storage area was observed. There were three extra-large, standing plastic tubs. The tubs were not labeled or dated and the substance inside could not easily be identified. The DM indicated there was one tub each of flour, sugar and thickener. There were large, long-handled scoops laying on top of the substances inside each tub. When asked about scoops being left in bulk storage, the DM indicated she did not know that should not be allowed and asked why. It was explained, the scoop handles could be a potential source of contamination after being handled by several different kitchen staff members. On 9/17/22 at 3:45 p.m., the Administrator provided a copy of current facility policy titled, Food Receiving and Storage, dated 8/2022. The policy indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). Such foods will be rotated using a 'first in - first out' system On 9/17/22 at 3:45 p.m., the Administrator provided a copy of current facility policy titled, Preventing Foodborne Illness - Food Handling, dated 8/2022. The policy indicated, .Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness . Antimicrobial hand gel CANNOT be used in place of handwashing in food service areas . food service employees will be trained in the proper use of utensils such as tongs, [scoops], gloves, deli paper and spatulas as tools to prevent foodborne illness 3.1-21(i)(1) 3.1.21(i)(3)

A. Based on observation, interview, and record review, the facility failed to ensure a resident admitted to the behavior unit with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Based on observation, interview, and record review, the facility failed to communicate pertinent information, COVID status, and an assessment of a resident's condition to a receiving hospital for a change in condition for 1 of 3 residents reviewed for transfer and discharge (Resident 81). Findings include: A. During an interview, on 9/20/22 at 10:11 a.m., Resident D indicated the Social Services Director (SSD) did not like him. He came in from outside and the SSD indicated to him he needed to go to the local homeless shelter for no reason. He indicated he was given documents that were a 30 day notice and a right to appeal. He provided the documents to review. Resident D began shaking badly and indicated this conversation was upsetting to him. He said he received the papers but did not understand what the notice of discharge or request for a hearing meant. On the day of his discharge, he was in his room at the facility and the SSD indicated it was time to go. He had just been laying down. He indicated he was sent to the local homeless shelter and the staff at local homeless shelter indicated the facility had no right to send him there. He indicated the SSD used to say that she would send him to the local homeless shelter as a threat to get him to go the psych hospital. On the local homeless shelter day, he was mad and he faced the wall. The police came and got him to go to the front door. The police said if he didn't go to the local homeless shelter then he would go to jail in the police car. He had 3 or 4 big bags of clothes and medications. He indicated he did not know how to take medications or when. The people at local homeless shelter told him they do not dispense medications. He did not take any medications during his stay at local homeless shelter because he didn't know how to take it. The local homeless shelter staff called the facility and put all his stuff in a van and brought him back to the nursing facility. One resident at local homeless shelter tried to start something with him, he just turned and walked away. His medication remained locked in his locked locker the whole time he was at Local homeless shelter. Resident D indicated with his occasional severe shaking he was unable to read. He indicated he did not try to read the medication packaging. He did not know how to take the medication, he did not know what kind of medications he takes now, so he left them alone. He indicated sometimes he thought about killing people. He had never killed anyone or tried to kill anyone. He only thought about killing his brother and sister because they took his money and threw him out. He indicated he was mad at the SSD but had not thought about killing her. Sometimes he felt like fighting, but not fighting to kill them. During an interview on 9/20/22 at 10:47 a.m., the Administrator (ED) and SSD indicated they were trying to discharge Resident D from the facility because of his behaviors. The psych physician indicated he had a personality disorder, not behaviors. His behaviors were at a very high level compared to the other residents. The facility was trying to care for his needs. They were able to care for his needs. But this was a personality disorder. He did not need to be around other people. On 9/15/22 at 11:50 a.m., Resident D's record was reviewed. Resident D was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided on the locked behavior unit. On 9/15/22 at 11:54 a.m., a review of Resident D's care plans was completed. They were created on 5/4/22. The care plans lacked documentation of no revisions after the resident's 2 psychiatric hospital stays, 2/24 to 3/11/22 and 7/20 to 7/29/22, and 5 incidents with other residents. The care plan problems were: 1. Resident D had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. The resident uses anti-anxiety medication related to anxiety disorder. 3. The resident uses anti-psychotic medications related to [CONDITION(S)] disorder, [CONDITION(S)] type. Behavior management, Potential for injury to self or others. 4. Resident D exhibits restlessness, nervousness and/or other anxiety symptoms related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 5. Resident D had impaired cognitive function/impaired thought process related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Impaired thought processes/altered mental status related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, revised on 9/22/22, indicated the problem was Resident D had (Auditory, Visual) hallucinations (perception of something not present), delusional episodes, talking to himself in hallway and in his room, he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He was manipulative towards others, lunging at staff making threats, and making threatening gestures. The goal and interventions had not been updated since the care plan was created on 5/4/22. Resident D's reportable incidents to the Indiana Department of Health for the last 8 months were as follows: a. On 2/17/22, it was reported that Resident D wanted to borrow Resident 16's cell phone. She denied him and he called her a b***h. b. On 5/10/22, it was reported that Resident D made contact with Resident 17. Resident 17 was hallucinating and was sent to the hospital. c. On 5/17/22, it was reported that Resident 83 made racial comments to Resident D, and Resident D made contact with Resident 83. d. On 6/2/22, it was reported that Resident 17 made racial comments to Resident D, and Resident D pushed Resident 17. It was known that Resident 17 was in need of psych services. e. On 6/22/22, it was reported that Resident 83 made contact with Resident D for no reason. f. On 7/16/22, it was reported that Resident D pushed Resident C. Resident C fell and fractured his wrist. On 9/15/22 at 11:50 a.m., Resident D's soft file was provided by the SSD. These were dated paragraphs of information regarding Resident D and his progress to discharge. No times were noted. - On 2/23/22 with no time noted, the Social Services Director (SSD) indicated she had a conversation with the Ombudsman 41. She recommended the SSD to schedule a discharge care plan meeting, issue 30-day notice and allow Resident D to make an appeal within 10 days. She stated if an appeal had not been made within 10 days, then the facility had the right to discharge Resident D to the local homeless shelter. She recommended the SSD set the resident up with an appointment with the local mental health outpatient center. SSD had told the Ombudsman 41 the resident had made sexual comments, verbal and physical aggression towards staff and peers, but was independent with all ADLs, scored high on BIMS (brief interview for mental status) and inquired about discharge to the local homeless shelter. -On 3/9/22 with no time noted, SSD indicated she contacted the office of the Ombudsman but was unable to get through, left a voicemail and emailed Ombudsman 43. The SSD received a phone number for the local homeless shelter. -On 3/9/22 with no time noted, SSD received a call from Ombudsman 42 who stated she was filling in. SSD provided information to Ombudsman 42 on Resident D. She explained safety concerns with the resident returning to the facility. She stated that the facility should decide based on the safety of the patients in the facility but indicated to understand that the psych hospital can call the board of health to file a complaint and there could be repercussions. Ombudsman 42 recommended that SSD try to work with psych hospital to find alternative placement that would agree to accept him, especially all male facility. -On 3/11/22 with no time noted, Resident D scored 13/15 on BIMS. SSD contacted Ombudsman 42 to discuss the facility's right to discharge Resident D to Local homeless shelter due to concerns with him. She stated the facility had the right to discharge him to the Local homeless shelter. SSD informed Ombudsman 42 that Resident D was independent with all ADLs, recommended for medication management, and informed Ombudsman 42 that SSD had already contacted the local mental health outpatient center regarding scheduling an appointment. The SSD had contacted the transportation number that was provided to SSD from the mental health outpatient center. SSD provided information of the discharge location to the transportation provider, and transportation stated they just needed a contact number at the local homeless shelter to inform them of pick-up times for Resident D on appointment days. The transportation provider stated the local mental health outpatient center would contact transportation to schedule transport with date and time, they stated SSD does not need to schedule this with them. -On 3/11/22 with no time noted, a care plan meeting was held with SSD, Assistant Director of Nursing (ADON) and Resident D. SSD discussed recently being readmitted to facility this morning from an inpatient psychiatric (psych) stay. SSD asked Resident D if he recalled the reason for the psych stay, Resident D indicated he got into a fight. SSD agreed and discussed behaviors of becoming very loud with threatening behavior yelling and screaming out. We discussed his ADL (activity of daily living) status of being independent with all ADLS except medication management., discussed his potential 30-day notice to Local homeless shelter due to safety concerns of other residents. Resident D became very agitated and began yelling and screaming at SSD and ADON, stated he's not leaving, and he wanted to stay at the facility. SSD had difficulty speaking to Resident D due to yelling, screaming out. SSD educated Resident D on current verbal behavior and disruption to other peers. Resident continued to yell and scream. SSD attempted to redirect him but was unsuccessful. He screamed at SSD and ADON to leave his room. - On 3/16/22 at 2:53 p.m., the SSD was notified by the DON of Resident D had become agitated with staff regarding the smoking time. He slammed his jacket on the chair in hallway. SSD spoke with Resident D this afternoon regarding his behaviors. He denied having these behaviors. SSD re-educated him on appropriate behaviors. He expressed understanding. No behaviors noted during this visit. - On 3/18/22 at 12:54 p.m., a Social Services (SS) note indicated Resident D was visited by Psych therapist on this day with no concerns regarding behavior, psychosocial well-being, or mood. The Social Service Director (SSD) also visited with Resident D who was pleasant. No signs or symptoms of psychosocial well-being, mood concerns, or behaviors noted. - On 3/21/22 with no time noted, the SSD was notified Resident D was upset with a female peer and told her she cannot have another boyfriend. SSD and ADON spoke with him. He admitted to having this behavior and state he was jealous. SSD educated Resident D of previous conversation of him having behaviors and the potential for a 30-day discharge. He expressed understanding that this behavior could cost him a 30-day notice. He asked for a second chance. SSD stated she would speak with the Administrator. They would speak to him again next week. - On 3/23/22 at 1:33 p.m., an SSD note indicated the SSD visited with Resident D who was in good spirits. He showed no behaviors, no signs or symptoms of psychosocial well-being or mood concerns. - On 3/24/2022 at 2:34 p.m., an SSD note indicated the SSD and ADON visited with Resident D. SSD discussed threatening behaviors towards staff with yelling and screaming out, his impulsive outbursts, and safety concerns. Resident D was educated on 30 Day Discharge Notice that was issued to him on this day. He was educated on the right to file an appeal, and provided details on how to do so, and educated Resident D that he would discharge to the local homeless shelter. Educated Resident D on being followed by the local mental health outpatient center for medication management after his discharge. Resident D became agitated and began to raise his voice, he continued to ask for another chance. SSD educated Resident D again on his behaviors. Writer emailed a 30-Day Notice to Discharge Resident D to the Ombudsman. -On 4/8/22 at 10:46 a.m., a nursing note indicated the Assistant Director of Nursing (ADON), currently the Interim DON, indicated Resident D scored at a high risk on an elopement assessment due to being independently mobile and having dementia. -On 4/22/22 12:21 a.m., the Nurse Practitioner (NP) 40 indicated in a late entry that she had a discharge visit with Resident D. She indicated he was being seen today for discharge planning to the local homeless shelter per the facility. He had a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He did not appear to be in any acute distress at this time or during this visit. He was resting quietly in a chair. He was oriented to person and place with periods of confusion. He was pleasant and cooperative. Medications were sent with Resident D upon his discharge. - On 4/22/22 at 2:53 p.m., the Discharge Summary indicated the SSD had spoken with Resident D several times throughout this week regarding his upcoming discharge on 4/22/22. She informed Resident D of the clinic providing transportation from the facility to their clinic for an initial appointment on 4/22/22, then would be transported to the local homeless shelter. Resident D became agitated throughout these visits and asked on different occasions for another chance. SSD attempted to redirect Resident D by educating him but was unable to due to him yelling at writer. Staff members visited with Resident D on this day regarding his discharge to the local homeless shelter related to the 30-day discharge notice. Resident refused to leave facility. He was yelling and screaming, with threatening behaviors. He told the staff the only way he was leaving was if the cops were called. Non-emergency police were contacted to assist with escorting Resident D to an outpatient clinic's vehicle. The police escorted Resident D outside and into van. He was discharged with medications, contact numbers, and discharge information. - On 4/25/22 at 5:56 p.m., the Staffing Coordinator/Unit Manager indicated Resident D returned to facility at 5:15 p.m. today. Resident returned with medications and his belongings. He was placed in a room on the locked behavior unit. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He was alert and oriented times 3. He ambulated on own without an assistive device. His gait was steady. - On 4/25/22 at 6:00 p.m., Resident D's Admission/Readmission form indicated he was admitted from the local homeless shelter. He was oriented to person, place, time, and situation. He had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His cognition was intact. - On 4/26/22 with no time noted, the SSD indicated she spoke with the local homeless Shelter Director. He indicated the shelter sent Resident D back to the facility as no one contacted them to inform them of Resident D being dropped off. - On 5/26/22 SSD was notified of Resident D smacking a Certified Nursing Aide (CNA) on the buttocks. SSD asked Resident D why he did it, educated him on appropriate behaviors and explained this behavior was inappropriate. Resident D apologized. - On 6/1/22 with no time noted, SSD was notified of Resident D becoming agitated and verbally aggressive as he stated he was jealous of the other peers wanting a girlfriend. SSD was able to redirect him with conversation, walking on the unit and offered activities of interest. He appeared in a better mood with no further behaviors noted. - On 7/20/22 with no time noted, the SSD, DON and the Rounding Psych physician and the Rounding Psych NP discussed Resident D and his behaviors. Possible in-patient referral was discussed. The Rounding Psych physician who also works at the local inpatient Psych denied him for inpatient psych stating medications would not help his behaviors. This was his personality and medication would not change or help him. He recommended the facility send Resident D to the local mental health outpatient center emergency room and recommended the facility to not accept him back to the facility. - On 8/4/22 with no time noted, the SSD attempted to contact the local mental health outpatient center to discuss group home placement but was unable to get through and unable to leave a voice message. - On 8/9/22 with no time noted, SSD spoke with Ombudsman 44 and requested recommendations and thoughts regarding placement for Resident D. Ombudsman 44 indicated a place to try who accepted residents with behaviors. - On 9/19/22 at 8:31 a.m., Administrator indicated she received a call from the local homeless shelter, and he indicated they would not accept him. He said you must have our permission; we will not accept him. - On 9/19/22 at 2:32 p.m., the SSD indicated she had provided all transfer documents to Resident D. He did not sign any transfer or discharge documents. - On 9/19/22 at 2:35 p.m., the Administrator indicated Resident D did not have a behavioral contract with the facility. On 9/19/22 at 3:13 p.m., the Activity Director (AD) indicated Activity Aide 36 had a good relationship with Resident D and was able to redirect him. Resident D liked to do crafts, loved newspapers, and activity staff talked to him. She indicated she did not know if the evening/night shift or weekends had special activities for him, but they did know where the activity room key was kept so they could have had access to supplies for his leisure. The facility also bought him cigarettes when he was out. Activity personnel were in the building 7 days a week until 7:00 p.m. On 9/19/22 at 3:14 p.m., the SSD indicated Resident D loved cleaning and organizing things in his room. The staff knew the resident very well. He liked to talk about cars. He liked to compare prices. The AD indicated she would take a computer to him to look at ads. The SSD indicated she was looking into making a binder of activities of interest for him. On 9/20/22 at 10:53 a.m., the SSD indicated the psych physician indicated to the facility to send Resident D to the local mental health outpatient center emergency room and not accept him back. They did not follow these instructions. On 9/20/22 at 11:00 a.m., the SSD provided a list of referred facilities to whom she had applied to send Resident D. Many of these buildings did not have a locked unit. Her documentation indicated she referred him to 37 buildings, 3 of them twice. On 9/20/22 at 11:16 a.m., the SSD indicated the Director of the Local homeless shelter called and talked to SSD and Administrator. He was very upset about Resident D arriving at the homeless shelter. He indicated the facility had to have permission. He called on 4/25/22 and insisted Resident D come back to the facility. On 9/12/22, the Admissions Agreement was provided by the facility. A document within the Admission Agreement titled, Indiana Resident Rights and Facility Responsibilities, was reviewed. It indicated, .The resident has the right to be cared for in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality .A copy of the resident's rights must be available in a publicly accessible area. The copy must be at least 12-point type .The transfer and discharge rights of residents of a facility are as follows .before an interfacility transfer or discharge occurs, the facility must .place a copy of the notice in the resident's clinical record and transmit a copy to the following .the local long term care ombudsman program for involuntary relocations or discharges only .the notice of transfer or discharge .must be made by the facility at least thirty (30) days before the resident is transferred or discharged .At the planning conference, the resident's medical, psychosocial, and social needs with respect to the relocation shall be considered and a plan devised to meet these needs .If the relocation plan is disputed, a meeting shall be held prior to the relocation with the administrator or his or her designee, the resident, and the resident's legal representative .The purpose of the meeting shall be to discuss possible alternatives to the proposed relocation plan B. A record review was completed for Resident 81 on 9/20/22 at 9:41 a.m. She had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse Practitioner progress note, dated 9/2/22 at 12:32 p.m., indicated a blood pressure of 99/58. It indicated that Resident 81 had pitting [CONDITION(S)] in her lower extremities and hands. [MEDICATION(S)] (diuretic) was increased on 8/29/22. A nursing progress note, dated 9/3/22 at 10:13 a.m., indicated that the resident refused to be weighed indicating that she did not feel good and did not want to be rolled (turned) yet. A nursing progress note, dated 9/3/33 at 2:33 p.m., indicated that Resident 81 refused [MEDICATION(S)] indicating that the side effects, unusual dry mouth/thirst of [MEDICATION(S)] and uncontrollable hand movement making it hard for her to eat. A nursing progress note, dated 9/4/22 at 1:36 p.m., indicated that the resident refused [MEDICATION(S)] (a diuretic) indicating that she thought that the medication made her shake. There was no documentation to indicate that the physician was notified. A nursing progress note, dated 9/4/22 at 4:21 p.m., indicated that Resident 81 had a blood pressure of 129/84. A nursing progress note, dated 9/6/22 at 6:17 p.m., indicated a blood pressure reading of 109/57 and that resident was on daily diuretics but had to receive 80mg of [MEDICATION(S)] intramuscular due to increased swelling. She was noted to be anxious with no shortness of breath and oxygen saturation of 96% on room air. It indicated that her blood pressure was slightly low the day prior and her [MEDICATION(S)] (a medication used to treat high blood pressure) was held as a result. She had labs ordered for later in the day, BMP (basic metabolic profile), CBC (complete blood count) and BNP (b-natriuretic profile) to evaluate volume status. Resident 81 was sent to the local hospital on 9/7/22 for unstable vital signs, weakness, dilated pupil, and difficulty speaking. There were no vital signs documented at time of transfer. Resident 81 was admitted to the hospital with [CONDITION(S)] (low blood pressure) and altered mental status. The VP of Clinical Services was interviewed on 9/20/22 at 12:49 p.m. She indicated that a discharge/transfer summary was not completed upon transfer of Resident 81 to the hospital to communicate Resident 81's pertinent information and assessment of her condition. A policy titled, Discharge/Transfer/Death with a date of 8/2022, was provided by the Administrator on 9/21/22 at 1:06 p.m., it indicated, .A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs, b. The post-discharge plan, c. The discharge summary . 3.1-12(a)(4) 3.1-12(a)(6)(A)

Based on observation, interview, and record review, the facility failed to ensure a resident was oriented and prepared for discharge with no plan with the receiving facility, the resident experienced psychosocial harm for 1 of 3 residents reviewed for discharge (Resident D). Findings include: On [DATE] at 11:50 a.m., Resident D's chart and the soft file from the Social Services Director (SSD) were reviewed. The soft file, was provided by the SSD. These were dated paragraphs of information regarding Resident D and his progress to discharge. No times were noted. Resident D was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided on the locked behavior unit. On [DATE] at 11:54 a.m., a review of Resident D's care plans were completed. They were created on [DATE], with no revisions, even with 2 psych hospital stays, ,d+[DATE]-[DATE] and ,d+[DATE]-[DATE], and 5 incidents with other residents. Resident C sustained a fractured wrist after he was pushed by Resident D. The care plan problems were: 1. Resident D had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. The resident uses anti-anxiety medication related to anxiety disorder. 3. The resident uses anti-psychotic medications related to [CONDITION(S)] disorder, [CONDITION(S)] type. Behavior management, Potential for injury to self or others. 4. Resident D exhibits restlessness, nervousness and/or other anxiety symptoms related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 5. Resident D had impaired cognitive function/impaired thought process related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Impaired thought processes/altered mental status related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan was revise dated [DATE], it indicated the problem was Resident D had (Auditory, Visual) hallucinations (perception of something not present), delusional episodes, talking to himself in hallway and in his room, he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He was manipulative towards others, lunging at staff making threats, and making threatening gestures. The goal and interventions had not been updated since the care plan was created on [DATE]. Resident D's reportable incidents to the Indiana Department of Health for the last 8 months were as follows: a. On [DATE], it was reported that Resident D wanted to borrow Resident 16's cell phone. She denied him and he called her a b***h. b. On [DATE], it was reported that Resident D made contact with Resident 17. Resident 17 was hallucinating and was sent to the hospital. c. On [DATE], it was reported that Resident 83 made racial comments to Resident D, and Resident D made contact with Resident 83. d. On [DATE], it was reported that Resident 17 made racial comments to Resident D, and Resident D pushed Resident 17. It was known that Resident 17 was in need of psych services. e. On [DATE], it was reported that Resident 83 made contact with Resident D for no reason. f. On [DATE], it was reported that Resident D pushed Resident C. Resident C fell and fractured his wrist. On [DATE] with no time noted, the SSD indicated she had a conversation with the Ombudsman 41. She recommended the SSD to schedule a discharge care plan meeting, issue 30-day notice and allow Resident D to make an appeal within 10 days. She stated if an appeal had not been made within 10 days, then the facility had the right to discharge Resident D to the [NAME] Mission. She recommended the SSD set the resident up with Midtown [NAME] (mental health center). SSD had told the Ombudsman 41 the resident had made sexual comments, verbal and physical aggression towards staff and peers, but was independent with all ADLs, scores high on BIMS (brief interview for mental status) and inquired about discharge to the [NAME] Mission. On [DATE] with no time noted, SSD indicated she contact the office of the Ombudsman but was unable to get through, left a voicemail and emailed Ombudsman 43. The SSD received a phone number for [NAME] Mission. On [DATE] with no time noted, SSD indicated she was asked to contact Midtown once a discharge date was established and she would set up an initial appointment. Midtown provided their transportation number through [NAME] to contact. Resident would be seen once every 3 months by a psychiatrist, and a therapist twice a month. On [DATE] with no time noted, SSD received a call from Ombudsman 42 who stated she is filling in. SSD provided information to Ombudsman 42 on Resident D. She explained safety concerns with the resident returning to the facility. She stated that the facility should decide based on the safety of the patients in the facility but indicated to understand that the psych hospital can call the board of health to file a complaint and there could be repercussions. Ombudsman 42 recommended that SSD try to work with psych hospital to find alternative placement that would agree to accept him, especially all male facility. On [DATE] with no time noted, SSD referred Resident D to several facilities, most have denied him. On [DATE] with no time noted, Resident D scored ,d+[DATE] on BIMS. SSD contacted Ombudsman 42 to discuss the facility's right to discharge Resident D to [NAME] Mission due to concerns with him. She stated the facility had the right to discharge him to the [NAME] Mission. SSD informed Ombudsman 42 that Resident D was independent with all ADLs, recommended for medication management, and informed Ombudsman 42 that SSD had already contacted Midtown [NAME] regarding scheduling an appointment. The SSD had contacted the transportation number that was provided to SSD from Midtown. SSD provided information of the discharge location to the transportation provider, and transportation stated they just needed a contact number at the [NAME] Mission to inform them of pick-up times for Resident D on appointment days. The transportation provider stated Midtown [NAME] will contact transportation to schedule transport with date and time, they stated SSD does not need to schedule this with them. On [DATE] with no time noted, a care plan meeting was held with SSD, ADON and Resident D. SSD discussed recently being readmitted to facility this morning from Assurance Psych. SSD asked Resident D if he recalls the reason for the psych stay, Resident D indicated he got into a fight. SSD agreed and discussed behaviors of becoming very loud with threatening behavior yelling and screaming out. We discussed his ADL (activity of daily living) status of being independent with all ADLS except medication management., discussed his potential 30-day notice to [NAME] Mission due to safety concerns of other residents. Resident D became very agitated and began yelling and screaming at SSD and ADON, stated he's not leaving, and he wants to stay at the facility. SSD had difficulty speaking to Resident D due to yelling, screaming out. SSD educated Resident D on current verbal behavior and disruption to other peers. Resident continued to yell and scream. SSD attempted to redirect him but was unsuccessful. He screamed at SSD and ADON to leave his room. [DATE] at 2:53 p.m., the SSD was notified by the DON of Resident D had become agitated with staff regarding the smoking time. He slammed his jacket on the chair in hallway. SSD spoke with Resident D this afternoon regarding his behaviors. He denied having these behaviors. SSD re-educated him on appropriate behaviors. He expressed understanding. No behaviors noted during this visit. On [DATE] at 12:54 p.m., a Social Services (SS) note indicated Resident D was visited by Greenhouse Psych therapist on this day with no concerns regarding behavior, psychosocial well-being, or mood. The Social Service Director (SSD) also visited with Resident D who was pleasant. No signs or symptoms of psychosocial well-being, mood concerns, or behaviors noted. On [DATE] with no time noted, the SSD was notified Resident D was upset with a female peer and told her she cannot have another boyfriend. SSD and ADON spoke with him. He admitted to having this behavior and state he was jealous. SSD educated Ray of previous conversation of him having behaviors and the potential for a 30-day discharge. He expressed understanding that this behavior could cost him a 30-day notice. He asked for a second chance. SSD stated she would speak with the Executive Director (ED). They will speak to him again next week. On [DATE] at 1:33 p.m., a SS note indicated the SSD visited with Resident D who was in good spirits. He showed no behaviors, no signs or symptoms of psychosocial well-being or mood concerns. On [DATE] at 2:34 p.m., a SS note indicated the SSD and ADON visited with Resident D. SSD discussed threatening behaviors towards staff with yelling and screaming out, his impulsive outbursts, and safety concerns. Resident D was educated on 30 Day Discharge Notice that was issued to him on this day. He was educated on the right to file an appeal, and provided details on how to do so, and educated Resident D that he would discharge to [NAME] Mission. Educated Resident D on being followed by Midtown [NAME] Health for medication management after his discharge. Resident D became agitated and began to raise his voice, he continued to ask for another chance. SSD educated Resident D again on his behaviors. Writer emailed a 30-Day Notice to Discharge Resident D to the Ombudsman. On [DATE] at 12:29 p.m., a SS note indicated the SSD contacted Oak St. Health and attempted to schedule an initial primary care physician (PCP) appointment. Oak St. Health stated someone from admissions will contact SSD next week to schedule initial appointment. Oak St. Health would provide transportation to and from his appointments. On [DATE] at 10:46 a.m., a nursing note indicated the Assistant Director of Nursing (ADON), currently the Interim DON, indicated Resident D scored at a high risk on an elopement assessment due to being independently mobile and having dementia. On [DATE] 12:21 a.m., the Nurse Practitioner (NP) 40 indicated in a late entry that she had a discharge visit with Resident D. She indicated he was being seen today for discharge planning to the [NAME] Mission per the facility. He had a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He did not appear to be in any acute distress at this time or during this visit. He was resting quietly in a chair. He was oriented to person and place with periods of confusion. He was pleasant and cooperative. Medications were sent with Resident D upon his discharge. On [DATE] at 2:53 p.m., the Discharge Summary indicated the SSD had spoken with Resident D several times throughout this week regarding his upcoming discharge on [DATE]. She discussed scheduling an initial PCP appointment through Oak St. Health, informed Resident D of Oak St. Health providing transportation from the facility to their clinic for an initial appointment on [DATE], then will be transported to [NAME] Mission. Oak St. Health would refill his medications monthly. She provided Resident D with the transportation number to Southeast Trans for transportation. She contacted Midtown [NAME] Health to schedule initial appointment, they indicated they can transport him to and from appointments, Midtown to contact writer back with initial appointment date as writer left a voice mail at Midtown [NAME]. Resident D became agitated throughout these visits and asked on different occasions for another chance. SSD attempted to redirect Resident D by educating him but was unable to due to him yelling at writer. Staff members have visited with Resident D on this day regarding his discharge to the [NAME] Mission related to the 30-day discharge notice. Resident refused to leave facility. He was yelling and screaming, with threatening behaviors. He told the staff the only way I'm leaving was if the cops were called. Non-emergency police were contacted to assist with escorting Resident to an Oak St. Health vehicle. The police escorted Resident D outside and into van. SSD had made contact Oak St. Health regarding Resident D's initial appointment; they stated Resident D had arrived and would be checked in. He was discharged with medications, contact numbers, and discharge information. On [DATE] with no time noted, the SSD contacted [NAME] Midtown to follow up regarding scheduling an appointment for Resident D's transportation. Midtown indicated she recalled speaking with SSD in March and informed SSD that their policy had changed for scheduling appointments and scheduling transportation for clients. She stated they do not schedule appointments or transportation because it is all now walk-ins only on Monday - Friday, from 9:00 a.m. to 12:00 p.m. Midtown provided SSD a transportation number to contact to schedule for pick up to and from Midtown. Midtown indicated patient would now need to schedule their own appointments. On [DATE] at 5:56 p.m., the Staffing Coordinator/Unit Manager indicated Resident D returned to facility at 5:15 p.m. today. Resident returned with medications and his belongings. He was placed in a room on the locked behavior unit. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He was alert and oriented x 3. He ambulated on own without an assistive device. His gait was steady. On [DATE] at 6:00 p.m., Resident D's Admission/Readmission form indicated he was admitted from [NAME] Mission. He was oriented to person, place, time, and situation. He had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . His cognition was intact. On [DATE] with no time noted, the SSD indicated she spoke with the [NAME] Mission Director (WMD). He indicated the facility send Resident D back to the facility as no one contacted them to inform them of Resident D being dropped off. SSD informed WMD that she was unaware of needing to inform them of residents' arrival because they took walk-ins. The WMD indicated that was no longer the case. On [DATE] SSD was notified of Resident D smacking a Certified Nursing Aide (CNA) on the buttocks. SSD asked Resident D why he did it, educated him on appropriate behaviors and explained this behavior was inappropriate. Resident D apologized. On [DATE] with no time noted, SSD was notified of Resident D becoming agitated and verbally aggressive as he stated he was jealous of the other peers wanting a girlfriend. SSD was able to redirect him with conversation, walking on the unit and offered activities of interest. He appeared in a better mood with no further behaviors noted. On [DATE] with no time noted, the SSD, DON and the Rounding Psych physician and the Rounding Psych NP discussed Resident D and his behaviors. Possible in-patient referral was discussed. The Rounding Psych physician who also works at Assurance Psych denied him at Assurance stating medications will not help his behaviors, stat this was his personality and medication will not change or help him. He recommended the facility send Resident D to [NAME] ER and recommended the facility to not accept him back to the facility. On [DATE] with no time noted, the SSD attempted to contact [NAME] Midtown to discuss group home placement but was unable to get through and unable to leave a voice message. On [DATE] with no time noted, SSD emailed Ombudsman office and attempted to contact Ombudsman 44 and left a voice mail. On [DATE] with no time noted, SSD spoke with Ombudsman 44 and requested recommendations and thoughts regarding placement for Resident D. Ombudsman 44 indicated a place to try who accepted residents with behaviors. On [DATE] at 8:31 a.m., ED indicated she received a call from the WMD and he indicated they would not accept him. He said you must have our permission, we will not accept him. On [DATE] at 2:32 p.m., the SSD indicated she had provided all transfer documents to Resident D. He did not sign any transfer or discharge documents. On [DATE] at 2:35 p.m., the ED indicated Resident D did not have a behavioral contract with the facility. On [DATE] at 2:36 p.m., the SSD indicated she believed Resident D left with a 30-day supply of all April MAR medications because he was a Medicaid recipient. 1. [MEDICATION(S)] tab 20 mg (milligram), take 1 tablet by mouth once daily for [CONDITION(S)]. 2. [MEDICATION(S)] (anti-psychotic) tab 50 mg, take 1 tablet by mouth every morning. 3. [MEDICATION(S)] tab 300 mg, take 1 tablet by mouth every night at bedtime. 4. [MEDICATION(S)] (anti-anxiety) tab 5 mg, take 5 mg by mouth 3 times a day for anxiety. 5. [MEDICATION(S)] ([MEDICATION(S)]) 10 gr (grams)/15 mL, take 30 mL by mouth once daily for hyperammonemia (high ammonia). 6. [MEDICATION(S)] Hcl (antidepressant/sedative) tab 50 mg, take 1 tablet by mouth every night at bedtime for [CONDITION(S)]. 7. [MEDICATION(S)]/[MEDICATION(S)] ([MEDICATION(S)] promotor for [CONDITION(S)]) tab ,d+[DATE] mg, take 1 tablet by mouth once daily. 8. [MEDICATION(S)] Hcl ([MEDICATION(S)] promotor) cap 100 mg, take 100 mg by mouth once daily at 9:00 a.m. for [CONDITION(S)]. 9. [MEDICATION(S)] (calcium channel blocker for high blood pressure) tab 10 mg, take 1 tablet by mouth once daily for hypertension. 10. [MEDICATION(S)] Hcl tab 10 mg, take 1 tablet by mouth at bedtime for major depressive disorder. 11. [MEDICATION(S)] cap 300 mg, take 1 capsule by mouth three times daily for [CONDITION(S)] disorder. 12. [MEDICATION(S)] tab 25 mg, take 1 tablet by mouth daily for hypertension. 13. [MEDICATION(S)] tab 200 mg, take 1 tablet by mouth once daily for [CONDITION(S)] disorder. 14. Vitamin D cap 1.25 mg (50,000 units), take q capsule by mouth every week for vitamin daily deficiency. 15. Acetaminophen tabs 325 mg, take 2 tablets by mouth every 6 hours as needed for pain. On [DATE] at 3:12 p.m., the ED indicated Resident D did not have a self-administration assessment, but the resident had no narcotics. On [DATE] at 3:13 p.m., the Activity Director (AD) indicated Activity Aide 36 had a good relationship with Resident D and was able to redirect him. Resident likes to do crafts, loves newspapers, and we talked to him. She indicated she did not know if the evening/night shift or weekends had special activities for him, but they did know where the activity room key was kept so they could have had access to supplies for his leisure. The facility also buys him cigarettes when he is out. Activity personnel are in the building 7 days a week until 7:00 p.m. On [DATE] at 3:14 p.m., the SSD indicated Resident D loved cleaning and organizing things in his room. The staff knows the resident very well. He likes to talk about cars. He like to compare prices. The AD indicated she would take a computer to him to look at ads. The SSD indicated she was looking into making a binder of activities of interest for him. On [DATE] at 3:19 p.m., the ED indicated the Staff Coordinator was trained to run the locked behavior health unit and for the most part there was a dedicated staff on the behavioral health unit. The ED provided the specific training the Staff Coordinator did to be over the locked behavior unit. She watched 6 YouTube videos, totally 62.5 minutes. Then, she educated the behavioral health staff, who also watched the 6 videos. The YouTube videos were provided online by BJC Behavioral Health. They were called, Do This Not That: Providing Care for Medical Patients with Psychiatric Issues. 1. The video to educate about anxiety issues was 9:09 minutes long. 2. The video to educate about anger and aggression issues was 11:57 minutes long. 3. The video to educate about delusions issues was 9:37 minutes long. 4. The video to educate about suicide risk issues was 11:52 minutes long. 5. The video to educate about depression issues was 10:15 minutes long. 6. The video to educate about hallucination issues was 9:47 minutes long. On [DATE] at 2:17 p.m., the SSD indicated she provided the Notice of Transfer or Discharge to Resident D on [DATE] at 4:30 p.m. It was at the end of the business day and did not count as day 1. It indicated the effective date for the discharge was [DATE]. Resident D was removed from the locked unit and escorted by the police out of the building on [DATE]. The SSD indicated she did not realize the date was different on the Notice of Transfer/Discharge. The reason indicated the safety of the individuals in the facility was endangered. Resident D was removed from the building after 28 days had expired on [DATE]. A Discharge Information document with Resident D name and dated [DATE] indicated Resident D would be discharged with 30 days' worth of medications. His prescriptions would be filled monthly by Oak St. Health. Part of his discharge information was a copy of his April MAR. On [DATE] at 2:20 p.m., the ED indicated Resident D did not sign any discharge documents. The ombudsman had indicated the resident would have 10 days to appeal. She believes he was not appealing by screaming and yelling when escorted out of the building by the police. On [DATE] at 2:22 p.m., the SSD indicated during a [DATE] meeting with the psychiatric physician 47 and the NP, it was disclosed Resident D was denied at admission to Assurance. Physician 47 indicated to send Resident D to [NAME] ER and not accept him back. On [DATE] at 2:26 p.m., the SSD indicated the ombudsman correspondence was with Ombudsman 42, 43, and 44. A review of documents provided by the SSD on [DATE] at 2:17 p.m., provided typed narratives of several conversations. On [DATE] at 3:11 p.m., the SSD indicated that the information regarding the contact with the ombudsman program was in the soft file narrative. On [DATE] at 9:41 a.m., the DON indicated she was the Assistant Director of Nursing (ADON) when Resident D left for [NAME] Mission on [DATE]. His ride was here and he did not want to go, His 30 days was over and he had to go. He sat up front in a lobby chair. The police indicated he had to leave the building or the police would arrest him. He was not aware he was asked to leave before the 30 days were over. He was yelling in the lobby about how he didn't want to go and he wanted to stay here. In the begin, he was offered to make an appeal of the 30 day notice, the SSD, ED, and ADON, were present. It probably would have been an appropriate idea to begin an appeal if he had said or was yelling he did not want to leave here. She indicated she didn't know of anyone was advocating for the resident's wants and needs. He had his medications with him in bubble pack cards. He did not have any narcotics with him. During an interview, on [DATE] at 10:11 a.m., Resident D indicated the SSD doesn't like him. He came in from outside and the SSD indicated to him he needed to go to the [NAME] Mission for no reason. He indicated he was given documents that were a 30 day notice and a right to appeal. He provided the documents to review. Resident D began shaking badly, this conversation was upsetting to him. He said he received the papers but did not understand what the notice of discharge or request for a hearing meant. He indicated he was send to [NAME] Mission and they (the staff at [NAME] Mission) indicated the facility had no right to send him there. He was in room at the facility and the SSD indicated it was time to go. He had been laying down. He indicated she used to say that she would send him to [NAME] Mission as a threat to get him to go the (psych) hospital. On the [NAME] Mission day, he was mad and he faced the wall. The police came and got him to go to the front door. The police said if he didn't go to the [NAME] Mission then he would go to jail in the police car. He had ,d+[DATE] big bags of clothes and medications. He indicated he did not know how to take medications or when. The people at [NAME] Mission told him they do not dispense medications. He did not take any medications during his stay at [NAME] Mission because he didn't know how to take it. The [NAME] Mission staff called the facility and put all his stuff in a van and brought him back to Envive. On arrival, the ED indicated he could stay at the facility. Resident D did not know why the ED let him come back. He came back with his medications. At the [NAME] Mission, his medications were locked in a locker, he had the key. One resident at [NAME] Mission tried to start something with him, he just turned and walked away. His medication remained locked in his locked locker the whole time he was at [NAME] Mission because didn't know how to take the medications, so he left them alone. Resident D indicate with his sometime severe shaking he was unable to read. He indicated he did not try to read the medication packaging. He didn't know how to take the medication, he did not know what kind of medications he takes now. He indicated sometimes he thought about killing people. He had never killed anyone or tried to kill anyone. He only thought about killing his brother and sister because they took his money and threw him out. He indicated he was mad at the SSD but had not thought about killing her. Sometimes he felt like fighting, but not fighting to kill them. He indicated he did not know he could have called the health department to make a complaint. If he knew that, he would have never gone to [NAME] Mission. He was not aware of any elder agencies to help him. On [DATE] at 10:46 a.m., the SSD indicated she provided the 30 day notice to discharge to Resident D on [DATE] at 4:34 p.m She indicated she provided the notice and immediately put the progress note in his chart. On [DATE] at 10:47 a.m., the ED and SSD were trying to get him to leave the facility because of his behaviors. The psych physician indicate he had a personality disorder, not behaviors. His behaviors were at a very high level compared to the other residents. The facility was trying to care for his needs. We were able to care for his needs. But this was a personality disorder. He didn't need to be around other people. On [DATE] at 10:53 a.m., the SSD indicated the psych physician indicated to the facility to send Resident D to [NAME] ER and not accept him back. They did not follow these instructions. On [DATE] at 11:00 a.m., the SSD provided a list of referred facilities to whom she had applied to send Resident D. Many of these buildings did not have a locked unit. Her documentation indicated she referred him to 37 buildings, 3 of them twice. On [DATE] at 11:16 a.m., the SSD indicated the Director of the [NAME] Mission called and talked to SSD and ED. He was very upset about Resident D arriving at [NAME] Mission. He indicated the facility had to have permission. He called on [DATE] and insisted Resident D come back to the facility. On [DATE] at 12:03 p.m., the DON indicated the list of medications were on the April MAR provided in Resident D's discharge documents, but the quantity of medications we not part of the discharge summary. She indicated the facility did not count they medications given to Resident D upon his discharge. On [DATE] at 12:05 p.m., the VPCS indicated the facility did not need to count the non-narcotic medications. Those medications belonged to Resident D. If we would have destroyed them, we would have completed a disposition of the medications. On [DATE] at 12:29 p.m., the [NAME] President of Clinical Services (VPCS) indicated the SSD believed because Resident D was a Medicaid recipient he left here with a 30 day supply of all his medications. The VPCS indicated the facility did not count how many medications Resident D left with on [DATE] and did not count how many medications he returned with on [DATE]. She indicated we do not know how many pills went out or came beck in. There are no regulations requiring we do so. On [DATE] at 12:32 p.m., the DON indicated when the medications were returned to the building after being at the [NAME] Mission they were put back in use for Resident D. On [DATE] at 2:44 p.m., the Ombudsman Leader (OL) indicated Ombudsman 41 was not employed by the Ombudsman program on [DATE] and believed the SSD entry for that date was invalid. The OL indicated she had been in the facility several times for other residents but information or questions regarding Resident D's discharge never came up. She indicated they never received a Notification of Discharge document from the facility for Resident D. Whenever they get a notice of discharge, they will go to the facility to advocate for the resident. In our training, we learn to not send people to specific places, and we do not approve transfer discharges. No ombudsman spoke with Resident D. If the Ombudsman would have known they planned to discharge Resident D to [NAME] Mission they would not have agreed to this placement. The SSD never asked us to see Resident D. She only asked questions about how to help the facility discharge residents, nothing about how to advocate for the residents. On [DATE] at 4:03 p.m., Ombudsman 42 indicated she talked with the SSD on [DATE]. The SSD provided no name and gave no specific information, she just indicated they had a resident who had aggressive behaviors, especially with women. The SSD indicated they wanted to discharge him to [NAME] Mission. Ombudsman 42 indicated she did not think that was appropriate to send him there, and the SSD needed to talk to them first because he was aggressive and had behaviors. Ombudsman 42 indicated it was apparent that the SSD did not like that information. Ombudsman 42 indicated she did not advise or tell them to send him to [NAME] Mission, she told them to call [NAME] Mission. She warned the SSD of the possibility of consequences if she refused to take him back, someone could call the Board of Health and file a complaint because that was considered dumping (residents suffering from mental illness are often released even thought they are unable to care form themselves). On [DATE], the Admissions Agreement was provided by the facility. A document within the Admission Agreement, titled, Indiana Resident Rights and Facility Responsibilities, was reviewed. It indicated, .The resident has the right to be cared for in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality .A copy of the resident's rights must be available in a publicly accessible area. The copy must be at least 12-point type .The transfer and discharge rights of residents of a facility are as follows .before an interfacility transfer or discharge occurs, the facility must .place a copy of the notice in the resident's clinical record and transmit a copy to the following .the local long term care ombudsman program for involuntary relocations or discharges only .the notice of transfer or discharge .must be made by the facility at least thirty (30) days before the resident is transferred or discharged .At the planning conference, the resident' [TRUNCATED]

Based on observation, interview, and record review, the facility failed to monitor for new or worsening wounds which resulted in actual harm when a change of condition in his skin integrity led to his hospitalization and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 9/12/22 at 11:36 a.m., Resident B was observed. He was lying in bed, flat on his back. Although his eyes were open, he did not respond appropriately to questions and closed his eyes and appeared to sleep. His bed was a low air loss mattress bed and was observed to be operating at the appropriate setting. On 9/13/22 at 10:56 a.m., Resident B was observed. He was lying flat on his back. On 9/13/22 at 11:33 a.m., Resident B remained on his back. On 9/13/22 at 11:51 a.m., Resident B was observed and remained lying flat on his back. On 9/14/22 at 9:57 a.m., Resident B was observed. He was lying in bed flat on his back. On 9/14/22 at 2:10 p.m., Resident B remained flat on his back. On 9/15/22 at 10:00 a.m., Resident B was observed. He was lying flat on his back. On 9/15/22 from 11:45 a.m., Resident B was observed. He was lying flat on his back. On 9/15/22 from 1:05 p.m., until 2:35 p.m., a continuous observation was conducted for Resident B. Although he had been assisted to try and eat lunch, Resident B was never turned or repositioned to offload the pressure from his bottom. On 9/16/22 at 12:13 a.m., Resident B was observed. He remained in bed, flat on his back. During an interview on 9/16/22 at 12:33 a.m., LPN 23 indicated Resident B should be turned or repositioned to offload the sore on him bottom at least every two hours. On 9/19/22 at 3:05 p.m., Resident B's medical record was reviewed. His record indicated he had been a long-term care resident for many years, and previously resided on the Behavioral Health Unit. He had chronic disease diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had an active order for weekly skin assessments to be completed every Wednesday on day shift. On 9/16/22 at 10:28 a.m., the Director of Nursing (DON) provided copies of Resident B's weekly skin assessments and were reviewed at this time. On 3/30/22, no skin alterations were noted on the weekly skin check log. However, a Nurse Practitioner (NP) progress note, dated 3/31/22 at 10:33 a.m., indicated Resident B was being seen per nursing request for rash on buttocks. Nursing was unclear of onset of rash, and Resident B reported tenderness, local pain and itching, down there. The NP diagnosed Resident B with genital [CONDITION(S)] and prescribed Acyclovire (an oral antiviral medication). The skin assessment logs indicated from 3/16/22 to 4/20/22 indicated LPN 23 had conducted the assessments and no new alterations in his skin integrity were noted. The record lacked documentation of a change in condition related to the development of a new wound/skin area. The record lacked documentation of continued monitoring of the outbreak area. The record lacked documentation that the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/19/22 at 9:30 a.m., the DON provided copies of Resident B's March and April Certified Nursing Assistant (CNA) Point of Care (POC) documentation for March indicated: Resident B was at risk for behaviors and monitored each shift with no refusal of care noted. Resident B was at risk for alterations in skin integrity but only monitored as needed. March 1st-24th were all blank, NA (not applicable), or 5 (none observed). March 25, 26 and 27th were left blank. On March 30th, a new area of discoloration was noted but also coded no, it was not a new area. March 31st, was coded NA (not applicable). It appeared no bed baths or showers had been provided as each observation was blank or coded NA. Shower sheets were requested for March but were not able to be provided by survey exit. Point of care Documentation for the month of April indicated: Resident B was at risk for behaviors and monitored each shift with no refusal of care noted. Resident B was at risk for alterations in skin integrity but still only monitored as needed. On April 24th, 25th and 26th, no new areas were noted. On the 27th an open area was noted but not coded a new. A nursing progress note, dated 4/24/22 at 5:52 a.m., indicated Resident B had an open wound on his coccyx. The nurse assessed the area and applied a dressing. The Resident was repositioned on his left side and the nurse educated the resident about the importance of being turned every two hours. An NP progress note, dated 4/25/22 at 1:46 p.m., indicated Resident B was being seen for a new open area on his intergluteal cleft. Alleyn ([ALLEVYN]] is a range of moist wound environment dressings designed specifically for the management of chronic and exuding fluid from the wounds) currently covering open area. A small amount of serosanguinous dressing was noted on the dressing. No slough was noted within wound. An order was given for silver alginate and to cover with Alleyn. The NP note did not include measurements. A Pressure Ulcer Skin Log, dated 4/27/22, indicated Resident B had three areas that were acquired on 4/24/22. Wound 1: Stage III (full thickness skin loss where fat is visible) pressure ulcer to the coccyx with moderate serosanguinous drainage that measured 3 cm (centimeters) long by 3 cm side and 0.5 cm deep. Wound 2: Unstageable (full thickness skin loss where the wound bed is not visible due to slough or eschar) to the left buttock, purple in color which measured 11 cm long by 6.8 cm wide. Wound 3: Unstageable to the left glute, red/purple in color which measured 8 cm long by 6 cm wide. A nursing progress note, dated 5/1/22 at 6:15 a.m., indicated Resident B was noted to have difficulty swallowing pills and was shaking uncontrollably with signs/symptoms of shortness of breath. The On-Call doctor was notified and gave no new orders, just continue to monitor. His O2 (oxygen) was not in place and his 02 saturation (sats) was 87%. When his 02 was placed his sats increased to 94%. A Pressure Ulcer Skin Log, dated 5/4/22, indicated Resident B's areas were improved. Wound 1: Unstageable to the left glute, purple/red in color and measured 7.5 cm long by 5.5 cm wide, being treated with skin prep. Wound 2: Unstageable to the sacrum, red in color with slough and serosanguineous drainage that now measured 13 cm long by 9 cm wide. A NP progress note, dated 5/4/22 at 2:28 a.m., indicated Resident B was being seen after nursing staff reported he had a decreased level of orientation for the last day, and she ordered labs for a CBC (complete blood count) and Urinalysis. A nursing progress note, dated 5/6/22 at 11:11 a.m., indicated Resident B was sent to the ER (emergency room ) for further evaluation due to continued decreased levels of conscious. On 5/16/22 Resident B remained at the hospital and required a surgical debridement of the wound and a bone biopsy was conducted which revealed necrosis of the bone. A hospital Discharge Summary dated 6/1/22 indicated, .Collateral was obtained via his nurse at his ECF [extended care facility]. His nurse stated that normally patient is AAx4 [alert and oriented to person, time, place and situation] at baseline but this morning he woke up and remained somnolent and would not open his eyes or swallow his medicines. He stated that he was overall sluggish and had to manually remove the medication from his mouth after he administered them. When asking patient regarding his symptoms he did endorse feeling confused The primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An MRI completed on 5/8/22 revealed findings consistent with [CONDITION(S)] of coccygeal segments with subjacent [CONDITION(S)]. Resident B's current CNA assignment sheet was reviewed and indicated, up for all meals, however throughout the surveyor timeframe, Resident B was never observed out of bed. The record lacked documentation of Resident B's refusals to get out of bed. The pressure ulcer wound treatments were observed twice. 1. A wound treatment observation occurred on 9/14/22 from 3:15 p.m., until 4:00 p.m. The following was observed: Licensed Practical Nurse (LPN 23) indicated she would be changing the wound vacuum (vac) dressing to Resident B's coccyx wound. Certified Nursing Assistant (CNA) 23, CNA 51, and CNA 22 were present for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] CNAs 23 and CNA 51 entered room after using hand sanitizer in the hall and applied a clean pair of gloves. CNA 23 indicated it usually took two people to hold and position the resident during the treatment. The CNAs stood on the right side of the resident and held him over to his left side. LPN 23 put on a clean pair of gloves at the door, then opened sani-wipes and wiped off the overbed table surface, placed a plastic barrier on the table and set up station with supplies to provide wound care. LPN 23 removed the old dressing dated with yesterday's date from the resident's ischium. There was a minimal amount of yellow fluid on the old dressing. LPN 23 did not have the ordered dressing present to apply to the wound. LPN 23 received the xeroform dressing and applied it to the wound to the intact skin around the peri-wound. She applied a dressing over the xeroform and secured the dressing with a white adhesive tape over the xeroform. CNA 23 was waving away gnats during the treatment. LPN 23 indicated that resident had a wound on his sacrum and was going to change the wound vac dressing. LPN 23 exited the room and came back into the room with linens. She placed a new pair of gloves on and did not perform hand hygiene prior to putting on gloves. LPN 23 cleaned a pair of scissors with a disinfectant. LPN 23 called Resident B by name, adjusted his nasal cannula tubing and lowered the head of his bed. LPN 23 measured from the peri-wound to the opposite peri-wound instead of the wound edges. LPN 23 removed the wound vac dressing. She measured the wound that was a stage 4 pressure ulcer (full thickness skin and tissue loss with muscle, bone, and/or tendon visible). She used a saline syringe and pushed saline into the wound on his sacrum to clean the wound. LPN 23 adjusted the resident's indwelling catheter. She used hand sanitizer and then applied a new pair of gloves. She used a saline syringe and pushed the saline into the wound on his sacrum. She opened the wound vac dressing. LPN 23 indicated that the depth of the sacral wound was 2.2 centimeters and used a cotton tipped applicator to obtain the depth. There was undermining around the entire the wound. The VP of clinical operations came into the room to assist LPN 23. LPN 23 was cutting a clear adhesive dressing to the peri-wound after applying skin prep to the peri-wound. LPN 23 was using the clear adhesive dressing and placing on the dressing to border of the wound (windowpane) instead of using the clear dressing sheet and covering the entire wound. LPN 23 cut the foam dressing and placed the foam dressing against her uniform. On 9/14/22 at 3:56 p.m., the [NAME] President (VP) of Clinical Operations was summoned to the room. She attempted to identify tunneling of the wound with a tongue depressor. The VP of Clinical Operations placed gloved fingers into the wound. She cut the foam dressing with scissors that were laying on the bed on and placed the foam dressing into the wound. The VP of Clinical Operations stayed with LPN 23 and finished the dressing change. As Resident B was lying on his side, there were abnormal areas observed on the back of his left calf. LPN 23 indicated that the areas were bruising and shearing. One area was open and had a black edge at the top of the wound. These areas were identified as deep tissue injuries by the VP of Clinical Operations. When asked when the last time Resident B had been turned or repositioned, CNA 51 started to give an answer, but was interrupted by the LPN 23 who indicated, it's 4:00 p.m. now, so he would have been turned at 2:00 p.m. 2. A second wound treatment observation occurred on 9/16/22. The following was observed: At 1:18 p.m., Resident B's active sacral pressure ulcer change order was reviewed. It indicated to cleanse with normal saline (NS) and apply the wound vac on every dayshift on Mondays, Wednesdays, and Fridays for wound care related to a stage 4 sacral pressure ulcer. At 1:38 p.m., Certified Nursing Assistant (CNA) 22 entered Resident B's room to assist the Director of Nursing (DON) with positioning the resident during the sacral wound dressing change. She did not wash her hands before putting on disposable gloves that she had in her pocket. At 1:38 p.m., the DON did not wash her hands before she put on gloves. She used a Super Sani cloth to wipe the resident's over-the-bed table and laid a white trash bag on it. The DON's table set up included wound vac supplies, hand sanitizer, an [MEDICATION(S)] gentle dressing, and a pink bin of dressing supplies. The DON removed her gloves and did not wash her hands but used hand sanitizer gel on her hands. The resident's door was left wide open and the resident's privacy curtain was left partially open. When CNA 22 removed Resident B's hip pillow, the resident's body did not shift to center. The DON and CNA 22 moved the resident onto his left side. Bodily fluids were observed on the resident's calf pillow that was used to relieve pressure on his heels. A weeping wound was observed on his left posterior-lateral calf. The bodily fluids were a tannish color, some fluids were dried on the pillowcase in several places, some were still wet. The wound was not dressed, and it was slightly larger than the size of a quarter. At 1:43 p.m., LPN 23 did not knock and wait for permission to enter the resident's room, she just called out knock knock. She requested to assist with holding the resident in position for the sacral dressing change. She did not wash her hands or use hand sanitizer gel. She put on gloves and held the resident's legs. The DON removed the outer portion of the previous sacral dressing and indicated it did not have the date, time, or initials for the staff person who placed it. It should have been labeled correctly. She removed her gloves, sanitized her hands, and put on new gloves. She laid a white towel on the resident's bed as a clean area. She removed the soiled black sponge from the resident's deep wound. She removed her gloves, sanitized her hands, and put on new gloves. The DON indicated she would clean the resident's wound with normal saline (NS). She was observed digging in the pink bin of dressing supplies with her gloved hands. She retrieved a 10 mL syringe of NS and opened it. Without changing gloves, she squirted the NS into the surface of the center of the wound. She indicated there was undermining of the wound from 3:00 to 6:00. She did not clean the undermined areas. With the same soiled gloves, she put a gauze square over the end of her index finger and wiped the center of the resident's wound, she did not wipe the undermined area. She the indicated the wound measured 3 cm (centimeter) x 6 cm and she would measure the depth of wound after she changed her contaminated gloves. She removed the gloves and sanitized her hands. After putting on new gloves she opened the sterile packaging for the wound vac dressing and suction system. She reached back into the bin of dressing supplies and pulled out a pair of scissors. She did not clean them before cutting the plastic adhesive part of the wound vac system into strips. Then, she cut the black sponge into 2 round circles and a long black strip. She placed the cut wound supplies inside the sterile packaging to keep them clean. The DON indicated the resident's wound was 70% granulation tissues and 30% slough. She indicated she forgot to measure the depth. At 1:53 p.m., the DON began placing adhesive plastic strips on the resident skin around the sacral wound. The first strip was from 9:00 to 12:00, the second strip, slightly over the wound was from 12:00 to 6:00 o'clock position. She placed the round black sponge in the wound. She placed another long plastic strip and adhesive plastic from the top of the wound to the left lateral hip. Then placed the long black sponge over it. She began placing cut adhesive plastic strips over the black sponges but was not able to make a seal. LPN 23 lifted her hand off of the resident's unwashed legs and pressed her unwashed gloved hand on the long plastic covered sponge before it was sealed. She pressed down with her hand trying to affect a seal. The DON was cutting more adhesive plastic strips with the unwashed scissors and continued to place them, trying the get a seal on the wound vac. The DON placed a suction device with tubing attached to it at the end of the long plastic covered black sponge. She attached additional tubing and then attached it to the wound vac machine. She checked the wound vac machine again. She placed an additional plastic adhesive strip over the wound. She pressed down on the plastic covered sponges many times trying to create a seal. She continued to push on the wound and the long plastic covered foam strip in several places for 3 minutes, from 2:05 to 2:08 p.m. She was unable to create a seal and was out of the plastic strips. At 2:09 p.m., LPN 23 opened the resident's curtain, removed her gloves, washed her hands, and left to get more adhesive plastic for the wound. She did not close the door when she left. The Nurse Practitioner (NP) did not knock and entered the room, she was in a position to see the resident exposed in his bed. She wanted the keys to the QMA's cart. As soon as the NP left, an x-ray technician did not knock and came into the room, she was in a position to see the resident exposed in his bed. She wanted to know if we were almost finished with him. At 2:12 p.m., the DON indicated the wound on Resident B's left lower leg area was open with a stage 3 pressure wound. This open area was not over a bony prominence. The three raised, irregular, deep purple areas around the wound, she indicated were pressure ulcers at stage 2. These areas were not over a bony prominence. CNA 22, with her unwashed gloves hands that had been holding the resident on his side, pressed on the purple areas to see if they wound blanch. They did not. CNA 22 removed her gloves, sanitized her hands, and put on new gloves. At 2:15 p.m., the [NAME] President of Clinical Services (VPCS) came in the room to see if the staff needed assistance, she was in a position to see the resident exposed in his bed. At 2:17 p.m., the DON indicated there was an issue with privacy during Resident B's dressing change. The door and privacy curtains should have remained closed. At 2:18 p.m., after asking about hand washing during dressing changes, the DON left to wash her hands. She was observed to wash her hands correctly, but she rubbed the paper towels on water running from her hands to her elbows, then finished drying her hands with contaminated paper towels. At 2:21 p.m., LPN 23 provided another packaged wound vac system. The DON opened it, cut more adhesive plastic strips with the contaminated scissors, and used them on the resident's new wound vac dressing to complete the seal. During an interview on 9/16/22 at 9:20 a.m., the Former DON (who was DON at the time Resident B developed the wound) indicated at the time of the development of the wound, weekly skin assessments were being conducted by the nurse on the floor and documented on paper. During an interview on 9/16/22 at 10:30 a.m., with the DON and Administrator present, the DON indicated weekly skin assessments should have been conducted by the floor nurse on duty. Any new break in skin integrity were reported to the DON for follow up. A turning and repositioning program was standard practice. In the weeks leading up to the development of the area he was wanting to stay in bed more, and he did refuse a lot of care. Care plans were put into place for continuity of care so that all the nursing staff could have a complete picture of the resident and their specific needs. During an interview on 9/16/22 at 10:36 a.m., with the Administrator present, LPN 23 indicated she typically did not work on the floor. Every now and then she would be called to help the nurse on the floor with insulin if needed or would be pulled to the floor for call-ins. It was the floor nurses' responsibility to complete the weekly skin assessments. She had not assessed Resident B on a weekly basis, and only saw the area on his bottom after it had opened up, and at that time there was a dressing in place. So, she never visualized the wound until the resident returned from the hospital During an interview on 9/16/22 at 11:07 a.m., the DON indicated it was the nurse on duty's responsibility to conduct the weekly skin assessments and it was important for the direct care nurse to complete skin checks to maintain continuity of care. During a follow up interview on 9/16/22 at 11:22 a.m., LPN 23 indicated she had reviewed the weekly skin check log with her signature and indicated, oh, well if I signed it I did it. LPN 23 indicated if she was called down for a skin assessment, it was usually just a quick look over as the CNA would have been cleaning him up. During an interview on 9/19/22 at 8:40 a.m., the Former DON indicated, after a discussion with the current DON, Administrator, and VPCO, it was assumed that Resident B's [CONDITION(S)] infection must have come from the genital [CONDITION(S)] outbreak. Unfortunately, it looked like the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A current policy, titled, Handwashing/Hand Hygiene, dated 9/2022, was provided by the VPCS, on 9/19/22 at 10:53 a.m. A review of the policy indicated, .Handwashing is the single most important factor in preventing transmission of infections .All healthcare workers shall utilize hand hygiene frequently and appropriately A current policy, titled, Dressing Change, dated 9/2022, was provided by the VPCS, on 9/19/22 at 3:45 p.m. A review of the policy indicated, .to ensure measure that will promote and maintain good skin integrity while maintaining standard measures that will minimize/control contamination . create a clean field .Wash hands with soap and water. Open dressing pack. Put on first pair of disposable gloves. Remove soiled dressing and discard in plastic bag or trash can. Dispose of gloves in plastic bag or trash can. Wash hands with soap and water. Put on second pair of disposable gloves. Follow doctor's recommendations for treatment. Apply dressing and secure with tape when done with treatment if necessary. If using scissors make sure, it is clean with antiseptic .Removes gloves and discard. Wash hands with soap and water On 9/12/22, the Admissions Agreement was provided by the facility. A document titled, Federal Resident Rights and Facility Responsibilities, was reviewed. It indicated, .The resident has a right to personal privacy .includes accommodations, medical treatment This Federal tag related to Complaint IN 598. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure a resident on the behavior unit with Alzheimer's disease, [CONDITION(S)] with delusions, and [CONDITION(S)] disorder was supervised and had interventions implemented to prevent resident to resident altercations which resulted in Resident D pushing Resident C, and Resident C breaking his arm for 1 of 2 residents reviewed for abuse (Residents D, C, 16, 17, and 83). Findings include: 1. On 9/15/22 at 11:50 a.m., Resident D's record was reviewed. Resident D was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He resided on the locked behavior unit. On 9/15/22 at 11:54 a.m., a review of Resident D's care plans was completed. They were created on 5/4/22. The care plans lacked documentation of no revisions after the resident's 2 psychiatric hospital stays, 2/24 to 3/11/22 and 7/20 to 7/29/22, and 5 incidents with other residents. The care plan problems were: 1. Resident D had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. The resident uses anti-anxiety medication related to anxiety disorder. 3. The resident uses anti-psychotic medications related to [CONDITION(S)] disorder, [CONDITION(S)] type. Behavior management, Potential for injury to self or others. 4. Resident D exhibits restlessness, nervousness and/or other anxiety symptoms related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 5. Resident D had impaired cognitive function/impaired thought process related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Impaired thought processes/altered mental status related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, revised on 9/22/22, indicated the problem was Resident D had (Auditory, Visual) hallucinations (perception of something not present), delusional episodes, talking to himself in hallway and in his room, he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He was manipulative towards others, lunging at staff making threats, and making threatening gestures. The goal and interventions had not been updated since the care plan was created on 5/4/22. Resident D's reportable incidents to the Indiana Department of Health for the last 8 months were as follows: a. On 2/17/22, it was reported that Resident D wanted to borrow Resident 16's cell phone. She denied him and he called her a b***h. b. On 5/10/22, it was reported that Resident D made contact with Resident 17. Resident 17 was hallucinating and was sent to the hospital. c. On 5/17/22, it was reported that Resident 83 made racial comments to Resident D, and Resident D made contact with Resident 83. d. On 6/2/22, it was reported that Resident 17 made racial comments to Resident D, and Resident D pushed Resident 17. It was known that Resident 17 was in need of psych services. e. On 6/22/22, it was reported that Resident 83 made contact with Resident D for no reason. f. On 7/16/22, it was reported that Resident D pushed Resident C. Resident C fell and fractured his wrist. On 9/15/22 at 11:50 a.m., Resident D's soft file was provided by the SSD. These were dated paragraphs of information regarding Resident D and his progress to discharge. No times were noted. - On 2/23/22 with no time noted, the Social Services Director (SSD) indicated the resident had made sexual comments, verbal and physical aggression towards staff and peers, but was independent with all ADLs, scored high on BIMS (brief interview for mental status) and inquired about discharge to the local homeless shelter. -On 3/11/22 with no time noted, a care plan meeting was held with SSD, Assistant Director of Nursing (ADON) and Resident D. SSD discussed recently being readmitted to facility this morning from an inpatient psychiatric (psych) stay. SSD asked Resident D if he recalled the reason for the psych stay, Resident D indicated he got into a fight. SSD agreed and discussed behaviors of becoming very loud with threatening behavior yelling and screaming out. We discussed his ADL (activity of daily living) status of being independent with all ADLS except medication management., discussed his potential 30-day notice to Local homeless shelter due to safety concerns of other residents. Resident D became very agitated and began yelling and screaming at SSD and ADON, stated he's not leaving, and he wanted to stay at the facility. SSD had difficulty speaking to Resident D due to yelling, screaming out. SSD educated Resident D on current verbal behavior and disruption to other peers. Resident continued to yell and scream. SSD attempted to redirect him but was unsuccessful. He screamed at SSD and ADON to leave his room. - On 3/16/22 at 2:53 p.m., the SSD was notified by the DON of Resident D had become agitated with staff regarding the smoking time. He slammed his jacket on the chair in hallway. SSD spoke with Resident D this afternoon regarding his behaviors. He denied having these behaviors. SSD re-educated him on appropriate behaviors. He expressed understanding. No behaviors noted during this visit. - On 3/18/22 at 12:54 p.m., a Social Services (SS) note indicated Resident D was visited by Psych therapist on this day with no concerns regarding behavior, psychosocial well-being, or mood. The Social Service Director (SSD) also visited with Resident D who was pleasant. No signs or symptoms of psychosocial well-being, mood concerns, or behaviors noted. - On 3/21/22 with no time noted, the SSD was notified Resident D was upset with a female peer and told her she cannot have another boyfriend. SSD and ADON spoke with him. He admitted to having this behavior and state he was jealous. SSD educated Resident D of previous conversation of him having behaviors and the potential for a 30-day discharge. He expressed understanding that this behavior could cost him a 30-day notice. He asked for a second chance. SSD stated she would speak with the Executive Director (ED). They would speak to him again next week. - On 3/23/22 at 1:33 p.m., an SSD note indicated the SSD visited with Resident D who was in good spirits. He showed no behaviors, no signs or symptoms of psychosocial well-being or mood concerns. - On 3/24/2022 at 2:34 p.m., an SSD note indicated the SSD and ADON visited with Resident D. SSD discussed threatening behaviors towards staff with yelling and screaming out, his impulsive outbursts, and safety concerns. Resident D was educated on 30 Day Discharge Notice that was issued to him on this day. Resident D became agitated and began to raise his voice, he continued to ask for another chance. SSD educated Resident D again on his behaviors. -On 4/8/22 at 10:46 a.m., a nursing note indicated the Assistant Director of Nursing (ADON), currently the Interim DON, indicated Resident D scored at a high risk on an elopement assessment due to being independently mobile and having dementia. -On 4/22/22 12:21 a.m., the Nurse Practitioner (NP) 40 indicated in a late entry that she had a discharge visit with Resident D. She indicated he was being seen today for discharge planning to the local homeless shelter per the facility. He had a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He did not appear to be in any acute distress at this time or during this visit. He was resting quietly in a chair. He was oriented to person and place with periods of confusion. He was pleasant and cooperative. Medications were sent with Resident D upon his discharge. - On 4/22/22 at 2:53 p.m., the Discharge Summary indicated the SSD had spoken with Resident D several times throughout this week regarding his upcoming discharge on 4/22/22. She informed Resident D of the clinic providing transportation from the facility to their clinic for an initial appointment on 4/22/22, then would be transported to the local homeless shelter. Resident D became agitated throughout these visits and asked on different occasions for another chance. SSD attempted to redirect Resident D by educating him but was unable to due to him yelling at writer. Staff members visited with Resident D on this day regarding his discharge to the local homeless shelter related to the 30-day discharge notice. Resident refused to leave facility. He was yelling and screaming, with threatening behaviors. He told the staff the only way he was leaving was if the cops were called. Non-emergency police were contacted to assist with escorting Resident D to an outpatient clinic's vehicle. The police escorted Resident D outside and into van. He was discharged with medications, contact numbers, and discharge information. - On 4/25/22 at 5:56 p.m., the Staffing Coordinator/Unit Manager indicated Resident D returned to facility at 5:15 p.m. today. Resident returned with medications and his belongings. He was placed in a room on the locked behavior unit. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He was alert and oriented times 3. He ambulated on own without an assistive device. His gait was steady. - On 5/26/22 SSD was notified of Resident D smacking a Certified Nursing Aide (CNA) on the buttocks. SSD asked Resident D why he did it, educated him on appropriate behaviors and explained this behavior was inappropriate. Resident D apologized. - On 6/1/22 with no time noted, SSD was notified of Resident D becoming agitated and verbally aggressive as he stated he was jealous of the other peers wanting a girlfriend. SSD was able to redirect him with conversation, walking on the unit and offered activities of interest. He appeared in a better mood with no further behaviors noted. - On 7/20/22 with no time noted, the SSD, DON and the Rounding Psych physician denied him for inpatient psych stating medications would not help his behaviors. This was his personality and medication would not change or help him. - On 9/19/22 at 2:35 p.m., the ED indicated Resident D did not have a behavioral contract with the facility. On 9/19/22 at 2:36 p.m., the April MAR medications indicated Resident D took the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] tab 20 mg (milligram), take 1 tablet by mouth once daily for [CONDITION(S)]. 2. [MEDICATION(S)] (anti-psychotic) tab 50 mg, take 1 tablet by mouth every morning. 3. [MEDICATION(S)] tab 300 mg, take 1 tablet by mouth every night at bedtime. 4. [MEDICATION(S)] (anti-anxiety) tab 5 mg, take 5 mg by mouth 3 times a day for anxiety. 5. [MEDICATION(S)] ([MEDICATION(S)]) 10 gr (grams)/15 mL, take 30 mL by mouth once daily for hyperammonemia (high ammonia). 6. [MEDICATION(S)] Hcl (antidepressant/sedative) tab 50 mg, take 1 tablet by mouth every night at bedtime for [CONDITION(S)]. 7. [MEDICATION(S)]/[MEDICATION(S)] ([MEDICATION(S)] promotor for [CONDITION(S)] disease) tab 25-100 mg, take 1 tablet by mouth once daily. 8. [MEDICATION(S)] Hcl ([MEDICATION(S)] promotor) cap 100 mg, take 100 mg by mouth once daily at 9:00 a.m. for [CONDITION(S)]. 9. [MEDICATION(S)] (calcium channel blocker for high blood pressure) tab 10 mg, take 1 tablet by mouth once daily for hypertension. 10. [MEDICATION(S)] Hcl tab 10 mg, take 1 tablet by mouth at bedtime for major depressive disorder. 11. [MEDICATION(S)] cap 300 mg, take 1 capsule by mouth three times daily for [CONDITION(S)] disorder. 12. [MEDICATION(S)] tab 25 mg, take 1 tablet by mouth daily for hypertension. 13. [MEDICATION(S)] tab 200 mg, take 1 tablet by mouth once daily for [CONDITION(S)] disorder. 14. Vitamin D cap 1.25 mg (50,000 units), take q capsule by mouth every week for vitamin daily deficiency. 15. Acetaminophen tabs 325 mg, take 2 tablets by mouth every 6 hours as needed for pain. On 9/19/22 at 3:13 p.m., the Activity Director (AD) indicated Activity Aide 36 had a good relationship with Resident D and was able to redirect him. Resident D liked to do crafts, loved newspapers, and activity staff talked to him. She indicated she did not know if the evening/night shift or weekends had special activities for him, but they did know where the activity room key was kept so they could have had access to supplies for his leisure. The facility also bought him cigarettes when he was out. Activity personnel were in the building 7 days a week until 7:00 p.m. On 9/19/22 at 3:14 p.m., the SSD indicated Resident D loved cleaning and organizing things in his room. The staff knew the resident very well. He liked to talk about cars. He liked to compare prices. The AD indicated she would take a computer to him to look at ads. The SSD indicated she was looking into making a binder of activities of interest for him. On 9/19/22 at 3:19 p.m., the ED indicated the Staff Coordinator was trained to run the locked behavior health unit and for the most part there was a dedicated staff on the behavioral health unit. The ED provided the specific training the Staff Coordinator did to be over the locked behavior unit. She watched 6 YouTube videos, totally 62.5 minutes. Then, she educated the behavioral health staff, who also watched the 6 videos. The YouTube videos were provided online by BJC Behavioral Health. They were called, Do This Not That: Providing Care for Medical Patients with Psychiatric Issues. 1. The video to educate about anxiety issues was 9:09 minutes long. 2. The video to educate about anger and aggression issues was 11:57 minutes long. 3. The video to educate about delusions issues was 9:37 minutes long. 4. The video to educate about suicide risk issues was 11:52 minutes long. 5. The video to educate about depression issues was 10:15 minutes long. 6. The video to educate about hallucination issues was 9:47 minutes long. During an interview, on 9/20/22 at 10:11 a.m., Resident D indicated the SSD did not like him. He came in from outside and the SSD indicated to him he needed to go to the local homeless shelter for no reason. He indicated he was given documents that were a 30 day notice and a right to appeal. He provided the documents to review. Resident D began shaking badly and indicated this conversation was upsetting to him. He said he received the papers but did not understand what the notice of discharge or request for a hearing meant. On the day of his discharge, he was in his room at the facility and the SSD indicated it was time to go. He had just been laying down. He indicated he was sent to the local homeless shelter and the staff at local homeless shelter indicated the facility had no right to send him there. He indicated the SSD used to say that she would send him to the local homeless shelter as a threat to get him to go the psych hospital. On the local homeless shelter day, he was mad and he faced the wall. The police came and got him to go to the front door. The police said if he didn't go to the local homeless shelter then he would go to jail in the police car. He had 3 or 4 big bags of clothes and medications. He indicated he did not know how to take medications or when. The people at local homeless shelter told him they do not dispense medications. One resident at local homeless shelter tried to start something with him, he just turned and walked away. Resident D indicated with his occasional severe shaking he was unable to read. He indicated he did not try to read the medication packaging. He did not know how to take the medication, he did not know what kind of medications he takes now, so he left them alone. He indicated sometimes he thought about killing people. He had never killed anyone or tried to kill anyone. He only thought about killing his brother and sister because they took his money and threw him out. He indicated he was mad at the SSD but had not thought about killing her. Sometimes he felt like fighting, but not fighting to kill them. During an interview on 9/20/22 at 10:47 a.m., the ED and SSD indicated they were trying to discharge Resident D from the facility because of his behaviors. The psych physician indicated he had a personality disorder, not behaviors. His behaviors were at a very high level compared to the other residents. The facility was trying to care for his needs. They were able to care for his needs. But this was a personality disorder. He did not need to be around other people. On 9/20/22 at 10:53 a.m., the SSD indicated the psych physician indicated to the facility to send Resident D to the local mental health outpatient center emergency room and not accept him back. They did not follow these instructions. 2. Resident C was interviewed on 9/13/22 at 11:35 a.m. He wanted to speak in private about a situation that occurred in the facility. He indicated that Resident D had gotten in his face. He had asked Resident D to get out of his personal space when Resident D pushed him down and broke his wrist. The police came and told Resident C that they could not arrest Resident D. He indicated that it happened in the hallway, just outside his room. The nursing staff arrived and told him to stay on the ground. The ambulance was notified, and he was taken to the emergency room for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Resident C pointed to a splint on his arm and indicated that he must wear it to help the fracture heal. He indicated that incident had had no effect on him. Since the incident, he did not do anything except play his video game system and smoke. The staff gave him nerve pills. On 9/13/22 at 3:00 p.m., Resident C's record review was completed. Resident C had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 7/16/22, indicated that Resident C and Resident D had an altercation on 7/16/22 resulting in Resident C being pushed down. Resident C had orders to send him to the emergency room for left arm evaluation. A note, dated 7/16/22 at 9:41 p.m., indicated Resident C returned from the emergency room with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A radiology report was reviewed from the emergency room . It indicated that there was a comminuted fracture of the distal radial surface and nondisplaced ulnar styloid fracture on 7/16/22 at 11:33 a.m. Resident C had orders, dated 7/21/22, for a left arm immobilizer to be on except for skin checks, OT (Occupational Therapy) services 5 days per week for 60 days for ADL (Activities of Daily Living) retraining, therapeutic exercise, therapeutic activity, patient/caregiver education, and group therapy due to decline in function following a fall with left wrist fracture. Resident had a care plan, dated 7/19/22. It indicated that resident had a wrist fracture with a goal of returning to his prior level of function after healing and rehabilitation. A policy title Behavior Assessment/Monitoring with a date of 8/2022 provided by the ED on 9/19/22 at 3:45 p.m. indicated, .The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure infection control practices for COVID-19 were implemented to prevent and contain the spread of the COVID-19 virus which resulted in immediate jeopardy when the facility failed to ensure Transmission Based Precautions (TBP) were implemented for residents after positive [MEDICATION(S)] tests and/or exposure to positive residents, to ensure TBP isolation signage and Personal Protective Equipment (PPE) were readily available, to ensure staff were informed of newly identified [MEDICATION(S)] positive residents, and staff wore appropriate PPE while providing care for residents who were presumed COVID-19 positive after exhibiting signs/symptoms of the virus. The immediate jeopardy began on 1/4/22 when the facility failed to immediately isolate and place two residents, (Residents BC and BB) in TBP after they became symptomatic and had a COVID-19 positive [MEDICATION(S)] test. Resident BC's roommate (Resident BD) was not moved to another room or placed on TBP isolation after his exposure to BC, putting him at imminent risk of infection. Resident BC received a visit from a hospice nurse, Registered Nurse (RN) 22. She entered his room without proper PPE and provided resident care. RN 22 then moved to another resident's room, (Resident BF) who was also a hospice resident that tested positive for COVID-19 and was observed in the room without appropriate PPE in place. Resident BB's roommate, (Resident L) was not placed on TBP isolation after his exposure and was observed on multiple occasions as he independently ambulated throughout the entire B hall, into the main front entrance lobby without staff redirecting back to his room or encouragement to wear appropriate PPE, and Resident L was observed sleeping in other residents' rooms who had tested negative (Residents J and B) putting them both at imminent risk of infection. Multiple observations of staff revealed inappropriate use of a N95 respirators, inappropriate donning of and/or lack of donning required PPE before entrance into TBP isolation rooms, inappropriate hand hygiene, and lack of awareness of the COVID-19 status of each resident on the hall where the outbreak occurred. These deficient practices put 3 of 37 residents (Residents BD, J, and B) at immediate risk of infection by direct exposure of positive/symptomatic residents during a facility outbreak. Further, these deficient practices had the potential to effect 37 of 84 residents residing on the B hall where the outbreak occurred. The Administrator, the Interim Administrator, the Regional Clinical Support Nurse, and Director of Nursing Services were notified of the Immediate Jeopardy at 6:25 p.m. on 1/5/22. The immediate jeopardy was removed on 1/6/22, but noncompliance remained at a lower scope and severity of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During an interview, on 1/5/22 at 12:16 a.m., the Director of Nursing Services (DNS) indicated the facility had 10 positive COVID-19 cases based on Point of Care (POC: rapid Covid result testing) determined earlier that day. The DNS indicated the facility was not going to move the residents into the red zone (COVID-19 positive isolation unit) until they received confirmation by PCR (lab testing) results back which could take up to 48 to 72 hours. This determination was made due to the fact POC tests often gave false positive results. On 1/5/22 at 12:58 a.m., Resident J and Resident L were observed sleeping in the same room. They were not wearing masks. Resident J was asleep in her bed, and Resident L was asleep in his wheelchair, within 6 feet of her bed. At this time, no staff was observed to redirect Resident L out of the room. On 1/5/22 at 1:42 a.m., Resident L was observed. He remained asleep in Resident J's room. At this time, no staff was observed to redirect Resident L out of the room. During an interview, on 1/5/22 at 11:24 a.m., Resident L indicated his roommate, Resident BB, tested positive for COVID-19 the day before around noon. The facility staff had not moved his roommate out of the room, and Resident L indicated that was why he went to Resident J's room most of the night. He also later went to Resident B's room and slept for about an hour. Resident L indicated he refused to sleep in the room with his roommate (Resident BB) because Resident BB was COVID-19 positive. On 1/5/22 at 12:52 p.m., Resident L was observed in commons room watching T.V., without re-direction from passing staff. During an interview, on 1/5/22 at 1:30 p.m., Resident L indicated staff told him he needed to go sleep in Resident B's room. Resident L and Resident B both tested negative for COVID-19 on 1/4/22. Resident L indicated the bed in Resident B's room was an old crank bed and he could not operate it to get in and out of bed because of issues with his right leg. Resident L indicated he had received 2 shots of the COVID-19 vaccine. 2. On 1/5/22 at 12:57 a.m., QMA 9 was observed as she entered Resident BB's room after he tested positive and exhibited symptoms and began to assess him by taking his vital signs. She put gloves on but did not don an isolation gown or perform hand hygiene before she entered his room. She indicated Resident BB's oxygen saturation was 89 percent (%). She then continued on her assignment and made contact with additional unidentified residents. On 1/5/22 at 1:18 a.m., a brief review of Resident BB's paper chart was completed. His COVID-19 vaccination card was observed in his chart, it showed he was vaccinated with Moderna. On 1/5/22, a Surveillance Line List, provided by the facility, dated 1/4/22, indicated Resident BB was symptomatic with fever, cough, and myalgia (muscle pain). On 1/5/22 at 4:15 p.m., the Administrator indicated Resident BB's vital signs at 1:45 p.m. were blood pressure 128/70, temperature 101.4 Fahrenheit (F), pulse 90, respirations 20. On 1/5/22 at 6:21 p.m., Regional Clinical Support provided Resident BB's documentation of his positive COVID-19 test on 1/4/22. 3. On 1/5/22 at 12:21 a.m., Qualified Medication Aide (QMA) 9 was observed at the B hall nurse's station desk. She wore a surgical mask under her N95 mask, which prevented a tight seal of the N95. On 1/5/22 at 12:22 a.m., Certified Nursing Aide (CNA) 10 and 11 were both observed on the B hall. They wore a surgical masks under their N95 masks, which prevented a tight seal of the N95. They both indicated they were working from 7:00 p.m. to 7:00 a.m. During an interview, on 1/5/22 at 12:32 a.m., CNA 10 indicated she thought there were 4 rooms on the B hall who had positive residents but was unaware of any other resident's COVID-19 status. On 1/5/22 at 12:34 a.m. no isolation signage, or personal protection equipment (PPE) information was observed to be posted on any resident doors. On 1/5/22 at 1:34 a.m., Licensed Practical Nurse (LPN) 12 indicated she had not completed all the PCR tests, she still had 5 residents left, but did not want to wake them. She would complete their testing later that morning during morning medication administration. On 1/5/22 at 1:37 a.m., the Interim Administrator was observed in the B hall. She wore an N95 respirator, but the bottom strap hung lose under her chin so that a seal was not created. She did not have on eye protection. She indicated the facility had 10 positive POC test results on 1/4/22, 6 residents on B hall, 3 residents on C hall, and 1 resident on D hall, so the entire building was considered Yellow (unknown COVID-19 status) and on TBP. On 1/5/22 at 11:34 a.m., CNA 13 indicated she heard from other staff that only Resident Y was COVID-19 positive on the B hall and was unaware of the COVID-19 status of any other residents, or the need to follow TBP precautions. On 1/5/22 at 3:56 p.m., LPN 21 indicated Resident C and Resident BH shared one room. Resident C tested positive for COVID-19 on 1/4/22 but had not been moved to the COVID-19 unit until the afternoon of 1/5/22. On 1/5/21 at 11:00 a.m., the Receptionist and the Interim Administrator were observed wearing N95 masks but no face shields near the reception desk. On 1/5/22 at 11:34 a.m., CNA 13 was observed exiting Resident D's room after changing her bed linens, she dragged the bag of soiled linen on the carpet to the soiled linen closet. She was still wearing her soiled gown and gloves. She removed the gown and gloves in soiled linen closet near B hall nurse's station. She was wearing a surgical mask under her N95 mask. The lower strap of N95 was hanging below her chin. She indicated she heard from other staff that only Resident Y was Covid positive on the B hall. On 1/5/22 at 1:25 p.m., CNA 16 was observed assisting Resident G in his room with eating. She was not wearing a gown or gloves. She indicated she did not see the yellow zone signs on the front door of the facility when she entered the building. On 1/5/22 at 3:50 p.m., Housekeeper 18 was observed as he worked on the B hall. He wore a N95 mask with his nose outside the mask. He did not don and doff an isolation gown or gloves or perform hand hygiene before he entered several residents' rooms on the B hall where the outbreak occurred. He briefly entered 9 rooms on the B hall. Both straps of his N95 mask were below his ears. On 1/5/22 at 4:05 p.m., the Administrator indicated, Staff member 18 should have received infection control education before he worked on the floor as a housekeeper. Staff member 18 was only supposed to have vacuumed the B hallway, and not have entered resident rooms. On 1/5/22 at 4:11 p.m., Housekeeper 18 indicated he did not feel good and had a runny nose. He did not report it to his supervisor. On 1/7/22 at 9:13 a.m., Qualified Medication Aide (QMA) 29 was observed as she left Resident BL's yellow zone room. She was still wearing her soiled gown and gloves. She removed them in the hallway, just outside the room. She rolled up the soiled gown and placed it in the medication cart trash can. On 1/7/22 at 9:21 a.m., QMA 29 was observed as she left Resident BM's yellow zone room, she closed the door behind her. She was still wearing her soiled gown and gloves. She removed them in the hallway. She rolled up the soiled gown and placed it in the medication cart trash can. On 1/7/22 at 9:36 a.m., QMA 29 was observed as she left Resident K's yellow zone room and walked up to the medication cart. She was still wearing her soiled gown and gloves. She placed the [MEDICATION(S)] (bronchodilator to ease breathing) on top of the medication cart, threw the medication cups away, then removed her soiled gown and gloves. She rolled up the soiled gown and placed it in the medication cart trash can. 4. On 1/5/22 at 4:35 p.m., CNA 19 was observed carrying linens against her body. She indicated she was going to change linens in Resident J's room. On 1/7/22 11:18 a.m., the Regional Clinical Support indicate staff should have been carrying bags of soiled linens and not dragging them on the floor. If the linen bags were too heavy, they should have gotten a cart. Staff should have doffed soiled PPE before exiting any resident rooms because trash cans were available in the resident room. Clean linens should be carried away from the body. During an interview, on 1/7/22 at 9:46 a.m., the Regional Clinical Support indicated the facility did not have a policy on handling linen. She added, There is the standard of practice that clean linens are carried away from the body, dirty linens are put into a bag. The bag shouldn't be dragged on the ground 5. During an interview on 1/5/22 at 11:28 a.m., LPN 21 indicated Residents BC, Y, and BB all tested positive for COVID-19 on 1/4/22. At that time, none of the COVID-19 positive residents had been moved to the red zone (a separate isolation area for COVID-19 positive residents), 2 of the 3 residents still had roommates in the rooms, and no signs were placed on their doors to indicate the residents had COVID-19 and what PPE (personal protective equipment) staff should put on before they entered the residents' room. At that time, Resident BC was observed from the hallway, through the open door to his room. He was seated in a chair that was placed between his bed and his roommate's bed. His roommate, Resident BB, was observed lying in his bed next to the seated Resident BC. There was no sign on the room door to indicate the resident was on transmission-based precautions (TBP). During an interview on 1/5/22 at 11:37 a.m., LPN 21 indicated, she was the nurse who performed COVID-19 testing on the B wing residents on 1/4/22. She saw the positive results for Residents BC, Y, and BB. LPN 21 indicated the residents who tested positive on 1/4/22 were still in their rooms and had not been moved to isolation at that time. On 1/5/22 at 1:39 p.m., Residents BC and BB were observed in their rooms. Resident BB was observed seated in a chair that was placed between his bed and his roommate's bed. His roommate, Resident BD, was observed lying in his bed next to the seated Resident BC. During an interview at that time, the Therapy Director indicated he could identify both residents. He observed the residents in their room, from the hallway, through the residents' open door, and confirmed the identity of Residents BC and BD. The Therapy Director confirmed the residents were still in the room together. On 1/5/22 at 1:40 p.m., Residents BC and BD were observed with the Interim Administrator present. She confirmed Resident BC had tested positive for COVID-19 and his roommate, Resident BB had tested negative. The Interim Administrator indicated Resident BC should have been moved out of the room, and transferred to the Red Zone to not further expose Resident BD. During an interview on 1/5/22 at 3:49 p.m., LPN 21 indicated she was familiar with Resident BC and had cared for him before. He had been able to feed himself, help with his own care, and hold conversation. However, when she took care of him on 1/3/22 he was weak, and he had no appetite. His speech was not as clear as usual, and he was complained of not feeling well. LPN 21 indicated she felt like the resident just was not right and was not his usual self. LPN 21 indicated no COVID-19 test was performed at that time. On 1/5/22 at 6:21 p.m., the Regional Clinical Support RN (Registered Nurse) provided a document that indicated on 1/4/22, Resident BC tested positive for COVID-19, and Resident BD tested negative. 6. On 1/5/22 at 11:30 a.m., RN 22 was observed as she exited Resident BC's and BD's room. She wore a KN95 face mask and goggles. During an interview at that time, RN 22 indicated, she was a visiting hospice nurse. She had just completed resident care and nursing assessment which included a set of vital sings for Resident BC. She had been in his room for approximately 10-15 minutes. She wore a KN95 mask, goggles, and gloves while she provided care for the resident. She had not put on an isolation gown. RN 22 indicated she was not aware the COVID-19 status of the residents and had not been informed if any residents in the facility had tested positive for COVID-19. On 1/5/22 at 11:38 a.m., RN 22 was observed from the hallway, through an open door, in the room of Resident BF. RN 22 wore a KN95 mask, goggles, and an isolation gown that was untied in the back and hung lose and open. She did not have gloves on. RN 22 indicated, she still had not been told if there were COVID-19 positive residents on that hall. There were no signs on Resident BF's door to indicate she was in TBP or had tested positive for COVID-19. Resident BF was observed and still in her room at that time. On 1/5/22 at 1:42 p.m., the Administrator confirmed Resident BF was still in her room. There were no signs on Resident BF's door to indicate she was in TBP or had tested positive for COVID-19. On 1/5/22 at 6:21 p.m., the Regional Clinical Support RN provided a document that indicated on 1/4/22, Resident BF tested positive for COVID-19. 7. On 1/4/22 at 11:55 p.m., the main entry doors to the facility were observed. Signs on the doors indicated, Yellow Zone Transmission Based Precautions Contact Droplet. PPE required: N95 mask, universal eye protection: faceshield or goggles must cover the top, bottom and sides of the eyes with no gaps (*For all HCP [health care personnel] regardless of vaccination status), Single gown - with each encounter, Gowns must be single use per resident. If crisis capacity- follow this rule one gown per each staff member, per each resident, per shift; gloves (hand hygiene donning/ doffing). On 1/5/22 at 11:14 a.m., CNA 13 (certified nursing assistant) was observed as she changed the bed linens in Resident D's room. CNA 13 was observed wearing 2 surgical masks under an N95 mask. The bottom strap of the N95 mask was not secured behind her head and it hung loosely at her chin. During an interview on 1/5/22 at 11:16 a.m., CNA 13 indicated she wore 2 surgical masks under her N95 mask and did not secure the bottom strap of the N95 mask, because it was uncomfortable. The N95 mask was worn to protect the staff and the resident. The N95 mask protected against COVID-19 more than the surgical mask. CNA 13 indicated she had been taught how to properly wear the N95 mask, she knew it should be a tight seal against her face, and she should use both straps to secure the mask onto her face, but it was uncomfortable that way. On 1/5/22 at 11:21 a.m., CNA 20 was observed walking through the B wing hall. She wore a surgical mask with an N95 mask on top of it. The bottom strap of the N95 mask hung loosely at CNA 20's chin. CNA 20 also wore a disposable gown, that was untied in the back and hung loosely off her shoulders, a face shield, and gloves. She was observed as she carried linens into Resident B's room and closed the door behind her. On 1/5/22 at 1:25 p.m., CNA 16 was observed seated directly next to the bed of Resident G. CNA 16 was observed as she hand-fed pizza to the resident. CNA 16 wore an N95 mask and a face shield. She did not have on a gown or gloves. At that time, the ED was observed as he asked CNA 16 why she did not have on a gown and gloves while she was in the resident's room providing care. CNA 16 indicated she did not have on full PPE because the resident did not have COVID-19. The ED indicated the entire facility was a yellow zone due to COVID-19 positive residents and staff. On 1/5/22 at 3:46 p.m., CNA 13 was observed changing the bed linens in Resident G's room. She wore 2 surgical masks, covered by an N95 mask. The bottom strap of the N95 mask was not secured and hung loosely at her chin. She also wore a face shield and gloves. She did not have on a gown as she changed the resident's bed linens. On 1/5/22 at 6:30 p.m., CNA 13 was observed in Resident BK's room providing care. CNA 13 had on 2 surgical masks, covered by an N95 mask. The bottom strap of the N95 mask was not secured and hung loosely at her chin. She also wore a face shield, gloves, and a gown that was untied in the back. During an interview on 1/5/22 at 10:25 a.m., the Interim Administrator, Director of Nursing Services (DNS) indicated they had just started work at the facility on Monday 1/3/22 and were still in the process of determining the full extent of the COVID-19 status of the building and facility-specific infection control procedures. So far 10 residents had tested positive for COVID-19 on rapid POC tests, and to their knowledge had all been moved to the Red Zone which was located on the A hall. The Interim Administrator indicated in her previous experience at other facilities with outbreaks, any resident who tested positive regardless of POC or PCR test would be moved to the Red Zone, and any resident who had contact with those positive residents would be placed on TBP and monitored closely for the development of signs/symptoms. During an interview on 1/5/22 at 11:15 a.m., RN 21 indicated she knew there were several COVID-19 positive residents still in their rooms on the B hall because she tested them the night before and has provided care to them that morning. She indicated there were only 2 PPE bins on the hall at that time, and no signs about COVID status were posted on any resident doors. On 1/5/22 at 11:16 a.m., CNA 20 was observed as she wore only a surgical mask and face shield. She indicated no one told her that any resident on the B hall was positive, and she had not been putting on isolation gowns or gloves before she provided care to any of the residents. During an interview on 1/5/22 at 12:55 p.m., the Administrator (ADM), the Interim Administrator, the DNS, and the Regional Clinical Support were present. The Interim Administrator and DNS were brand new to the facility and their first day was Monday, 1/3/22. Upon their first visit and tour of the building, Licensed Practical Nurse (LPN) 24 notified the DON, Resident Z was not feeling well and acted off. The DNS personally assessed him at that time and indicated he looked weak. Staff added oxygen (02) via a nasal canula (NC) and got his 02 saturations up to 86%. His blood pressure (BP) was 82/51, so they called for an order to send him to the emergency department and Resident Z was discharged to the hospital. The following day, the Admissions Director went to visit Resident Z at the hospital but was informed he had tested positive for COVID-19, so she called the facility to let them know. At that time, on 1/4/22 around 3:30-4:00 p.m., the facility began POC [MEDICATION(S)] testing for every resident. During the initial round of tests, more resident began to test positive and by 6:00 p.m. a total of 10 residents had positive POC tests. Additionally, earlier that day, on 1/4/22, staff notified the DNS, Certified Nursing Assistant (CNA) 14 was not feeling well. The DNS observed CNA 14 in a resident's room (on the B hall where the outbreak occurred) with two other staff (CNA 15 and RN 25). CNA 14 was sitting in a chair without an isolation gown on, as she had removed it because she was so sweaty. The DON immediately removed CNA 14 from the room, gave her a POC test which was positive, and she was sent home. CNA 15 and RN 25 were given POC tests and were determined to be negative, so they were allowed to finish their shifts. Dietary Aid (DA) 26 reported he did not feel well, and also tested positive on a POC test. He was sent home. The Interim Administrator and DNS did not know if the rest of the dietary/kitchen staff had been POC tested after their contact with DA 26. Only that the Dietary Manager (DM) had recently had COVID-19 and was within her 90-day grace period of immunity, therefore would not have required testing. At this time the Administrator, the Interim Administrator, the DNS, and the Regional Clinical Support were notified that 6 residents who tested positive were still in their rooms. Resident BC who was positive and symptomatic, still had a roommate and had received a visit from a hospice nurse who had not donned appropriate PPE, staff were not donning appropriate PPE before entering resident rooms, and Resident , who had been exposed by his symptomatic and positive roommate, Resident BB, had been observed in other resident rooms, and throughout the building. There were no COVID-19 status Red/Yellow stop-signs observed on any resident doors, and that several staff did not know the COVID-19 status of the building and therefore were unaware they needed to follow TBP precautions. The Administrator indicated any positive resident should be moved to the Red Zone, and signs should be posted immediately. The Scheduler who also helped complete POC testing, should have sent a text message to all employees to inform them that residents were positive and to take TBP precautions. 8. On 1/5/22 at 12:32 a.m., LPN 12 was observed on the C hall as she pushed a rolling cart with COVID-19 rapid/[MEDICATION(S)] tests. She had on a surgical mask and face shield. She indicated she was testing residents on the C wing due to the current COVID-19 outbreak in the facility. In order to complete the tests from one resident to the next, LPN 12 indicated she had not worn an N95 face mask, nor had she donned an isolation gown before testing. On 1/5/22 at 12:39 a.m., LPN 8 was observed on the D hall. She wore a surgical mask and a face shield. At this time, LPN 8 indicated she assisted in the COVID-19 outbreak testing of residents on the D hall but had not worn an N95 face mask or isolation gowns when she tested the residents. On 1/5/22 at 11:20 a.m., the Therapy Director and another therapy staff were observed in a resident room on the B hall where the COVID-19 outbreak occurred. Both staff wore a surgical mask and face shield. The Therapy Director indicated they were about to get the resident up an into her wheelchair. The Therapy Director indicated he was aware the whole building was on Yellow TBP precautions, but indicated he only needed to don full PPE if he provided direct resident ADL care. On 1/5/22 at 11:30a- Housekeeper 36 was observed at the D hall nurses' station. He wore an N95 face mask, but the bottom strap was not in place, and hung lose below his chin so that a seal was not created. On 1/5/22 at 11:34 a.m., A resident was observed on the D hall through her open door. She had removed her pants and briefs. At this time, CNA 35 entered her room without performing hand hygiene. He wore only an N95 and face shield but did not don an isolation gown or gloves. On 1/5/22 at 1:25 p.m., CNA 16 was observed in Resident G's room as she assisted him with a meal. She wore an N95 face mask and face shield, but did not have on an isolation gown, or gloves. At this time, the ADM observed CNA 16 and asked why she was not wearing full PPE as the whole building was in outbreak and TBP precautions. CNA 16 indicated, because he doesn't have COVID. On 1/5/22 at 1:28 p.m., the Facilities Owner was observed in a resident commons area and wore only a surgical mask and face shield. He rummaged through a supply box as Resident L, (a resident with direct, prolonged exposure to his COVID positive roommate) slowly wheeled past him. On 1/5/22 at 1:50 p.m., the facilities Owner was observed in the front lobby wearing a surgical mask with a face shield and had not put on an N95. On 1/5/22 at 3:43 p.m., CNA 13 was observed. A surgical mask was observed under her N95 so that a proper seal was not created. Resident G was observed in the hallway as he spoke with CNA 13 who did not redirect him back to his room or encourage him to put a mask on. On 1/5/22 at 3:54 p.m., the facilities Owner wore a surgical mask with a face shield. He had not put on an N95. During a continuous observation on 1/7/22 from 10:34 a.m. until 10:40 a.m., the following was observed: At 10:34 a.m., CNA 32 knocked on the kitchen door and requested cereal, milk, and coffee for two residents. At 10:37 a.m., the Kitchen Manager handed CNA 32 a tray with three individual milk cartons, three covered plastic bowels (not disposable Styrofoam) and a cup of coffee. At 10:38 a.m., CNA 32 walked onto the B hall (where the COVID-19 outbreak occurred) and entered the room of unidentified resident with the tray and all its items. The contact/droplet isolation sign on the resident's door indicated the required PPE before entry. CNA 32 did not perform hand hygiene, don an isolation gown, or place on gloves before she entered the room. In the room, CNA 32 set the kitchen tray down on top of the resident's individual refrigerator. She approached the resident's bed and rolled a bedside table full of personal belongings over to the resident. CNA 32 adjusted the height of the table and positioned it near the resident. She rearranged several personal items on the table with her bare hand to make room for the bowl of cereal and carton of milk which she placed on the table for the resident. At 10:40 a.m., CNA 32 exited the room with the tray, and did not perform hand hygiene. She took the tray to the B hall nurses' station and sat it down on the ledge of the nurses' station counter. During an interview on 1/5/22 at 5:34 p.m., the Regional Clinical Support RN indicated, the facility did not have written a covid policies because the guidance changed so frequently. She indicated the facility followed state health department and CDC (Centers for Disease Control) guidance. Indiana Department of Health Long-Term Care COVID-19 Toolkit, dated 12/14/21, indicated, .limit movement throughout facility during TBP, minimize resident's movement around the building, encouraging all residents in TBP to stay in their room or as in memory care consider placement in single room with dedicated HCP to care for this resident . Outbreak testing plan: All close contacts without a history of COVID-19 in the previous 90 days should be tested at 2 days from exposure. If the test is negative, they should be tested again at 5-7 days from exposure. Unvaccinated or immunocompromised (U) residents should be placed in TBP for 14 days even if tested negative. Vaccinated (V) residents should be monitored for symptoms, they must mask in presence of others for 14 days. They should be placed in TBP if symptomatic or have a positive test Indiana Department of Health Long-term Care COVID-19 Clinical Guidance, dated 1/4/22, indicated, .Exposure or close contact is defined as an interaction for a cumulative total of 15 minutes or more in 24 hours, fewer than 6 feet distance with a known COVID-19 case starting from two days before the onset of symptoms or positive test if asymptomatic .Residents with symptoms of COVID-19 at any time should be tested immediately and be placed in TBP until they meet criteria for discontinuation of TBP, irrespective of their vaccination status . Residents with mild to moderate COVID-19 should be isolated in red zone for 10 days, and those with severe COVID-19 or immunocompromising condition for 20 days CDC Guidance titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 9/10/21, indicated, .a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit The immediate jeopardy that began on 1/4/22 was removed on 1/6/22 after the facility ensured all residents who tested positive for COVID-19 were moved to the Red Zone, TBP isolation signage was posted, staff received additional in-service and education about the proper use of, donning and doffing of PPE. The noncompliance remained at the lower scope and severity level of F of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaint IN 620. 3.1-18(a)

Based on record review and interview, the facility failed to ensure appropriate care and treatment were provided to a resident with head injuries, facial bruising, abnormal neurological checks, suspected internal/external rotation anomaly, and complaints of pain after a fall when the resident was moved prior to the arrival of Emergency Medical Services (EMS) for 1 of 3 residents reviewed for falls (Resident F). The immediate jeopardy began on [DATE] when Resident F was found on the floor by the toilet. The resident was assessed to have sustained a concussion with injuries to the left head and forehead, and the neuro checks were positive with left eye drooping. Resident F was assisted into the wheelchair and taken to the nurses' station. 911 was called and the resident was transferred to a local hospital, then transferred to another hospital with a trauma unit. Resident F had a C7 cervical vertebrae fracture that was not treatable and later died at the hospital with the cause of death of complications of a fractured C-7 vertebrae. The Administrator, Assistant Administrator, and Regional Nurse Consultant were notified of the immediate jeopardy at 2:54 p.m. on [DATE]. This immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During a confidential interview, it was indicated Resident F died because of her falls at the facility. Resident F had dementia, was confused, she was not able to use her call light, and was not capable of understanding she needed to use the call light for help before trying to go to the bathroom. On [DATE], Resident F had a fall and was sent to the hospital. When Resident F arrived at the hospital, her face was black and blue, and looked like she had been hit by a truck. Resident F was taken to the closest local hospital, but they transferred her to another hospital who admitted her as a trauma patient. Resident F had an x-ray which indicated a new fracture of her C-7 cervical vertebra. She was not a candidate for surgery, and a decision was made to place her on inpatient hospice. All they could do was keep her comfortable until she died . During that time, she had to wear a stabilizing neck collar. She died 10 days later, and her cause of death was deemed an accident, as complications from fractured C-7 vertebrae. On [DATE] at 2:20 p.m., Resident F's medical record was reviewed. Resident F's most recent comprehensive nursing assessment was a discharge MDS (minimum data set) assessment dated [DATE]. The MDS indicated Resident F was moderately cognitively impaired and needed extensive assistance for all ADLs (activities of daily living to include, but were not limited to transfers, toileting, walking in her room, and walking on her unit). She was frequently incontinent of bowel and bladder. She had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident F was at risk for falls and had experienced one fall in the prior seven days, with no injuries. Resident F's physician orders, current from [DATE] through [DATE], indicated the resident had additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident F had a comprehensive care plan titled, Falls, initiated [DATE], and most recently revised [DATE]. The care plan indicated Resident F had multiple risk factors for falls which included, but were not limited to, impaired cognition, unsteady balance, dementia, and weakness. Interventions for this care plan included but were not limited to monitor the resident frequently when the call lights were not available, ensure that resident was using assistive devices, ensure walker/rollator and wheelchair were within reach, offer to use the toileted every two hours, and 30 minute visual checks. A document titled, Accident & Incident Report and Investigation, dated [DATE], indicated Resident F fell at 5:20 a.m. She was found on the floor in the hallway by a CNA (Certified Nursing Assistant). The resident stated she did not know what she was doing but fell on the floor. No suspected injuries were noted, her vital signs, and neuro (neurological) checks were within normal limits. Immediate action taken at the time of this fall was to place Resident F on visual safety checks every 30 minutes, and to offer her the toilet every two hours. A document titled, Post Fall Thirty (30) Minute Observations, dated [DATE] at 5:30 p.m., indicated 30-minute visual checks were initiated at this time. The Post Fall Thirty Minute Observations Check tool indicated Resident F was observed walking by herself in the hallway at 5:30 p.m. on [DATE], with no complaints of pain, and had been offered to go to the bathroom. A document titled, Accident & Incident Report and Investigation, dated [DATE] and documented by Registered Nurse (RN) 25, indicated Resident F fell at 5:30 p.m. She was found on the floor of the bathroom and stated she was trying to use the bathroom. She sustained a skin bruise, concussion injuries on left head and forehead, and neuro checks were positive with her left eye drooping. The NP (nurse practitioner) was notified, and a new order was received to send the resident out to the Emergency Department (ED). The incident report indicated Resident F's most recent BIMS (Brief Interview for Mental Status) score was 2 (out of 15) indicating severe cognitive impairment. Her vital signs at the time of the fall included blood pressure ,d+[DATE], heart rate 109, and respirations were 24 breaths per minute. Staff suspected she hit her head and had a change in her cognition as noted by confusion. An anomaly of internal/external rotation of her extremities was suspected. She sustained a skin tear to her left hand that measured 1.5 cm (centimeters) and was administered [MEDICATION(S)] ,d+[DATE] (a narcotic pain medication). Resident F was assisted to the wheelchair and taken to the nursing station. A nursing progress note, dated [DATE] at 5:30 p.m. and documented by RN 25, indicated Resident F was found on the floor, she stated she was trying to go use the restroom and then lost balance with the walker. resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . She also had a formed hematoma. NP notified and ordered the resident to be sent out emergently. A document titled, Post Fall Investigation, dated [DATE] and documented by RN 25, indicated Resident F was incontinent at the time of her fall, and stated she was trying to get to the bathroom and fell . The report indicated the resident usually put herself to bed anytime she wanted, but that evening she had been assisted to bed at 4:00 p.m. The record lacked documentation that Resident F tried to get up by herself or was being uncooperative, not following commands, nor assessment or vitals within normal limits after the fall. A document titled, ED physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She was complaining of right shoulder pain, neck pain, and face pain. She arrived in a cervical neck collar, her right shoulder was tender, and she had a left face abrasion. The attending physician consulted with a trauma surgeon from a different hospital and agreed to have her transferred there and admitted as a trauma patient. A CT Cervical Spine without IV contrast was taken on [DATE] at 7:43 p.m., and indicated Resident F sustained a new fracture of the C-7 superior facet. Left frontal and left parietal scalp hematomas were noted. A document titled, ED physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Her [MEDICATION(S)] and lumbar spine was tender to palpation. An abdominal/pelvis CT scan was completed on [DATE] at 4:34 a.m., and indicated, a compression deformity of the T-12 ([MEDICATION(S)] spine vertebrae) superior endplate which was new from her prior examination on [DATE]. An x-ray of her spine was completed on [DATE] at 11:40 a.m. and confirmed the C-7 fracture. A document titled, Death Summary, from the second local hospital, dated [DATE] at 11:09 a.m., indicated Resident F was on comfort care with [MEDICATION(S)] as needed for pain control. She passed away on [DATE] at 11:15 p.m. A document titled, Certificate of Death, dated [DATE], indicated Resident F passed away on [DATE] at 11:15 p.m., and the immediate cause of death was, complications of a fractured C-7 vertebrae. During an interview on [DATE] at 2:49 p.m., RN 25 indicated he was the nurse on shift at the time of Resident F's fall on [DATE]. He indicated, around 5:00 p.m. that evening, CNA 90 notified him that Resident F was on the floor. He went to assess her and found her on the floor of her bathroom. Resident F was fine on the floor and following commands. RN 25 assessed the resident on the bathroom floor and did all the vital signs and neuro checks there in the room which were documented on the Fall Incident Report. RN 25 then wanted to put her in the wheelchair and go to the nurses' station to monitor her because he noticed increased confusion, her eye was drooping, and she had pain. Resident F was unable to verbally tell where she was hurting, but indicated it was all over. She did get a [MEDICATION(S)] pill (pain medication) while she was waiting and took a cup of water. RN 25 had a CNA sit with her at the nurses' station while he called 911 and the family. When EMS arrived RN 25 informed them that Resident F was indicating her back and neck area were hurting, and EMS immobilized her neck and back to take her to the ED via ambulance. During an interview on [DATE] at 2:21 p.m., LPN 19 indicated if a CNA found a resident on the floor, they were to keep the resident safe, and not move the resident until the nurse assessed the resident. The nurse should call the physician immediately, identify injuries if any, and send the resident out to the ED as needed. If the resident was assessed, and found to have abnormal neuro checks, the resident should immediately be sent to the ED. The nurse should make sure the resident was safe, leave the resident on floor, and call 911 to come transport. The DON (Director of Nursing) should be notified, and the family should be notified after resident care had been completed. A Post Fall Investigation should be filled out with the incident report, and both documents should be given to the unit manager. During an interview on [DATE] at 2:22 p.m., LPN 20 indicated if a nurse found a resident on the floor, it should automatically be treated as an unwitnessed fall incident. The nurse should immediately assess the resident for injuries. If head injuries were suspected either by lacerations, bruises, or hematomas, and if neuro checks were abnormal the resident should be sent to ED immediately. In order to call 911, the nurse should ensure the resident was safe and comfortable on the floor and let EMS move them. During an interview on [DATE] at 9:39 a.m., the Regional Nurse Consultant indicated when the resident fell on [DATE] in the bathroom, the documentation indicated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse should have secured the resident's safety, assessed the resident, notified the physician, and the resident should have been sent out of the building to the ER. Whether the resident should have been gotten up off the floor into a wheelchair versus leaving her on the floor for EMS to move, would have been dependent on the conversation with the physician, even with documentation of injury per the nurse. The Regional Nurse Consultant indicated the fall documentation did not indicate what orders the physician may have given for care, other than the NP ordered the resident to be sent out to ED. RN 25 administered [MEDICATION(S)] ,d+[DATE] to the resident for pain after the fall and review of the fall documentation, did not clarify how much pain the resident was experiencing. The Regional Nurse Consultant indicated, if he had been in the same situation, he would have assessed the resident, left a CNA with the resident in order to place an emergent call to the physician for any orders and to ensure it was safe to assist the resident off the floor. The Regional Nurse Consultant's expectation would have been for staff to follow the facility fall policy and leave the resident in place and call 911 unless further instruction had been received from the physician to move the resident. During a second interview with RN 25 and the Regional Nurse Consultant on [DATE] at 1:38 p.m., RN 25 indicated after Resident F fell on [DATE], he and CNA 90 assisted the resident off the floor because she was trying to get herself up. The resident had been lying on her back on the bathroom floor when RN 25 got to her, she was bending her back and struggling to get up, so he and CNA 90 assisted her into a seated position where he completed an initial set of vitals and neuro checks which were within normal limits, and then helped her into the wheelchair, and brought her to the nurses' station for observation. After being placed at the nurses' station, the resident began to complain of pain. A second set of vitals was taken, and her neuro checks became abnormal to include drooping of her left eye and increased confusion. At this time, he called 911 which took approximately ,d+[DATE] minutes to arrive. RN 25 indicated he would not have gotten the resident off the floor if she had not been trying to get herself up. Resident F's record lacked documentation of an assessment and neuro checks after the fall that were within normal limits. The resident's record only contained documentation of one set of vitals and one assessment after the fall. Contact information for CNA 90 was requested multiple times during the survey but not provided by the exit of the survey on [DATE]. On [DATE] at 10:30 a.m., the Regional Nurse Consultant indicated CNA 90 had been contacted several times in attempts for the facility to interview the CNA regarding the fall, but the CNA had not been available. On [DATE] at 2:09 p.m., the Regional Nurse Consultant provided copies of current facility policies. A policy titled, Internal Fall Investigation Process, dated ,d+[DATE], indicated, .the following is to be completed by the licensed nurse on duty: resident is reported as observed on the ground; OR resident witnessed to have fallen, resident is left as found (not moved) until licensed nurse assessment is conducted. NOTE: If during review, it is determined the staff moved the resident prior to assessment, education must be conducted and documented, as well as disciplinary action taken, if warranted . If the fall was unwitnessed, or if resident states he/she struck his/her head, the licensed nurse must initiate neurological checks using the NEUROLOGICAL CHECK FLOWSHEET. Following assessment, physician is contacted and resident is either transported via EMS for ER evaluation; or deemed with no apparent injuries and assisted to bed or chair. Physician contact must include informing the physician if the resident is on an anticoagulant (due to potential bleeding tendencies), and if the resident is believed to have struck his/her head. This notification should be clearly documented in the nurse's notes A policy titled, Fall emergency, First Aid, dated,d+[DATE], indicated, Purpose- to ensure a resident who sustains a fall will be assessed and treated to prevent complications. Policy- Any resident who sustains a fall will be assess for injury at the time of the fall and will receive first aid treatment promptly. Licensed nurse will notify physician to ensure proper treatment is administered. Procedure- Certified Nursing Assistant: 1. If a resident falls, call for nurse and stay with resident. 2. Check if resident is breathing. 3. Do not move resident. Leave in same position until the nurse examines resident. 4. Talk to resident in a calm and supportive manner . Licensed Nurse: 1. Respond immediately to call. 2. Do not move resident prior to completion of a thorough assessment . 4. Assess resident from head to toe for any injuries. 5. Assess for pain immediately. 6. Assess extremities for injury noting any rotation inward or outward, any shortening of the limbs and/or any complaints of pain. 7. If there is any evidence of a fracture, do not move resident until EMS arrives. 8. Assess for injury to head. If noted, begin neurological checks immediately. 9. Assess for injury to other parts of the body (e.g. cuts, skin tears, abrasions, hematomas, etc.) The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility had educated nursing staff regarding leaving a resident in place until EMS arrived when a resident has a fall with a change in mental status, neurological change(s), and/or who the nurse suspects the resident to have sustained a traumatic head injury and/or fracture upon immediate assessment. All incidents and accidents known to have occurred within the facility in the past 60 days were reviewed. Plans were implemented for the on-call nursing administrative staff to be notified of all falls/incidents to confirm appropriate action was taken by the licensed nurse on duty, and for the Registered Nurse Consultant to conduct bi-weekly audits of all incidents/accidents known to have occurred within the facility for a minimum of six months to confirm continued compliance. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaint IN 469. 3.,d+[DATE](a)

Based on interview, and record review the facility failed to ensure pain medication was available and administered timely to a resident who experienced pain resulting in the resident reporting a night of intense pain for 1 of 3 residents reviewed for quality of care related to pain management (Resident C). Finding includes: Resident C's record was reviewed on 3/8/16 at 12:52 p.m. Resident C had [DIAGNOSES REDACTED]. An admission assessment note, dated 2/27/16 at 5:45 p.m., indicated Resident C was alert and oriented. The note further indicated she was experiencing phantom pain to her right stump and the physician had ordered narcotic pain medication. physician's orders [REDACTED]. Resident C's Medication Administration Record [REDACTED]. The Emergency Drug Kit (EDK) record did not indicate [MEDICATION NAME] had been removed from the kit for administration to Resident C until 2/28/16 at 2:30 a.m. During an interview on 3/8/16 at 1:20 p.m., LPN (Licensed Practical Nurse) #4 indicated she was the nurse on day shift for Resident C on 2/28/16. She indicated Resident C's medication had not been delivered so she called the pharmacy and they advised her to pull what she could from the EDK (Emergency Drug Kit). She indicated she removed pain medication from the kit and administered it. During an interview on 3/9/16 at 10:15 a.m., Resident C indicated she had not received any of her pain medication on 2/27/16. Resident C then became tearful and stated, That first night was h---! Resident C indicated she was in intense pain and had requested pain medication for the pain in her right knee stump. She indicated she admitted at 5:45 p.m. and didn't see a nurse until 8:00 p.m., at which time she requested her pain medication. She indicated it was not given to her. She indicated she asked again at 10:00 p.m. and the nurse told her she would have to get an order to remove it from the Emergency Drug Kit (EDK). Resident C indicated she did not receive the pain medication until 2:50 a.m. Resident C indicated she had received pain medication at the hospital at 5 p.m. prior to being discharged on [DATE]. She indicated the pain in her right [MEDICAL CONDITION] was very intense that night because of the transfer. She rated it at a 9/10 on a scale of 1-10. She indicated the pain then became unbearable because she went so long without pain medication. A nurse's note, dated 2/27/16 at 5:45 p.m., indicated Resident C was in pain and pain medication was administered. During an interview on 3/9/16 at 10:40 a.m., the Nurse Consultant indicated the clinical record should include an explanation when a prescribed medication was not given and indicated the medication prescribed for Resident C's pain was available from the EDK and should have been retrieved from the EDK. During an interview on 3/9/16 at 11:18 a.m., Unit Manager # 1 indicated documentation indicated Resident C was administered 2 [MEDICATION NAME] 5/325 mg tablets on 2/28/16 at 2:30 a.m. from the EDK. During an interview on 3/9/16 at 11:30 a.m., the DON (Director of Nursing) indicated she called LPN #3 to clarify her charting for 2/27/16. She indicated LPN #3 entered the nurse's note at the end of her shift on 2/28/16, and had not administered Resident C pain medication at 5:45 p.m., as indicated in the nurse's note. She indicated the pain medication was not administered until 2:30 a.m. on 2/28/16. A current policy, titled PAIN MANAGEMENT received from the Administrator on 3/10/16 at 9:00 a.m. The policy indicated, .PURPOSE: To identify those residents who utilize routine medications for pain or who utilize frequent PRN pain medications in an effort to ensure pain control is achieved. Policy: Upon admission each resident shall be assessed for presence of complaint of pain and/or lack of pain relief following currently ordered pain medication administration. If ineffective relief is noted, a Pain Assessment shall be completed in an effort to assess location frequency, etc., and notify physician accordingly to ensure currently ordered pain medication is evaluated and revised, as necessary This Federal tag relates to complaint IN 376. 3.1-37(a)

Based on record review and interview, the facility failed to adequately monitor and supervise a resident (Resident #143) who wandered to prevent the resident from entering other residents' rooms and attempting or engaging in non-consensual sexual interactions with 2 of 7 residents reviewed for safe living environment (Resident #83 and Resident #126). The Immediate Jeopardy was identified on 1/07/2016 and began on 12/18/2015 when the facility identified Resident #143's wandering behaviors and failed to implement interventions to prevent the resident from wandering into other residents' rooms. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/07/16 at 1:21 p.m. The Immediate Jeopardy was removed on 1/8/16, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy Findings include: 1. During an interview on 01/06/16 at 9:56 a.m., Resident #83 indicated on five or six different occasions Resident #143 had been in his room at 2:00 a.m. touching himself and attempted to grope Resident #83. Resident #83 indicated Resident #143 had never touched him because he swung at Resident #143 to keep him away. Resident #83 was unable to provide specific dates for these incidents. During a follow up interview on 1/06/16 at 3:22 p.m., Resident #83 indicated he reported the incidents where Resident #143 entered his room to third shift nurses five times. Resident #83 was unable to recall the names of the nurses he reported the incident to. Resident #83's record was reviewed on 1/07/16 at 11:25 a.m. Resident #83's Resident Admission Record, dated 5/30/15, indicated [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/08/15, indicated Resident #83's cognitive status score was 15 indicating he was cognitively intact. Resident #83's nurse's notes, dated 7/02/15 through 1/06/16, were reviewed and lacked documentation of Resident #83 reporting any residents wandering into his room or observations of Resident #143 wandering into his room. 2. During an interview on 1/7/16 at 9:31 a.m , Resident #2 indicated about three to four weeks ago, during the day, Resident #143 wandered into his room and touched his roommate, Resident #126, in the private area. He stated he and Resident #126 reported the incident to Licensed Practical Nurse (LPN) #2 and that she did not report the incident to the social worker. Resident #2 indicated Resident #143 had not attempted or ever touched him. Resident #2 indicated during the weeks Resident #126 was in the hospital (after he witnessed Resident touch his roommate's private area) Resident #143 frequently asked where his roommate (Resident #126) was and sat in his wheelchair outside the door to his room and peeked into the room. Resident #2's record was reviewed on 1/07/16 at 9:10 a.m. Resident #2's Resident Admission Record dated 5/15/2015 indicated he had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 8/12/15, indicated Resident #2's cognitive status score was 14, indicating he was cognitively intact. During an interview on 1/7/16 at 9:35 a.m., Resident #126 indicated Resident #143 came into his room and touched his private area. Resident #126 indicated he told Resident #143 to leave and he did. Resident #126 stated he reported the incident to Licensed Practical Nurse (LPN) #2. Resident #126 indicated the incident happened prior to him going to the hospital approximately four weeks ago. Resident #126's record was reviewed on 1/07/16 at 9:25 a.m. Resident #126's Resident Admission Record, dated 11/04/15, indicated [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/19/15, indicated Resident #126's cognitive status score was 15, indicating he was cognitively intact. 3. Resident #143's record was reviewed on 1/06/16 at 2:25 p.m. Resident #143's Resident Admission Record dated 7/31/2015 indicated [DIAGNOSES REDACTED]. Significant change Minimum Data Set (MDS) assessment, dated 10/28/15, indicated Resident #143's cognitive status score was 14, indicating Resident #143 was cognitively intact. A form titled, Mood and Behavior Communication Memo, dated 12/17/15, indicated Resident #126 and Resident #2 reported that Resident #143 came into their room and they asked the nurse to redirect Resident #143. The memo indicated the nurse redirected Resident #143 to his room. A care plan for Resident #143, dated 12/18/15, indicated he was care planned for wandering and had interventions including the following: redirect resident to his room and obtain a urinalysis and urine culture. A care plan, dated 12/28/15, indicated Resident #143 and his roommate, Resident #36 had a need for privacy and included the following interventions: establish a system to ensure privacy as evidenced by door sign, and staff not entering room when door is shut. On 1/06/15 at 1:55 p.m., the DON provided a document titled, Mood and Behavior Communication Memo, dated 12/26/15. The memo stated, The husband of a visitor for Resident #96 said he was in the hallway and Resident #143 came to the doorway and asked him to come here so he said (sic) ask a question when the visitor went over to see what he needed Resident #143 went to grab his private area. The visitor said he grabbed his (Resident #143) hand and told him not to do that and he should be ashamed of himself. A care plan, dated 12/28/15, stated Resident #143 had been, sexually inappropriate to visitor .attempted to grope visitor. The care plan interventions included, but was not limited to, Placed on 15 min. checks. A document titled, Fifteen Minute Observation, indicated Resident #143 was placed on bed checks every fifteen minutes beginning 12/28/15. A psychological Evaluations dated 1/04/16 indicated Patient is a (age specified) year old .mild cognitive impairment is observed .however patient appears alert, oriented, and able to make decisions for himself .Patient adamantly expressed that he is willingly participating in relationship with his roommate. He appears to understand the risks associated with sexual activity . During an interview on 1/06/16 at 3:56 p.m., Resident #143 indicated he accidentally wandered into another room once and was not sure when that was. He denied getting up in the middle of the night and wandering into rooms. He also denied an encounter with a visitor or attempting to touch the visitor inappropriately. During an interview on 1/6/15 at 4:03 p.m., Certified Nursing Assistant (CNA) #1 indicated she had never seen Resident #143 wandering at night. She indicated she had witnessed Resident #143 wander into Resident #83's room on two occasions. The first time she witnessed Resident #143 with his hand under #83's sheet. CNA #1 indicated Resident #83 was awake and did not say anything. She did not report it because Resident #83 would have told her if something inappropriate was happening. The second time the CNA #1 saw Resident #143 enter Resident #83's room she immediately had Resident #143 leave room his room. CNA #1 stated that both incidents occurred about three weeks ago in the evening after dinner. During an interview on 1/6/16 at 11:50 p.m., LPN #3, CNA #4, and Qualified Medication Aide (QMA) #5 all indicated they heard rumors of Resident #143 touching his roommate and indicated they did not report the rumors because they believed the managers and the Assistant Director of Nursing (ADON) already knew of the situation. During an interview on 1/7/16 at 12:37 a.m., LPN #6 indicated she heard rumors last week or two weeks ago about a resident on the D wing entering another resident's room and touching another resident sexually. The LPN indicated the resident was confused and she didn't report the allegation to anyone because she believed it had already been discussed with the Unit Manager and Assistant Director of Nursing (ADON). A typed interview statement received from the Director of Nursing (DON) on 1/7/15 at 9:05 a.m., indicated Resident #83 was interviewed on 1/06/16. He indicated Resident #143 never touched him, but made him very uncomfortable. During an interview on 1/07/16 at 9:05 a.m., the DON indicated Resident #143's 15 minute checks were not immediately put into place after the incident on 12/26/15 when Resident #143 attempted to touch a visitor, but initiated on 12/28/15. The DON indicated she was unaware of the incident until 12/28/15 due to the incident happening on the weekend, and staff not reporting the incident immediately. During an interview on 1/07/16 at 9:06 a.m., the DON indicated during the investigation of recent abuse allegations, Resident #126 reported being touched inappropriately by Resident #143. The DON also indicated that Resident #126's roommate Resident #2 indicated he witnessed the incident. An interview was conducted on 1/07/2016 at 10:01 a.m. with the Social Service Director (SS), Director of Nursing (DON), and Administrator. The DON indicated one behavior sheet from 12/17/15 resulted in development of a care plan to address Resident #143's wandering. The DON indicated staff should have known where care plans were located and the facility tried to include some care plan interventions or behaviors on CNA assignment sheets. The DON indicated the CNA assignment sheets were updated by the unit manager every couple of days after new care plans were put in place. The DON indicated no resident interviews were conducted after the 12/17/15 incident to determine if Resident #143 wandered in their rooms or abused them because she thought it was an isolated incident. The DON indicated a written report was received on 12/28/15 regarding Resident #143 grabbing a male visitor's genital area on 12/26/15. The DON and SSD indicated they did not receive the report until 12/28/15 due to holidays and weekend and indicated staff should have immediately reported the incident. The Social Service Director (SSD) indicated Resident #143 was placed on 15 minute checks due to his tendency towards touching males' genitals and his ability to move around the unit. The DON indicated the 15 min checks continued until 1/06/16 when the resident was placed on 1:1 supervision after receiving an allegation from Resident #83 of abuse by Resident #143. The DON indicated she wished she would have interviewed other residents when she learned of the allegation of Resident #143 grabbing a visitor. During an interview on 01/07/2016 at 10:33 a.m., CNA #7 indicated she completed the behavior form for Resident #143 on 12/26/15. She indicated she was at the at nurses station and Resident #96's granddaughter's husband came up to the desk and informed her that Resident #143 had stopped him in the hall and asked him to come to his room's door and then grabbed the visitor's privates. She indicated the visitor told her he grabbed Resident #143's hands away and told him no. She indicated the visitor was concerned that he would touch someone else and told her to have them keep children away from the resident. She indicated she called Qualified Medication Aide (QMA) #8 and informed her and QMA #8 called LPN #2. CNA #7 indicated QMA #8 told her to complete the behavior form and went to check on Resident #143. She indicated she believed QMA #8 informed the nurse manager on call of the visitor incident. CNA #7 indicated her assignment sheet did not say anything about Resident #143 wandering as of 12/26/15. She indicated she saw Resident #143 attempt to wander into the following residents' rooms: Resident #2, Resident #126, Resident #4, Resident #96, and Resident #83. She indicated she stopped Resident #143, redirected him, and informed the nurse. CNA #7 indicated the nurses always told her to continue watching him only. She indicated she never saw Resident #143 in another resident's room, only attempting to enter. During an interview on 1/07/16 at 3:45 p.m., Licensed Practical Nurse (LPN) #2 indicated Resident #2 and Resident #126 informed her Resident #143 had wandered into their room, but she did not report it because Resident #2 and Resident #126 asked her to redirect Resident #143. LPN #2 indicated Resident #2 told her Resident #143 had been in his room, he did not like Resident #143, he was weird, and he did not want him in his room. LPN #2 indicated she did not report the incident because it had not happened before. LPN #2 indicated Resident #83 said Resident #143 was in his room and asked her to keep him out. LPN #2 indicated she did not report the incident, but she should have. LPN #2 indicated Resident #83 had informed her he did not want Resident #143 in his room because he wasn't like that. LPN #2 indicated there was time between the two complaints about Resident #143, so she had not noticed a behavior pattern. She indicated she had been unaware of Resident #143's care plan for wandering. She indicated she should have reported his wandering. A facility policy, received from the Administrator on 01/05/16 at 3:41 p.m., dated 10/2014 and deemed current, titled Abuse Prohibition Reporting and Investigation, stated, This facility will not permit residents to be subjected to abuse by anyone, including employees, other residents, consultants, volunteers, staff or personnel of other agencies .Any resident implicated in the alleged abuse will be placed under appropriate monitoring/supervisions to prevent recurrence . The policy also stated, Supervisory personnel shall be responsible to monitor deployment of personnel on each shift in sufficient numbers to meet the needs of the residents , and to identify inappropriate behaviors which may lead to conflict or neglect. The policy stated, Supervisory personnel shall be responsible to monitor .occurrences, patterns and trends that may constitute abuse, in an effort necessary investigation be initiated should potential concern be identified. The Immediate Jeopardy that began on 12/18/15 was removed on 1/8/16 when Resident #143 received 1:1 staff to resident supervision and the facility educated residents and responsible parties and in-serviced all staff regarding abuse and abuse reporting requirements. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of need for continued supervision and monitoring for abuse prevention and reporting. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure its policies and procedures were implemented to prevent a resident (Resident #143) with wandering and inappropriate sexual behaviors from attempting or engaging in non-consensual sexual interactions with other residents and failed to ensure allegations of abuse were reported and thoroughly investigated for 2 of 7 residents reviewed for allegations of abuse (Resident #83 and Resident #126). In addition to the residents in Immediate Jeopardy, the facility failed to ensure its policis and procedures were implemented to prevent verbal abuse and an allegation of resident to resident verbal abuse resulting in harm or potential harm that is not Immediate Jeopardy was immediately reported and thoroughly investigated for 1 of 1 resident reviewed for an allegation of verbal abuse (Resident #134). The Immediate Jeopardy was identified on 1/07/2016 and began on 12/18/15 when the facility failed to ensure interventions to prevent Resident #143 from wandering into other residents' room. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/07/16 at 1:21 p.m. The Immediate Jeopardy was removed on 1/8/16, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy Findings include: 1. During an interview on 01/06/16 at 9:56 a.m., Resident #83 indicated on five or six different occasions Resident #143 had been in his room at 2:00 a.m. touching himself and attempted to grope Resident #83. Resident #83 indicated Resident #143 had never touched him because he swung at Resident #143 to keep him away. Resident #83 was unable to provide specific dates for these incidents. During a follow up interview on 1/06/16 at 3:22 p.m., Resident #83 indicated he reported the incidents where Resident #143 entered his room to third shift nurses five times. Resident #83 was unable to recall the names of the nurses he reported the incident to. Resident #83's record was reviewed on 1/07/16 at 11:25 a.m. Resident #83's Resident Admission Record, dated 5/30/15, indicated [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/08/15, indicated Resident #83's cognitive status score was 15 indicating he was cognitively intact. Resident #83's nurse's notes, dated 7/02/15 through 1/06/16, were reviewed and lacked documentation of Resident #83 reporting any residents wandering into his room or observations of Resident #143 wandering into his room. 2. During an interview on 1/7/16 at 9:31 a.m , Resident #2 indicated about three to four weeks ago, during the day, Resident #143 wandered into his room and touched his roommate, Resident #126, in the private area. He stated he and Resident #126 reported the incident to Licensed Practical Nurse (LPN) #2 and that she did not report the incident to the social worker. Resident #2 indicated Resident #143 had not attempted or ever touched him. Resident #2 indicated during the weeks Resident #126 was in the hospital (after he witnessed Resident touch his roommate's private area) Resident #143 frequently asked where his roommate (Resident #126) was and sat in his wheelchair outside the door to his room and peeked into the room. Resident #2's record was reviewed on 1/07/16 at 9:10 a.m. Resident #2's Resident Admission Record dated 5/15/2015 indicated he had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 8/12/15, indicated Resident #2's cognitive status score was 14, indicating he was cognitively intact. During an interview on 1/7/16 at 9:35 a.m., Resident #126 indicated Resident #143 came into his room and touched his private area. Resident #126 indicated he told Resident #143 to leave and he did. Resident #126 stated he reported the incident to Licensed Practical Nurse (LPN) #2. Resident #126 indicated the incident happened prior to him going to the hospital approximately four weeks ago. Resident #126's record was reviewed on 1/07/16 at 9:25 a.m. Resident #126's Resident Admission Record, dated 11/04/15, indicated [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/19/15, indicated Resident #126's cognitive status score was 15, indicating he was cognitively intact. 3. Resident #143's record was reviewed on 1/06/16 at 2:25 p.m. Resident #143's Resident Admission Record dated 7/31/2015 indicated [DIAGNOSES REDACTED]. Significant change Minimum Data Set (MDS) assessment, dated 10/28/15, indicated Resident #143's cognitive status score was 14, indicating Resident #143 was cognitively intact. A form titled, Mood and Behavior Communication Memo, dated 12/17/15, indicated Resident #126 and Resident #2 reported that Resident #143 came into their room and they asked the nurse to redirect Resident #143. The memo indicated the nurse redirected Resident #143 to his room. A care plan for Resident #143, dated 12/18/15, indicated he was care planned for wandering and had interventions including the following: redirect resident to his room and obtain a urinalysis and urine culture. A care plan, dated 12/28/15, indicated Resident #143 and his roommate, Resident #36 had a need for privacy and included the following interventions: establish a system to ensure privacy as evidenced by door sign, and staff not entering room when door is shut. On 1/06/15 at 1:55 p.m., the DON provided a document titled, Mood and Behavior Communication Memo, dated 12/26/15. The memo stated, The husband of a visitor for Resident #96 said he was in the hallway and Resident #143 came to the doorway and asked him to come here so he said (sic) ask a question when the visitor went over to see what he needed Resident #143 went to grab his private area. The visitor said he grabbed his (Resident #143) hand and told him not to do that and he should be ashamed of himself. A care plan, dated 12/28/15, stated Resident #143 had been, sexually inappropriate to visitor .attempted to grope visitor. The care plan interventions included, but was not limited to, Placed on 15 min. checks. A document titled, Fifteen Minute Observation, indicated Resident #143 was placed on bed checks every fifteen minutes beginning 12/28/15. A psychological Evaluations dated 1/04/16 indicated Patient is a (age specified) year old .mild cognitive impairment is observed .however patient appears alert, oriented, and able to make decisions for himself .Patient adamantly expressed that he is willingly participating in relationship with his roommate. He appears to understand the risks associated with sexual activity . During an interview on 1/06/16 at 3:56 p.m., Resident #143 indicated he accidentally wandered into another room once and was not sure when that was. He denied getting up in the middle of the night and wandering into rooms. He also denied an encounter with a visitor or attempting to touch the visitor inappropriately. During an interview on 1/6/15 at 4:03 p.m., Certified Nursing Assistant (CNA) #1 indicated she had never seen Resident #143 wandering at night. She indicated she had witnessed Resident #143 wander into Resident #83's room on two occasions. The first time she witnessed Resident #143 with his hand under #83's sheet. CNA #1 indicated Resident #83 was awake and did not say anything. She did not report it because Resident #83 would have told her if something inappropriate was happening. The second time the CNA #1 saw Resident #143 enter Resident #83's room she immediately had Resident #143 leave room his room. CNA #1 stated that both incidents occurred about three weeks ago in the evening after dinner. During an interview on 1/6/16 at 11:50 p.m., LPN #3, CNA #4, and Qualified Medication Aide (QMA) #5 all indicated they heard rumors of Resident #143 touching his roommate and indicated they did not report the rumors because they believed the managers and the Assistant Director of Nursing (ADON) already knew of the situation. During an interview on 1/7/16 at 12:37 a.m., LPN #6 indicated she heard rumors last week or two weeks ago about a resident on the D wing entering another resident's room and touching another resident sexually. The LPN indicated the resident was confused and she didn't report the allegation to anyone because she believed it had already been discussed with the Unit Manager and Assistant Director of Nursing (ADON). A typed interview statement received from the Director of Nursing (DON) on 1/7/15 at 9:05 a.m., indicated Resident #83 was interviewed on 1/06/16. He indicated Resident #143 never touched him, but made him very uncomfortable. During an interview on 1/07/16 at 9:05 a.m., the DON indicated Resident #143's 15 minute checks were not immediately put into place after the incident on 12/26/15 when Resident #143 attempted to touch a visitor, but initiated on 12/28/15. The DON indicated she was unaware of the incident until 12/28/15 due to the incident happening on the weekend, and staff not reporting the incident immediately. During an interview on 1/07/16 at 9:06 a.m., the DON indicated during the investigation of recent abuse allegations, Resident #126 reported being touched inappropriately by Resident #143. The DON also indicated that Resident #126's roommate Resident #2 indicated he witnessed the incident. An interview was conducted on 1/07/2016 at 10:01 a.m. with the Social Service Director (SS), Director of Nursing (DON), and Administrator. The DON indicated one behavior sheet from 12/17/15 resulted in development of a care plan to address Resident #143's wandering. The DON indicated staff should have known where care plans were located and the facility tried to include some care plan interventions or behaviors on CNA assignment sheets. The DON indicated the CNA assignment sheets were updated by the unit manager every couple of days after new care plans were put in place. The DON indicated no resident interviews were conducted after the 12/17/15 incident to determine if Resident #143 wandered in their rooms or abused them because she thought it was an isolated incident. The DON indicated a written report was received on 12/28/15 regarding Resident #143 grabbing a male visitor's genital area on 12/26/15. The DON and SSD indicated they did not receive the report until 12/28/15 due to holidays and weekend and indicated staff should have immediately reported the incident. The Social Service Director (SSD) indicated Resident #143 was placed on 15 minute checks due to his tendency towards touching males' genitals and his ability to move around the unit. The DON indicated the 15 min checks continued until 1/06/16 when the resident was placed on 1:1 supervision after receiving an allegation from Resident #83 of abuse by Resident #143. The DON indicated she wished she would have interviewed other residents when she learned of the allegation of Resident #143 grabbing a visitor. During an interview on 01/07/2016 at 10:33 a.m., CNA #7 indicated she completed the behavior form for Resident #143 on 12/26/15. She indicated she was at the at nurses station and Resident #96's granddaughter's husband came up to the desk and informed her that Resident #143 had stopped him in the hall and asked him to come to his room's door and then grabbed the visitor's privates. She indicated the visitor told her he grabbed Resident #143's hands away and told him no. She indicated the visitor was concerned that he would touch someone else and told her to have them keep children away from the resident. She indicated she called Qualified Medication Aide (QMA) #8 and informed her and QMA #8 called LPN #2. CNA #7 indicated QMA #8 told her to complete the behavior form and went to check on Resident #143. She indicated she believed QMA #8 informed the nurse manager on call of the visitor incident. CNA #7 indicated her assignment sheet did not say anything about Resident #143 wandering as of 12/26/15. She indicated she saw Resident #143 attempt to wander into the following residents' rooms: Resident #2, Resident #126, Resident #4, Resident #96, and Resident #83. She indicated she stopped Resident #143, redirected him, and informed the nurse. CNA #7 indicated the nurses always told her to continue watching him only. She indicated she never saw Resident #143 in another resident's room, only attempting to enter. During an interview on 1/07/16 at 3:45 p.m., Licensed Practical Nurse (LPN) #2 indicated Resident #2 and Resident #126 informed her Resident #143 had wandered into their room, but she did not report it because Resident #2 and Resident #126 asked her to redirect Resident #143. LPN #2 indicated Resident #2 told her Resident #143 had been in his room, he did not like Resident #143, he was weird, and he did not want him in his room. LPN #2 indicated she did not report the incident because it had not happened before. LPN #2 indicated Resident #83 said Resident #143 was in his room and asked her to keep him out. LPN #2 indicated she did not report the incident, but she should have. LPN #2 indicated Resident #83 had informed her he did not want Resident #143 in his room because he wasn't like that. LPN #2 indicated there was time between the two complaints about Resident #143, so she had not noticed a behavior pattern. She indicated she had been unaware of Resident #143's care plan for wandering. She indicated she should have reported his wandering. A facility policy, received from the Administrator on 01/05/16 at 3:41 p.m., dated 10/2014 and deemed current, titled Abuse Prohibition Reporting and Investigation, stated, This facility will not permit residents to be subjected to abuse by anyone, including employees, other residents, consultants, volunteers, staff or personnel of other agencies .Any resident implicated in the alleged abuse will be placed under appropriate monitoring/supervisions to prevent recurrence . The policy also stated, This facility will ensure that all alleged violations, including mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility. The policy also stated, All reports of abuse must be reported to the Administrator immediately and to the resident's representative. The Immediate Jeopardy that began on 12/18/15 was removed on 1/8/16 when Resident #143 received 1:1 staff to resident supervision and the facility educated residents and responsible parties and in-serviced all staff regarding abuse and abuse reporting requirements. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of need for continued monitoring for abuse prevention and reporting. 4. During an interview on 1/5/16 at 2:21 p.m., Resident #134 indicated Resident #55 threatened to whip his white m----r f-----g a-s if he didn't get up from a chair in the designated smoking area and threatened to have her son come and whoop him. He further indicated he didn't enjoy going outside anymore because of her. He indicated he informed the Activity Director. During an interview on 1/5/16 at 3:40 p.m., the Administrator indicated he was aware of the incident and it was reported and investigated. During an interview on 1/6/16 at 12:54 p.m., the Director of Nursing (DON) indicated the facility's system in determining whom to interview regarding abuse allegations was to interview residents with a BIMS score over 9 out of 15 and located in the area where the alleged abuse occurred. During an interview on 1/06/2016 at 1:56 p.m., with Activity Staff (AS) #2 and Activity Director (AD) #1, AD #1 indicated Resident #134 came to her after the 4:00 p.m. smoke break and informed her Resident #55 cursed at him and threatened him over a chair. She indicated she informed the Administrator immediately. AS #2 indicated Resident #55 was kind of a bully. She indicated she was present at the 4:00 smoke break but was not aware of the incident. She indicated she had heard Resident #55 say smart aleck comments to other residents during activities. She indicated Resident #55 always followed up the smart aleck remarks by saying she was joking and if staff told her she wasn't joking she would rise to another level. She indicated residents were scared to respond or talk back or scared to stand up to her. AS #2 indicated Resident #55 was loud and boisterous and looked at residents in a manner that was intimidating. She indicated staff attempted to appease Resident #55 to keep her calm as much as possible in activities. AD #1 indicated after the incident where Resident #55 cursed at Resident #134, she witnessed Resident #55 stare down Resident #134 and indicated she immediately got another chair for Resident #55. AD #1 indicated she believed Resident #55 was trying to intimidate Resident #134 by starring him down. AD #1 indicated she did not report the starring down incident to the Administrator and indicated staff attempted to deal with her themselves. AD #1 and AS #2 both indicated intimidation was a form of abuse and should have been reported. AD #1 indicated she believed administrative staff was aware of Resident #55's behavior because she did it enough. During an interview on 1/6/16 at 2:30 p.m., the Administrator additional chairs were added to the smoking area and indicated he was not aware of Resident #55 intimidating or bullying other residents He further indicated staff should have reported Resident #55 bullying and/or intimidating other residents per their abuse protocol. During an interview on 1/07/2016 at 1:20 p.m., Resident #134 indicated Resident #55 stares me down every time she sees me. He indicated Resident #55 was a bullyand people were afraid of her and indicated she always makes mean comments. Resident #134's record was reviewed on 1/5/16 at 3:00 p.m. A Minimum Data Set (MDS) assessment, dated 9/22/15, indicated Resident #134 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and did not exhibit behaviors. Resident #55's record was reviewed on 1/5/16 at 2:30 p.m. A MDS, dated [DATE], indicated Resident #55 was cognitively intact with a BIMS score of 15 out of 15, independently ambulated, and exhibited verbal behavioral symptoms towards others, such as threats and cursing. A document titled, Mood and Behavior Communication Memo, dated 12/3/15 at 4:00 p.m., indicated Resident #134 informed Activity Director (AD) #1 on 12/3/15 that Resident #55 threatened to kick his a-s if he didn't get up from a chair in the smoking area. The document indicated Resident #55 cursed at Resident #134. An incident report, dated 12/4/15, indicated the Administrator was informed of the allegation of abuse by Resident #55 to Resident #134 and indicated five residents where interviewed regarding abuse in relation to this incident. The investigation did not indicate all residents who attended activities or utilized the smoking area were interviewed to determine if there were additional residents who alleged or witnessed abuse by Resident #55. The investigation did not indicate staff were interviewed and did not indicate an intervention to prevent further verbal abuse by Resident #55. A facility policy, received from the Administrator on 01/05/16 at 3:41 p.m., dated 10/2014 and deemed current, titled Abuse Prohibition Reporting and Investigation, stated, This facility will not permit residents to be subjected to abuse by anyone, including employees, other residents, consultants, volunteers, staff or personnel of other agencies .Any resident implicated in the alleged abuse will be placed under appropriate monitoring/supervisions to prevent recurrence . The policy also stated, This facility will ensure that all alleged violations, including mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility. The policy also stated, All reports of abuse must be reported to the Administrator immediately and to the resident's representative. 3.1-28(a)

Based on record review and interview, the facility failed to ensure allegations of non-consensual sexual interactions were immediately reported and investigated for 2 of 2 allegations of sexual misconduct in a sample of 7 residents reviewed for allegations of abuse (Resident #83 and Resident #126). In addition to the residents in Immediate Jeopardy, the facility failed to ensure an allegation of resident to resident verbal abuse resulting in harm or potential harm that is not Immediate Jeopardy was immediately reported and thoroughly investigated for 1 of 1 resident reviewed for an allegation of verbal abuse (Resident #134). The Immediate Jeopardy was identified on 1/07/2016. The date the Immediate Jeopardy began was not clearly identified due to residents not providing specific dates for allegations of abuse, therefore the Immediate Jeopardy began on 1/7/16 when the facility did not have a system in place to ensure staff immediately reported and thoroughly investigated allegations of abuse. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/07/16 at 1:21 p.m. The Immediate Jeopardy was removed on 1/8/16, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy Findings include: 1. During an interview on 01/06/16 at 9:56 a.m., Resident #83 indicated on five or six different occasions Resident #143 had been in his room at 2:00 a.m. touching himself and attempted to grope Resident #83. Resident #83 indicated Resident #143 had never touched him because he swung at Resident #143 to keep him away. Resident #83 was unable to provide specific dates for these incidents. During a follow up interview on 1/06/16 at 3:22 p.m., Resident #83 indicated he reported the incidents where Resident #143 entered his room to third shift nurses five times. Resident #83 was unable to recall the names of the nurses he reported the incident to. Resident #83's record was reviewed on 1/07/16 at 11:25 a.m. Resident #83's Resident Admission Record, dated 5/30/15, indicated [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/08/15, indicated Resident #83's cognitive status score was 15 indicating he was cognitively intact. Resident #83's nurse's notes, dated 7/02/15 through 1/06/16, were reviewed and lacked documentation of Resident #83 reporting any residents wandering into his room or observations of Resident #143 wandering into his room. 2. During an interview on 1/7/16 at 9:31 a.m , Resident #2 indicated about three to four weeks ago, during the day, Resident #143 wandered into his room and touched his roommate, Resident #126, in the private area. He stated he and Resident #126 reported the incident to Licensed Practical Nurse (LPN) #2 and that she did not report the incident to the social worker. Resident #2 indicated Resident #143 had not attempted or ever touched him. Resident #2 indicated during the weeks Resident #126 was in the hospital (after he witnessed Resident touch his roommate's private area) Resident #143 frequently asked where his roommate (Resident #126) was and sat in his wheelchair outside the door to his room and peeked into the room. Resident #2's record was reviewed on 1/07/16 at 9:10 a.m. Resident #2's Resident Admission Record dated 5/15/2015 indicated he had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 8/12/15, indicated Resident #2's cognitive status score was 14, indicating he was cognitively intact. During an interview on 1/7/16 at 9:35 a.m., Resident #126 indicated Resident #143 came into his room and touched his private area. Resident #126 indicated he told Resident #143 to leave and he did. Resident #126 stated he reported the incident to Licensed Practical Nurse (LPN) #2. Resident #126 indicated the incident happened prior to him going to the hospital approximately four weeks ago. Resident #126's record was reviewed on 1/07/16 at 9:25 a.m. Resident #126's Resident Admission Record, dated 11/04/15, indicated [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/19/15, indicated Resident #126's cognitive status score was 15, indicating he was cognitively intact. 3. Resident #143's record was reviewed on 1/06/16 at 2:25 p.m. Resident #143's Resident Admission Record dated 7/31/2015 indicated [DIAGNOSES REDACTED]. Significant change Minimum Data Set (MDS) assessment, dated 10/28/15, indicated Resident #143's cognitive status score was 14, indicating Resident #143 was cognitively intact. A form titled, Mood and Behavior Communication Memo, dated 12/17/15, indicated Resident #126 and Resident #2 reported that Resident #143 came into their room and they asked the nurse to redirect Resident #143. The memo indicated the nurse redirected Resident #143 to his room. A care plan for Resident #143, dated 12/18/15, indicated he was care planned for wandering and had interventions including the following: redirect resident to his room and obtain a urinalysis and urine culture. A care plan, dated 12/28/15, indicated Resident #143 and his roommate, Resident #36 had a need for privacy and included the following interventions: establish a system to ensure privacy as evidenced by door sign, and staff not entering room when door is shut. On 1/06/15 at 1:55 p.m., the DON provided a document titled, Mood and Behavior Communication Memo, dated 12/26/15. The memo stated, The husband of a visitor for Resident #96 said he was in the hallway and Resident #143 came to the doorway and asked him to come here so he said (sic) ask a question when the visitor went over to see what he needed Resident #143 went to grab his private area. The visitor said he grabbed his (Resident #143) hand and told him not to do that and he should be ashamed of himself. A care plan, dated 12/28/15, stated Resident #143 had been, sexually inappropriate to visitor .attempted to grope visitor. The care plan interventions included, but was not limited to, Placed on 15 min. checks. A document titled, Fifteen Minute Observation, indicated Resident #143 was placed on bed checks every fifteen minutes beginning 12/28/15. A psychological Evaluations dated 1/04/16 indicated Patient is a (age specified) year old .mild cognitive impairment is observed .however patient appears alert, oriented, and able to make decisions for himself .Patient adamantly expressed that he is willingly participating in relationship with his roommate. He appears to understand the risks associated with sexual activity . During an interview on 1/06/16 at 3:56 p.m., Resident #143 indicated he accidentally wandered into another room once and was not sure when that was. He denied getting up in the middle of the night and wandering into rooms. He also denied an encounter with a visitor or attempting to touch the visitor inappropriately. During an interview on 1/6/15 at 4:03 p.m., Certified Nursing Assistant (CNA) #1 indicated she had never seen Resident #143 wandering at night. She indicated she had witnessed Resident #143 wander into Resident #83's room on two occasions. The first time she witnessed Resident #143 with his hand under #83's sheet. CNA #1 indicated Resident #83 was awake and did not say anything. She did not report it because Resident #83 would have told her if something inappropriate was happening. The second time the CNA #1 saw Resident #143 enter Resident #83's room she immediately had Resident #143 leave room his room. CNA #1 stated that both incidents occurred about three weeks ago in the evening after dinner. During an interview on 1/6/16 at 11:50 p.m., LPN #3, CNA #4, and Qualified Medication Aide (QMA) #5 all indicated they heard rumors of Resident #143 touching his roommate and indicated they did not report the rumors because they believed the managers and the Assistant Director of Nursing (ADON) already knew of the situation. During an interview on 1/7/16 at 12:37 a.m., LPN #6 indicated she heard rumors last week or two weeks ago about a resident on the D wing entering another resident's room and touching another resident sexually. The LPN indicated the resident was confused and she didn't report the allegation to anyone because she believed it had already been discussed with the Unit Manager and Assistant Director of Nursing (ADON). A typed interview statement received from the Director of Nursing (DON) on 1/7/15 at 9:05 a.m., indicated Resident #83 was interviewed on 1/06/16. He indicated Resident #143 never touched him, but made him very uncomfortable. During an interview on 1/07/16 at 9:05 a.m., the DON indicated Resident #143's 15 minute checks were not immediately put into place after the incident on 12/26/15 when Resident #143 attempted to touch a visitor, but initiated on 12/28/15. The DON indicated she was unaware of the incident until 12/28/15 due to the incident happening on the weekend, and staff not reporting the incident immediately. During an interview on 1/07/16 at 9:06 a.m., the DON indicated during the investigation of recent abuse allegations, Resident #126 reported being touched inappropriately by Resident #143. The DON also indicated that Resident #126's roommate Resident #2 indicated he witnessed the incident. An interview was conducted on 1/07/2016 at 10:01 a.m. with the Social Service Director (SS), Director of Nursing (DON), and Administrator. The DON indicated one behavior sheet from 12/17/15 resulted in development of a care plan to address Resident #143's wandering. The DON indicated staff should have known where care plans were located and the facility tried to include some care plan interventions or behaviors on CNA assignment sheets. The DON indicated the CNA assignment sheets were updated by the unit manager every couple of days after new care plans were put in place. The DON indicated no resident interviews were conducted after the 12/17/15 incident to determine if Resident #143 wandered in their rooms or abused them because she thought it was an isolated incident. The DON indicated a written report was received on 12/28/15 regarding Resident #143 grabbing a male visitor's genital area on 12/26/15. The DON and SSD indicated they did not receive the report until 12/28/15 due to holidays and weekend and indicated staff should have immediately reported the incident. The Social Service Director (SSD) indicated Resident #143 was placed on 15 minute checks due to his tendency towards touching males' genitals and his ability to move around the unit. The DON indicated the 15 min checks continued until 1/06/16 when the resident was placed on 1:1 supervision after receiving an allegation from Resident #83 of abuse by Resident #143. The DON indicated she wished she would have interviewed other residents when she learned of the allegation of Resident #143 grabbing a visitor. During an interview on 01/07/2016 at 10:33 a.m., CNA #7 indicated she completed the behavior form for Resident #143 on 12/26/15. She indicated she was at the at nurses station and Resident #96's granddaughter's husband came up to the desk and informed her that Resident #143 had stopped him in the hall and asked him to come to his room's door and then grabbed the visitor's privates. She indicated the visitor told her he grabbed Resident #143's hands away and told him no. She indicated the visitor was concerned that he would touch someone else and told her to have them keep children away from the resident. She indicated she called Qualified Medication Aide (QMA) #8 and informed her and QMA #8 called LPN #2. CNA #7 indicated QMA #8 told her to complete the behavior form and went to check on Resident #143. She indicated she believed QMA #8 informed the nurse manager on call of the visitor incident. CNA #7 indicated her assignment sheet did not say anything about Resident #143 wandering as of 12/26/15. She indicated she saw Resident #143 attempt to wander into the following residents' rooms: Resident #2, Resident #126, Resident #4, Resident #96, and Resident #83. She indicated she stopped Resident #143, redirected him, and informed the nurse. CNA #7 indicated the nurses always told her to continue watching him only. She indicated she never saw Resident #143 in another resident's room, only attempting to enter. During an interview on 1/07/16 at 3:45 p.m., Licensed Practical Nurse (LPN) #2 indicated Resident #2 and Resident #126 informed her Resident #143 had wandered into their room, but she did not report it because Resident #2 and Resident #126 asked her to redirect Resident #143. LPN #2 indicated Resident #2 told her Resident #143 had been in his room, he did not like Resident #143, he was weird, and he did not want him in his room. LPN #2 indicated she did not report the incident because it had not happened before. LPN #2 indicated Resident #83 said Resident #143 was in his room and asked her to keep him out. LPN #2 indicated she did not report the incident, but she should have. LPN #2 indicated Resident #83 had informed her he did not want Resident #143 in his room because he wasn't like that. LPN #2 indicated there was time between the two complaints about Resident #143, so she had not noticed a behavior pattern. She indicated she had been unaware of Resident #143's care plan for wandering. She indicated she should have reported his wandering. The Immediate Jeopardy that began on 1/7/16 was removed on 1/8/16 when the facility educated residents and responsible parties and in-serviced all staff regarding abuse and abuse reporting requirements. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of need for continued monitoring for abuse prevention and reporting. 4. During an interview on 1/5/16 at 2:21 p.m., Resident #134 indicated Resident #55 threatened to whip his white m----r f-----g a-s if he didn't get up from a chair in the designated smoking area and threatened to have her son come and whoop him. He further indicated he didn't enjoy going outside anymore because of her. He indicated he informed the Activity Director. During an interview on 1/5/16 at 3:40 p.m., the Administrator indicated he was aware of the incident and it was reported and investigated. During an interview on 1/6/16 at 12:54 p.m., the Director of Nursing (DON) indicated the facility's system in determining whom to interview regarding abuse allegations was to interview residents with a BIMS score over 9 out of 15 and located in the area where the alleged abuse occurred. During an interview on 1/06/2016 at 1:56 p.m., with Activity Staff (AS) #2 and Activity Director (AD) #1, AD #1 indicated Resident #134 came to her after the 4:00 p.m. smoke break and informed her Resident #55 cursed at him and threatened him over a chair. She indicated she informed the Administrator immediately. AS #2 indicated Resident #55 was kind of a bully. She indicated she was present at the 4:00 smoke break but was not aware of the incident. She indicated she had heard Resident #55 say smart aleck comments to other residents during activities. She indicated Resident #55 always followed up the smart aleck remarks by saying she was joking and if staff told her she wasn't joking she would rise to another level. She indicated residents were scared to respond or talk back or scared to stand up to her. AS #2 indicated Resident #55 was loud and boisterous and looked at residents in a manner that was intimidating. She indicated staff attempted to appease Resident #55 to keep her calm as much as possible in activities. AD #1 indicated after the incident where Resident #55 cursed at Resident #134, she witnessed Resident #55 stare down Resident #134 and indicated she immediately got another chair for Resident #55. AD #1 indicated she believed Resident #55 was trying to intimidate Resident #134 by starring him down. AD #1 indicated she did not report the starring down incident to the Administrator and indicated staff attempted to deal with her themselves. AD #1 and AS #2 both indicated intimidation was a form of abuse and should have been reported. AD #1 indicated she believed administrative staff was aware of Resident #55's behavior because she did it enough. During an interview on 1/6/16 at 2:30 p.m., the Administrator additional chairs were added to the smoking area and indicated he was not aware of Resident #55 intimidating or bullying other residents He further indicated staff should have reported Resident #55 bullying and/or intimidating other residents per their abuse protocol. During an interview on 1/07/2016 at 1:20 p.m., Resident #134 indicated Resident #55 stares me down every time she sees me. He indicated Resident #55 was a bullyand people were afraid of her and indicated she always makes mean comments. Resident #134's record was reviewed on 1/5/16 at 3:00 p.m. A Minimum Data Set (MDS) assessment, dated 9/22/15, indicated Resident #134 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and did not exhibit behaviors. Resident #55's record was reviewed on 1/5/16 at 2:30 p.m. A MDS, dated [DATE], indicated Resident #55 was cognitively intact with a BIMS score of 15 out of 15, independently ambulated, and exhibited verbal behavioral symptoms towards others, such as threats and cursing. A document titled, Mood and Behavior Communication Memo, dated 12/3/15 at 4:00 p.m., indicated Resident #134 informed Activity Director (AD) #1 on 12/3/15 that Resident #55 threatened to kick his a-s if he didn't get up from a chair in the smoking area. The document indicated Resident #55 cursed at Resident #134. An incident report, dated 12/4/15, indicated the Administrator was informed of the allegation of abuse by Resident #55 to Resident #134 and indicated five residents where interviewed regarding abuse in relation to this incident. The investigation did not indicate all residents who attended activities or utilized the smoking area were interviewed to determine if there were additional residents who alleged or witnessed abuse by Resident #55. The investigation did not indicate staff were interviewed and did not indicate an intervention to prevent further verbal abuse by Resident #55. A facility policy, received from the Administrator on 01/05/16 at 3:41 p.m., dated 10/2014 and deemed current, titled Abuse Prohibition Reporting and Investigation, stated, This facility will not permit residents to be subjected to abuse by anyone, including employees, other residents, consultants, volunteers, staff or personnel of other agencies .Any resident implicated in the alleged abuse will be placed under appropriate monitoring/supervisions to prevent recurrence . The policy also stated, This facility will ensure that all alleged violations, including mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility. The policy also stated, All reports of abuse must be reported to the Administrator immediately and to the resident's representative. 3.1-28(c) 3.1-28(d)

Based on record review and interview, the facility failed to ensure a resident (Resident #143) with wandering and inappropriate sexual behaviors was adequately supervised to prevent the resident from attempting or engaging in non-consensual sexual interactions with 2 of 7 residents reviewed for allegations of abuse (Resident #83 and Resident #126). In addition to the residents in Immediate Jeopardy, the facility failed to ensure a resident was not threatened with harm and cursed at by another resident (Resident #55) resulting in harm or potential harm that is not Immediate Jeopardy to 1 of 1 resident reviewed for an allegation of verbal abuse (Resident #134). The Immediate Jeopardy was identified on 1/07/2016 and began on 12/18/2015 when the facility identified Resident #143's wandering behaviors and failed to implement interventions to prevent the resident from wandering into other residents' rooms. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 1/07/16 at 1:21 p.m. The Immediate Jeopardy was removed on 1/8/16, but noncompliance remained at the lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy Findings include: 1. During an interview on 01/06/16 at 9:56 a.m., Resident #83 indicated on five or six different occasions Resident #143 had been in his room at 2:00 a.m. touching himself and attempted to grope Resident #83. Resident #83 indicated Resident #143 had never touched him because he swung at Resident #143 to keep him away. Resident #83 was unable to provide specific dates for these incidents. During a follow up interview on 1/06/16 at 3:22 p.m., Resident #83 indicated he reported the incidents where Resident #143 entered his room to third shift nurses five times. Resident #83 was unable to recall the names of the nurses he reported the incident to. Resident #83's record was reviewed on 1/07/16 at 11:25 a.m. Resident #83's Resident Admission Record, dated 5/30/15, indicated [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/08/15, indicated Resident #83's cognitive status score was 15 indicating he was cognitively intact. Resident #83's nurse's notes, dated 7/02/15 through 1/06/16, were reviewed and lacked documentation of Resident #83 reporting any residents wandering into his room or observations of Resident #143 wandering into his room. 2. During an interview on 1/7/16 at 9:31 a.m , Resident #2 indicated about three to four weeks ago, during the day, Resident #143 wandered into his room and touched his roommate, Resident #126, in the private area. He stated he and Resident #126 reported the incident to Licensed Practical Nurse (LPN) #2 and that she did not report the incident to the social worker. Resident #2 indicated Resident #143 had not attempted or ever touched him. Resident #2 indicated during the weeks Resident #126 was in the hospital (after he witnessed Resident touch his roommate's private area) Resident #143 frequently asked where his roommate (Resident #126) was and sat in his wheelchair outside the door to his room and peeked into the room. Resident #2's record was reviewed on 1/07/16 at 9:10 a.m. Resident #2's Resident Admission Record dated 5/15/2015 indicated he had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 8/12/15, indicated Resident #2's cognitive status score was 14, indicating he was cognitively intact. During an interview on 1/7/16 at 9:35 a.m., Resident #126 indicated Resident #143 came into his room and touched his private area. Resident #126 indicated he told Resident #143 to leave and he did. Resident #126 stated he reported the incident to Licensed Practical Nurse (LPN) #2. Resident #126 indicated the incident happened prior to him going to the hospital approximately four weeks ago. Resident #126's record was reviewed on 1/07/16 at 9:25 a.m. Resident #126's Resident Admission Record, dated 11/04/15, indicated [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/19/15, indicated Resident #126's cognitive status score was 15, indicating he was cognitively intact. 3. Resident #143's record was reviewed on 1/06/16 at 2:25 p.m. Resident #143's Resident Admission Record dated 7/31/2015 indicated [DIAGNOSES REDACTED]. Significant change Minimum Data Set (MDS) assessment, dated 10/28/15, indicated Resident #143's cognitive status score was 14, indicating Resident #143 was cognitively intact. A form titled, Mood and Behavior Communication Memo, dated 12/17/15, indicated Resident #126 and Resident #2 reported that Resident #143 came into their room and they asked the nurse to redirect Resident #143. The memo indicated the nurse redirected Resident #143 to his room. A care plan for Resident #143, dated 12/18/15, indicated he was care planned for wandering and had interventions including the following: redirect resident to his room and obtain a urinalysis and urine culture. A care plan, dated 12/28/15, indicated Resident #143 and his roommate, Resident #36 had a need for privacy and included the following interventions: establish a system to ensure privacy as evidenced by door sign, and staff not entering room when door is shut. On 1/06/15 at 1:55 p.m., the DON provided a document titled, Mood and Behavior Communication Memo, dated 12/26/15. The memo stated, The husband of a visitor for Resident #96 said he was in the hallway and Resident #143 came to the doorway and asked him to come here so he said (sic) ask a question when the visitor went over to see what he needed Resident #143 went to grab his private area. The visitor said he grabbed his (Resident #143) hand and told him not to do that and he should be ashamed of himself. A care plan, dated 12/28/15, stated Resident #143 had been, sexually inappropriate to visitor .attempted to grope visitor. The care plan interventions included, but was not limited to, Placed on 15 min. checks. A document titled, Fifteen Minute Observation, indicated Resident #143 was placed on bed checks every fifteen minutes beginning 12/28/15. A psychological Evaluations dated 1/04/16 indicated Patient is a (age specified) year old .mild cognitive impairment is observed .however patient appears alert, oriented, and able to make decisions for himself .Patient adamantly expressed that he is willingly participating in relationship with his roommate. He appears to understand the risks associated with sexual activity . During an interview on 1/06/16 at 3:56 p.m., Resident #143 indicated he accidentally wandered into another room once and was not sure when that was. He denied getting up in the middle of the night and wandering into rooms. He also denied an encounter with a visitor or attempting to touch the visitor inappropriately. During an interview on 1/6/15 at 4:03 p.m., Certified Nursing Assistant (CNA) #1 indicated she had never seen Resident #143 wandering at night. She indicated she had witnessed Resident #143 wander into Resident #83's room on two occasions. The first time she witnessed Resident #143 with his hand under #83's sheet. CNA #1 indicated Resident #83 was awake and did not say anything. She did not report it because Resident #83 would have told her if something inappropriate was happening. The second time the CNA #1 saw Resident #143 enter Resident #83's room she immediately had Resident #143 leave room his room. CNA #1 stated that both incidents occurred about three weeks ago in the evening after dinner. During an interview on 1/6/16 at 11:50 p.m., LPN #3, CNA #4, and Qualified Medication Aide (QMA) #5 all indicated they heard rumors of Resident #143 touching his roommate and indicated they did not report the rumors because they believed the managers and the Assistant Director of Nursing (ADON) already knew of the situation. During an interview on 1/7/16 at 12:37 a.m., LPN #6 indicated she heard rumors last week or two weeks ago about a resident on the D wing entering another resident's room and touching another resident sexually. The LPN indicated the resident was confused and she didn't report the allegation to anyone because she believed it had already been discussed with the Unit Manager and Assistant Director of Nursing (ADON). A typed interview statement received from the Director of Nursing (DON) on 1/7/15 at 9:05 a.m., indicated Resident #83 was interviewed on 1/06/16. He indicated Resident #143 never touched him, but made him very uncomfortable. During an interview on 1/07/16 at 9:05 a.m., the DON indicated Resident #143's 15 minute checks were not immediately put into place after the incident on 12/26/15 when Resident #143 attempted to touch a visitor, but initiated on 12/28/15. The DON indicated she was unaware of the incident until 12/28/15 due to the incident happening on the weekend, and staff not reporting the incident immediately. During an interview on 1/07/16 at 9:06 a.m., the DON indicated during the investigation of recent abuse allegations, Resident #126 reported being touched inappropriately by Resident #143. The DON also indicated that Resident #126's roommate Resident #2 indicated he witnessed the incident. An interview was conducted on 1/07/2016 at 10:01 a.m. with the Social Service Director (SS), Director of Nursing (DON), and Administrator. The DON indicated one behavior sheet from 12/17/15 resulted in development of a care plan to address Resident #143's wandering. The DON indicated staff should have known where care plans were located and the facility tried to include some care plan interventions or behaviors on CNA assignment sheets. The DON indicated the CNA assignment sheets were updated by the unit manager every couple of days after new care plans were put in place. The DON indicated no resident interviews were conducted after the 12/17/15 incident to determine if Resident #143 wandered in their rooms or abused them because she thought it was an isolated incident. The DON indicated a written report was received on 12/28/15 regarding Resident #143 grabbing a male visitor's genital area on 12/26/15. The DON and SSD indicated they did not receive the report until 12/28/15 due to holidays and weekend and indicated staff should have immediately reported the incident. The Social Service Director (SSD) indicated Resident #143 was placed on 15 minute checks due to his tendency towards touching males' genitals and his ability to move around the unit. The DON indicated the 15 min checks continued until 1/06/16 when the resident was placed on 1:1 supervision after receiving an allegation from Resident #83 of abuse by Resident #143. The DON indicated she wished she would have interviewed other residents when she learned of the allegation of Resident #143 grabbing a visitor. During an interview on 01/07/2016 at 10:33 a.m., CNA #7 indicated she completed the behavior form for Resident #143 on 12/26/15. She indicated she was at the at nurses station and Resident #96's granddaughter's husband came up to the desk and informed her that Resident #143 had stopped him in the hall and asked him to come to his room's door and then grabbed the visitor's privates. She indicated the visitor told her he grabbed Resident #143's hands away and told him no. She indicated the visitor was concerned that he would touch someone else and told her to have them keep children away from the resident. She indicated she called Qualified Medication Aide (QMA) #8 and informed her and QMA #8 called LPN #2. CNA #7 indicated QMA #8 told her to complete the behavior form and went to check on Resident #143. She indicated she believed QMA #8 informed the nurse manager on call of the visitor incident. CNA #7 indicated her assignment sheet did not say anything about Resident #143 wandering as of 12/26/15. She indicated she saw Resident #143 attempt to wander into the following residents' rooms: Resident #2, Resident #126, Resident #4, Resident #96, and Resident #83. She indicated she stopped Resident #143, redirected him, and informed the nurse. CNA #7 indicated the nurses always told her to continue watching him only. She indicated she never saw Resident #143 in another resident's room, only attempting to enter. During an interview on 1/07/16 at 3:45 p.m., Licensed Practical Nurse (LPN) #2 indicated Resident #2 and Resident #126 informed her Resident #143 had wandered into their room, but she did not report it because Resident #2 and Resident #126 asked her to redirect Resident #143. LPN #2 indicated Resident #2 told her Resident #143 had been in his room, he did not like Resident #143, he was weird, and he did not want him in his room. LPN #2 indicated she did not report the incident because it had not happened before. LPN #2 indicated Resident #83 said Resident #143 was in his room and asked her to keep him out. LPN #2 indicated she did not report the incident, but she should have. LPN #2 indicated Resident #83 had informed her he did not want Resident #143 in his room because he wasn't like that. LPN #2 indicated there was time between the two complaints about Resident #143, so she had not noticed a behavior pattern. She indicated she had been unaware of Resident #143's care plan for wandering. She indicated she should have reported his wandering. The Immediate Jeopardy that began on 12/18/15 was removed on 1/8/16 when Resident #143 received 1:1 staff to resident supervision and the facility educated residents and responsible parties and in-serviced all staff regarding abuse and abuse reporting requirements. The noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because of need for continued monitoring for abuse prevention and reporting. 4. During an interview on 1/5/16 at 2:21 p.m., Resident #134 indicated Resident #55 threatened to whip his white m----r f-----g a-s if he didn't get up from a chair in the designated smoking area and threatened to have her son come and whoop him. He further indicated he didn't enjoy going outside anymore because of her. He indicated he informed the Activity Director. During an interview on 1/5/16 at 3:40 p.m., the Administrator indicated he was aware of the incident and it was reported and investigated. During an interview on 1/6/16 at 12:54 p.m., the Director of Nursing (DON) indicated the facility's system in determining whom to interview regarding abuse allegations was to interview residents with a BIMS score over 9 out of 15 and located in the area where the alleged abuse occurred. During an interview on 1/06/2016 at 1:56 p.m., with Activity Staff (AS) #2 and Activity Director (AD) #1, AD #1 indicated Resident #134 came to her after the 4:00 p.m. smoke break and informed her Resident #55 cursed at him and threatened him over a chair. She indicated she informed the Administrator immediately. AS #2 indicated Resident #55 was kind of a bully. She indicated she was present at the 4:00 smoke break but was not aware of the incident. She indicated she had heard Resident #55 say smart aleck comments to other residents during activities. She indicated Resident #55 always followed up the smart aleck remarks by saying she was joking and if staff told her she wasn't joking she would rise to another level. She indicated residents were scared to respond or talk back or scared to stand up to her. AS #2 indicated Resident #55 was loud and boisterous and looked at residents in a manner that was intimidating. She indicated staff attempted to appease Resident #55 to keep her calm as much as possible in activities. AD #1 indicated after the incident where Resident #55 cursed at Resident #134, she witnessed Resident #55 stare down Resident #134 and indicated she immediately got another chair for Resident #55. AD #1 indicated she believed Resident #55 was trying to intimidate Resident #134 by starring him down. AD #1 indicated she did not report the starring down incident to the Administrator and indicated staff attempted to deal with her themselves. AD #1 and AS #2 both indicated intimidation was a form of abuse and should have been reported. AD #1 indicated she believed administrative staff was aware of Resident #55's behavior because she did it enough. During an interview on 1/6/16 at 2:30 p.m., the Administrator additional chairs were added to the smoking area and indicated he was not aware of Resident #55 intimidating or bullying other residents He further indicated staff should have reported Resident #55 bullying and/or intimidating other residents per their abuse protocol. During an interview on 1/07/2016 at 1:20 p.m., Resident #134 indicated Resident #55 stares me down every time she sees me. He indicated Resident #55 was a bullyand people were afraid of her and indicated she always makes mean comments. Resident #134's record was reviewed on 1/5/16 at 3:00 p.m. A Minimum Data Set (MDS) assessment, dated 9/22/15, indicated Resident #134 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and did not exhibit behaviors. Resident #55's record was reviewed on 1/5/16 at 2:30 p.m. A MDS, dated [DATE], indicated Resident #55 was cognitively intact with a BIMS score of 15 out of 15, independently ambulated, and exhibited verbal behavioral symptoms towards others, such as threats and cursing. A document titled, Mood and Behavior Communication Memo, dated 12/3/15 at 4:00 p.m., indicated Resident #134 informed Activity Director (AD) #1 on 12/3/15 that Resident #55 threatened to kick his a-s if he didn't get up from a chair in the smoking area. The document indicated Resident #55 cursed at Resident #134. An incident report, dated 12/4/15, indicated the Administrator was informed of the allegation of abuse by Resident #55 to Resident #134 and indicated five residents where interviewed regarding abuse in relation to this incident. The investigation did not indicate all residents who attended activities or utilized the smoking area were interviewed to determine if there were additional residents who alleged or witnessed abuse by Resident #55. The investigation did not indicate staff were interviewed and did not indicate an intervention to prevent further verbal abuse by Resident #55. A facility policy, received from the Administrator on 01/05/16 at 3:41 p.m., dated 10/2014 and deemed current, titled Abuse Prohibition Reporting and Investigation, stated, This facility will not permit residents to be subjected to abuse by anyone, including employees, other residents, consultants, volunteers, staff or personnel of other agencies .Any resident implicated in the alleged abuse will be placed under appropriate monitoring/supervisions to prevent recurrence . The policy also stated, This facility will ensure that all alleged violations, including mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility. The policy also stated, All reports of abuse must be reported to the Administrator immediately and to the resident's representative. 3.1-27(a)(1)

A. Based on observation, record review, and interview the facility failed to ensure medication was administered to manage pain resulting in acute pain and the resident yelling out during wound treatments for 1 of 3 residents reviewed for pain management (Resident B). B. Based on record review and interview, the facility failed to ensure communication between the facility and the [MEDICAL TREATMENT] provider for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #117). Findings include: A. On 1/12/16 at 11:29 a.m., with Qualified Medication Aide (QMA) # 98, Certified Nursing Assistant (CNA) #97, CNA #86, Licensed Practical Nurse (LPN) #96, and LPN #99 present, Resident B's wound care was observed. Resident B was positioned on his right side. During the procedure at:11:46 a.m., Resident B screamed out three times. LPN # 96 indicated the resident was feeling pain. LPN #99 was heard telling Resident B she was trying to get the dressing change completed as fast as she could and indicated she did not know how often Resident B received pain medication. At 11:48 a.m., Resident B screamed out again and LPN #99 was heard telling LPN #96 the resident had PRN (as needed) pain medication and indicated to Resident B pain medication would be given as soon as she finished the big dressing change. LPN #99 continued with the wound care and at 11:50 a.m., stated, This is going to be a bad part, and continued the wound care. At 11:52 a.m., Resident B screamed out I hurt. LPN #99 indicated the resident would probably get some medication after the dressing change was completed. LPN #99 continued with wound care while Resident B yelled out again. At 12:00 p.m., LPN #99 indicated Resident B was administered scheduled pain medication prior to the procedure and indicated she tried to do wound care around his scheduled or PRN medication. Resident B cursed and asked, How would you feel? when asked about his pain level. At 12:03 p.m. LPN #99 asked Resident B if he wanted pain medication and the resident indicated yes. LPN #96 administered sublingual (under the tongue) pain medication 37 minutes after wound care began at 12:06 p.m., and without delays, wound care continued until 12:26 p.m. Resident B was not observed to have verbal or non-verbal signs/symptoms of pain after the pain medication was administered. Resident B's record was reviewed on 1/12/16 at 10:05 a.m. Resident B had [DIAGNOSES REDACTED]. A pain care plan originally dated 5/13/15, and last updated on 1/11/16, indicated Resident B had the potential for pain in the following areas: general discomfort, buttocks, feet, back, and hands due to a [DIAGNOSES REDACTED]. A goal indicated he would have pain rated less than a 7 on a scale from 0-10, Interventions indicated staff would monitor for non-verbal signs of pain, asses his level of pain, and administer pain medication as ordered and monitor for efficacy. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Resident B's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A pressure ulcer assessment record, dated 1/11/16, indicated the wound measured 2.7 x 3.2 x 1.5, had moderate amount of serous drainage, 5.4 cm (centimeters) tunneling at 12:00. Wound associated pain was 8 out of 10 and the wound bed was red with red/dark edges. A pressure ulcer assessment record, dated 1/11/16, inicated the wound measured 4 x 3.3 x 1.5, had a moderate amount of serous exudates, with 2 cm tunneling/undermining at 11:00-12:00 locations of a clock face. The wound associated pain was rated a 5 out of 10, with a red wound bed and red wound edges. A pressure ulcer assessment record, dated 1/11/16, indicated the wound measured 5.7 x 3.7 x 3, had a moderate amount of serous exudates, 4 cm of tunneling/undermining located at 3:00-4:00 on a clock face, wound associated pain was rated 5 out of 10, with a red wound bed with red wound edges. During an interview on 1/12/16 at 12:30 p.m., LPN #95 indicated she administered Resident B's routine [MEDICATION NAME] pain medication at 10:00 a.m. and had not administered additional as needed pain medication. During an interview on 1/12/15 at 12:40 p.m., with the Director of Nursing, Administrator, and corporate nurse consultant present, the corporate nurse consultant indicated, if ordered, pain medication should have been administered prior to wound care. During an interview on 1/13/16 at 11:08, Physician #90 indicated he recently observed staff reposition Resident B and indicated he experienced pain and could not tolerate the repositioning. He went on to indicate he believed the most important thing was to keep him comfortable. A policy titled, Pain Assessment, dated 10/2014, was provided by the DON on 1/12/2016 at 3:05 p.m., and indicated the following, .Purpose: To identify those residents who utilize routine medications for pain or who utilize frequent PRN (as needed) pain medications in an effort to ensure adequate pain control is achieved .1. Upon admission, each resident shall be assessed for the presence of acute or chronic pain per the admission assessment. 2. If resident verbalizes pain, unaffected by the currently ordered pain medication, and/or exhibits non-verbal communication that pain is present, resident shall be identified through completion of regularly scheduled MDS' to ensure pain symptoms are evaluated and communicated to the physician .6. The care plan for the individual resident shall be reviewed to ensure pain management is addressed B. Resident #117's record was reviewed on 1/7/2016 at 12:17 p.m. The resident's [DIAGNOSES REDACTED]. A [MEDICAL TREATMENT] Center Communication Record Form indicated Resident #117 received [MEDICAL TREATMENT] on 12/2/2015 and did not indicate the [MEDICAL TREATMENT] center provided complete pre-vital and post-vital signs. A [MEDICAL TREATMENT] Center Communication Record Form indicated Resident #117 received [MEDICAL TREATMENT] on 12/7/2015 and did not indicate the [MEDICAL TREATMENT] center provided complete pre-vital and post-vital signs. A [MEDICAL TREATMENT] Center Communication Record Form indicated Resident #117 received [MEDICAL TREATMENT] on 12/11/2015 and did not indicate the [MEDICAL TREATMENT] center provided complete pre-vital and post-vital signs. A Transfer to Appointments Form indicated Resident #117 received [MEDICAL TREATMENT] on 1/4/2016. The record lacked documentation the [MEDICAL TREATMENT] center provided a returned [MEDICAL TREATMENT] Communication Record Form upon Resident #117's return to the facility. The record lacked documentation a Transfer to Appointments Form had been completed by the facility for his other [MEDICAL TREATMENT] appointments attended in January 2016. During an interview on 1/7/2016 at 9:41 a.m., Unit Manager #60 indicated Resident #117 received [MEDICAL TREATMENT] three times a week. A [MEDICAL TREATMENT] communication binder contained a [MEDICAL TREATMENT] Communication Record Form for the [MEDICAL TREATMENT] center to complete and return to the facility with Resident #117. The binder also contained a Transfer to Appointments Form completed by the facility and sent with the resident to [MEDICAL TREATMENT]. The Unit Manager indicated the binder was not always returned to the facility with completed information and she could not provide communication documentation for all of Resident #117's [MEDICAL TREATMENT] appointments. During an interview on 1/11/2016 at 3:54 p.m., the Director of Nursing (DON) indicated the facility was responsible for sending the completed Transfer to Appointments Form to the [MEDICAL TREATMENT] center and ensuring the retrieval of the completed [MEDICAL TREATMENT] Communication Record Form information from the [MEDICAL TREATMENT] center upon Resident #117's return to the facility. She indicated Resident #117 had attended all of his scheduled [MEDICAL TREATMENT] appointments for the month of January 2016. A policy titled, [MEDICAL TREATMENT] Coordination/Facility Services, dated 10/2014, was provided by the DON on 1/11/2016 at 9:00 a.m., and indicated the following, .Purpose: to ensure effective communication between the facility and [MEDICAL TREATMENT] center providing service to the facility .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 .2. Facility personnel shall ensure that all appropriate medical and administrative information accompanies resident at the time of transfer or referral to the [MEDICAL TREATMENT] center .4. Unit manager/licensed nurse shall monitor the needs of the [MEDICAL TREATMENT] resident and review any notes/orders accompanying resident from the [MEDICAL TREATMENT] center upon arrival to the facility This Federal tag relates to complaint IN 839. 3.1-37(a)

A. Based on observation, record review, and interview the facility failed to ensure medication was administered to manage pain resulting in acute pain and the resident yelling out during wound treatments for 1 of 3 residents reviewed for pain management (Resident B). B. Based on record review and interview, the facility failed to ensure communication between the facility and the [MEDICAL TREATMENT] provider for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #117). Findings include: A. On 1/12/16 at 11:29 a.m., with Qualified Medication Aide (QMA) # 98, Certified Nursing Assistant (CNA) #97, CNA #86, Licensed Practical Nurse (LPN) #96, and LPN #99 present, Resident B's wound care was observed. Resident B was positioned on his right side. During the procedure at:11:46 a.m., Resident B screamed out three times. LPN # 96 indicated the resident was feeling pain. LPN #99 was heard telling Resident B she was trying to get the dressing change completed as fast as she could and indicated she did not know how often Resident B received pain medication. At 11:48 a.m., Resident B screamed out again and LPN #99 was heard telling LPN #96 the resident had PRN (as needed) pain medication and indicated to Resident B pain medication would be given as soon as she finished the big dressing change. LPN #99 continued with the wound care and at 11:50 a.m., stated, This is going to be a bad part, and continued the wound care. At 11:52 a.m., Resident B screamed out I hurt. LPN #99 indicated the resident would probably get some medication after the dressing change was completed. LPN #99 continued with wound care while Resident B yelled out again. At 12:00 p.m., LPN #99 indicated Resident B was administered scheduled pain medication prior to the procedure and indicated she tried to do wound care around his scheduled or PRN medication. Resident B cursed and asked, How would you feel? when asked about his pain level. At 12:03 p.m. LPN #99 asked Resident B if he wanted pain medication and the resident indicated yes. LPN #96 administered sublingual (under the tongue) pain medication 37 minutes after wound care began at 12:06 p.m., and without delays, wound care continued until 12:26 p.m. Resident B was not observed to have verbal or non-verbal signs/symptoms of pain after the pain medication was administered. Resident B's record was reviewed on 1/12/16 at 10:05 a.m. Resident B had [DIAGNOSES REDACTED]. A pain care plan originally dated 5/13/15, and last updated on 1/11/16, indicated Resident B had the potential for pain in the following areas: general discomfort, buttocks, feet, back, and hands due to a [DIAGNOSES REDACTED]. A goal indicated he would have pain rated less than a 7 on a scale from 0-10, Interventions indicated staff would monitor for non-verbal signs of pain, asses his level of pain, and administer pain medication as ordered and monitor for efficacy. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Resident B's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A pressure ulcer assessment record, dated 1/11/16, indicated the wound measured 2.7 x 3.2 x 1.5, had moderate amount of serous drainage, 5.4 cm (centimeters) tunneling at 12:00. Wound associated pain was 8 out of 10 and the wound bed was red with red/dark edges. A pressure ulcer assessment record, dated 1/11/16, inicated the wound measured 4 x 3.3 x 1.5, had a moderate amount of serous exudates, with 2 cm tunneling/undermining at 11:00-12:00 locations of a clock face. The wound associated pain was rated a 5 out of 10, with a red wound bed and red wound edges. A pressure ulcer assessment record, dated 1/11/16, indicated the wound measured 5.7 x 3.7 x 3, had a moderate amount of serous exudates, 4 cm of tunneling/undermining located at 3:00-4:00 on a clock face, wound associated pain was rated 5 out of 10, with a red wound bed with red wound edges. During an interview on 1/12/16 at 12:30 p.m., LPN #95 indicated she administered Resident B's routine [MEDICATION NAME] pain medication at 10:00 a.m. and had not administered additional as needed pain medication. During an interview on 1/12/15 at 12:40 p.m., with the Director of Nursing, Administrator, and corporate nurse consultant present, the corporate nurse consultant indicated, if ordered, pain medication should have been administered prior to wound care. During an interview on 1/13/16 at 11:08, Physician #90 indicated he recently observed staff reposition Resident B and indicated he experienced pain and could not tolerate the repositioning. He went on to indicate he believed the most important thing was to keep him comfortable. A policy titled, Pain Assessment, dated 10/2014, was provided by the DON on 1/12/2016 at 3:05 p.m., and indicated the following, .Purpose: To identify those residents who utilize routine medications for pain or who utilize frequent PRN (as needed) pain medications in an effort to ensure adequate pain control is achieved .1. Upon admission, each resident shall be assessed for the presence of acute or chronic pain per the admission assessment. 2. If resident verbalizes pain, unaffected by the currently ordered pain medication, and/or exhibits non-verbal communication that pain is present, resident shall be identified through completion of regularly scheduled MDS' to ensure pain symptoms are evaluated and communicated to the physician .6. The care plan for the individual resident shall be reviewed to ensure pain management is addressed B. Resident #117's record was reviewed on 1/7/2016 at 12:17 p.m. The resident's [DIAGNOSES REDACTED]. A [MEDICAL TREATMENT] Center Communication Record Form indicated Resident #117 received [MEDICAL TREATMENT] on 12/2/2015 and did not indicate the [MEDICAL TREATMENT] center provided complete pre-vital and post-vital signs. A [MEDICAL TREATMENT] Center Communication Record Form indicated Resident #117 received [MEDICAL TREATMENT] on 12/7/2015 and did not indicate the [MEDICAL TREATMENT] center provided complete pre-vital and post-vital signs. A [MEDICAL TREATMENT] Center Communication Record Form indicated Resident #117 received [MEDICAL TREATMENT] on 12/11/2015 and did not indicate the [MEDICAL TREATMENT] center provided complete pre-vital and post-vital signs. A Transfer to Appointments Form indicated Resident #117 received [MEDICAL TREATMENT] on 1/4/2016. The record lacked documentation the [MEDICAL TREATMENT] center provided a returned [MEDICAL TREATMENT] Communication Record Form upon Resident #117's return to the facility. The record lacked documentation a Transfer to Appointments Form had been completed by the facility for his other [MEDICAL TREATMENT] appointments attended in January 2016. During an interview on 1/7/2016 at 9:41 a.m., Unit Manager #60 indicated Resident #117 received [MEDICAL TREATMENT] three times a week. A [MEDICAL TREATMENT] communication binder contained a [MEDICAL TREATMENT] Communication Record Form for the [MEDICAL TREATMENT] center to complete and return to the facility with Resident #117. The binder also contained a Transfer to Appointments Form completed by the facility and sent with the resident to [MEDICAL TREATMENT]. The Unit Manager indicated the binder was not always returned to the facility with completed information and she could not provide communication documentation for all of Resident #117's [MEDICAL TREATMENT] appointments. During an interview on 1/11/2016 at 3:54 p.m., the Director of Nursing (DON) indicated the facility was responsible for sending the completed Transfer to Appointments Form to the [MEDICAL TREATMENT] center and ensuring the retrieval of the completed [MEDICAL TREATMENT] Communication Record Form information from the [MEDICAL TREATMENT] center upon Resident #117's return to the facility. She indicated Resident #117 had attended all of his scheduled [MEDICAL TREATMENT] appointments for the month of January 2016. A policy titled, [MEDICAL TREATMENT] Coordination/Facility Services, dated 10/2014, was provided by the DON on 1/11/2016 at 9:00 a.m., and indicated the following, .Purpose: to ensure effective communication between the facility and [MEDICAL TREATMENT] center providing service to the facility .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 .2. Facility personnel shall ensure that all appropriate medical and administrative information accompanies resident at the time of transfer or referral to the [MEDICAL TREATMENT] center .4. Unit manager/licensed nurse shall monitor the needs of the [MEDICAL TREATMENT] resident and review any notes/orders accompanying resident from the [MEDICAL TREATMENT] center upon arrival to the facility 3.1-37(a)

Based on observation, interview, and record review, the facility failed to identify changes in skin condition and ensure effective pressure reducing interventions for 3 of 3 residents reviewed for pressure ulcers. This deficient practice resulted in a resident's existing pressure ulcers deteriorating to stage IV (full thickness tissue loss with exposed bone, tendon or muscle) or unstagegable pressure ulcers and development of additional pressure ulcers on the buttocks and bilateral, medial knees. This deficient practice also resulted in a resident with a stage III pressure ulcer (full thickness tissue loss where bone, tendon or muscle is not exposed) on the right great toe worsening to an unstageable pressure ulcer and resulted in lack of wound healing for a resident with a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying tissue) to the right heel (Residents B, C and D). Findings include: 1. During an observation on 1/11/15 at 4:00 p.m., Resident B was seated in a reclined broda chair by the C wing nursing station without a pressure reducing cushion in place. The resident had bilateral heel protectors on and his right and left knees had wound dressings in place. The knees were positioned against one another. During an observation on 1/12/16 at 11:29 a.m., with Qualified Medication Aide (QMA) # 98, Licensed Practical Nurse (LPN) #96, and LPN #99 present, Resident B's wounds were observed during a dressing change. QMA #98 and LPN #99 positioned Resident B on his left side. There was a stage IV pressure ulcer on the coccyx with a yellow and dark brown wound bed. The wound edges were reddened and yellow crusted. No drainage was observed. The left buttock wound was a stage IV pressure ulcer with a yellow wound bed with a moderate amount of continuous brownish colored drainage. The wound edges were reddened. The right buttock wound was observed as a stage IV pressure ulcer with a yellow wound bed with some red tissue. No drainage was observed and the wound edges were intact. The right lower buttock wound was observed as an unstageable pressure ulcer with a dark brown center and yellow tissue surrounding the dark center. During an observation on 1/12/16 at 10:00 a.m., Resident B was positioned on his back on a low air loss mattress. During observations on 1/12/16 at 12:33 p.m., 12:50 p.m., and 1:00 p.m., Resident B was lying in bed on his back. His legs were covered with a thin sheet and a blue foam knee protector pad was at the end of the bed. During an observation on 1/12/16 at 1:08 p.m., with LPN #96 present, Resident B was observed on his back, foam knee protector was at the end of the bed. Resident B had a stage two pressure ulcer with yellow wound bed and reddened wound edges on his right inner knee and a stage two pressure ulcer with a yellow wound bed and reddened wound edges on his left inner knee. During an observation on 1/13/16 at 10:14 a.m., with Certified Nursing Assistant (CNA) #92 present, Resident B was lying in bed on his back with a regular bed pillow positioned under his left hip. The pillow was compressed flat and did not position the Resident to reduce pressure to his coccyx and buttock wounds. Resident B's record was reviewed on 1/12/16 at 10:05 a.m. and indicated [DIAGNOSES REDACTED]. An admission assessment, dated 9/26/14, indicated Resident B was admitted to the facility without pressure ulcers. Laboratory tests results, dated 1/5/15, indicated Resident B had a total protein level of 6.8 gm/dL (reference range 6.0-8.2) and an [MEDICATION NAME] (helps tissue growth ad healing) of 3.7g/dl (reference range 3.2-5.7). The record lacked indication levels were monitored after this date. A hospice certification note, dated 1/12/15, indicated Resident B qualified for hospice due to his [DIAGNOSES REDACTED]. A pressure ulcer assessment record, dated 3/25/15, indicated Resident B developed a stage III (full thickness loss) pressure ulcer which measured 5.0 x 5.0 x 0.1 (length X width X depth in centimeters) on his left buttock. The record indicated the wound was measured weekly and indicated the wound became unstageable and measured 6.0 x 6.0 with an undetermined depth on 5/1/15. The wound bed was 100 percent necrotic and the wound edges were red. On 5/28/15, the wound stage was documented as stage 3 and the wound measured 5.0 X 5.0 with 0.1 depths. The wound bed was 10 percent slough and 90 percent beefy red. On 6/12/15, the wound stage was documented as unstageable and measured 2.6 x 2.4 with the depth undetermined. The wound bed was 100 percent slough and the wound edges were red. On 1/8/15, the wound stage was documented as stage IV and measured 3 x 3.2 x 5.2 with a moderate amount of serosangineous drainage with no tunneling. Wound associated pain was rated 7 out of 10, the wound bed was red, and the wound edges were red. On 1/11/16, the wound measured 2.7 x 3.2 x 1.5, had moderate amount of serous drainage, 5.4 cm (centimeters) tunneling at 12:00. Wound associated pain was 8 out of 10 and the wound bed was red with red/dark edges. A pressure ulcer assessment record, dated 4/23/15, indicated Resident B developed an unstageable pressure ulcer which measured 4 x 2 x undetermined depth to his right buttock. The wound bed was 100 percent necrotic with red wound edges. The record indicated weekly wound measurements and indicated on 6/8/15 the wound stage was documented as stage III and measured 1.6 x 1.2 x undermined depth. The wound bed was 100 percent slough with red wound edges. On 6/12/15 the wound stage was documented as unstageable and measured 1.4 x 1.0 x undetermined depth. The wound bed was 100 percent slough with red wound edges. On 1/8/15, the wound stage was documented as stage IV and measured 5 x 3 x 3.6 with no tunneling. Wound associated pain was a 7/10 and the wound bed was red with red wound edges. On 1/11/16 the wound measured 4 x 3.3 x 1.5, had a moderate amount of serous exudates, with 2 cm tunneling/undermining at 11:00-12:00 locations of a clock face. The wound associated pain was rated a 5/10, with a red wound bed and red wound edges. A pressure ulcer assessment record, dated 10/16/15, indicated Resident B developed a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a res-pink wound bed without slough) on his sacrum which measured 1.2 x 0.4 x less than 0.1. The wound had no tunneling and no pain. The wound bed was red and the wound edges had redness. The record indicated wounds were measured weekly and on 12/18/15 the wound stage declined to a stage III and measured 2.5 x 2 x 0.2. Wound associated pain was rated at a 4/10. The wound bed was red and the edges were red. On 1/8/16, the wound stage declined to a stage IV and measured 3.9 x 3.6 x 2.8, had a moderate amount of serosanginous drainage, no tunneling, wound associated pain rated 7/10, wound bed was red, and the wound edges were red. On 1/11/16 the wound measured 5.7 x 3.7 x 3, had a moderate amount of serous exudates, 4 cm of tunneling/undermining located at 3:00-4:00 on a clock face, wound associated pain was rated 5/10, with a red wound bed with red wound edges. A Minimum Data Set (MDS) assessment, dated 8/5/15, indicated Resident B was at risk for developing pressure ulcers and had one stage II pressure ulcer, 2 stage III pressure ulcers, and no stage IV pressure ulcers. The assessment indicated the resident was totally dependent on staff for bed mobility. A pressure sore care plan, initiated on 3/29/15, and last updated 10/30/15, indicated Resident B had a pressure ulcer. A goal indicated the pressure ulcer would decrease in size or heal by the next review. Interventions to meet this goal included: apply treatment as ordered, monitor per skin management program, monitor for signs/symptoms of infection, monitor for treatment efficacy and consult the physician if the ulcer did not improve. Additional interventions included pressure reducing devices to the bed and chair, low air loss mattress, encourage consumption of meals, fluids, and supplements, assist/encourage to turn and reposition at least every two hours and as needed, educate the resident and responsible party on factors of skin breakdown and interventions as needed, use the bed pad/sheets for bed mobility and positioning, and refer to incontinence, dietary, and pressure risk care plans. The record lacked indication Resident B refused interventions to prevent or promote healing of pressure ulcers. A pressure ulcer risk care plan, originally dated 5/13/15, and last updated 12/12/15, indicated Resident B was at risk for the development of pressure ulcers due to: dependence on staff for bed mobility, functional limitation in range of motion to bilateral upper extremities and bilateral lower extremities, bedfast, frequently slides down in bed, bowel incontinence, use of s/p (suprapubic) catheter, impaired cognition, use of [MEDICAL CONDITION] and narcotic pain medications, pain, increased pain with repositioning, use of oxygen, significant weight loss, current pressure ulcers, [DIAGNOSES REDACTED]. A goal indicated he would be free from pressure ulcers by the next review. Interventions included: weekly head to toe skin assessments, observation of skin condition during care, notification of skin problems to the charge nurse for further assessment and possible physician notification, pressure redirecting cushion to chair, pressure reducing mattress to be, low air loss mattress, encourage and assist with turning and repositioning at least every two hours and as needed, application of preventative topical medication as ordered, monitor labs as ordered, encourage food and fluid intake, refer to dietician as indicated, dietary supplements as ordered, hospice visits as scheduled, educate him on the risks of non adherence as needed and encourage him to comply. The record lacked indication Resident B refused interventions to prevent or promote healing of pressure ulcers A physician's orders [REDACTED]. The order indicated, not on his back. A physician's orders [REDACTED]. A Minimum Data Set (MDS), dated [DATE], indicated Resident B was totally dependent on two staff for bed mobility, had range of motion limitations in upper and lower extremities, had unhealed pressure ulcers, was at risk for developing additional pressure ulcers, and did not exhibit behaviors of rejecting care. A Certified Nursing Assistant assignment sheet, dated 1/4/16, indicated Resident B was dependent for activities of daily living, confused at times, needed encouraged to lay on his side, turned every two hours, and checked every 30 minutes. An initial pressure ulcer assessment, dated 1/5/16, indicated Resident B developed a stage 2 pressure ulcer which measured 2 x 2.5 x less than 0.1 on his right knee and a stage 2 pressure ulcer which measured 1 x 0.9 x 0.1 on his left knee. An initial pressure ulcer assessment, dated 1/11/16, indicated Resident B developed a stage III pressure ulcer to his right lower buttock which measured 2 x 1.9 x 0.1, with a dark brown wound bed and red edges. An initial pressure ulcer assessment, dated 1/11/16, indicated Resident B developed a stage 1 pressure ulcer on his left heel which measured 2.5 x 5.5, had a dark red wound bed with red wound edges. A physician's orders [REDACTED]. A care plan, dated 1/11/16, and updated on 1/12/16, indicated Resident B had pressure ulcers located on his left and right buttocks, coccyx, left and right knees, lower right buttock, and his left heel. A goal indicated the pressure ulcers would decrease in size/heal without complications by the next review. Interventions to meet this goal included: administer treatments as ordered, monitor skin management program, monitor for signs and symptoms of infection, monitor for treatment efficacy and notify physician if not improving, pressure reducing devices to bed and the chair, encourage consumption of meals, fluids and supplements, assist/encourage to turn and reposition at least every two hours and as needed, turn on his left and right only, turn every two hours, dressing changes as ordered, notify hospice nurse as needed, bunny boots to bilateral feet, abductor pillow (knee) at all times may remove for bathing and care. During an interview, on 1/11/2016 at 4:00 p.m., Licensed Practical Nurse #96 indicated the chair in which Resident B was seated did not have a pressure reducing cushion. During an interview, on 1/12/16 at 1:08 p.m., LPN #96 pointed to a foam cushion at the end of Resident B's bed and indicated she did not know when the resident got the foam cushion and indicated it was to prevent his skin from breaking down between his knees. During an interview on 1/13/16 at 10:14 a.m., CNA #92 indicated she was assigned to Resident B and indicated she repositioned Resident B every two hours. The CNA indicated Resident B wasn't supposed to be on his back too much and indicated she didn't want to position him on his side because he wouldn't have anything to look at but the wall. She indicated she placed a pillow under his left hip to help relieve the pressure. She indicated she should probably get more pillows to help relieve the pressure and indicated Resident B complained of pain when she moved him, but he did not refuse repositioning. During an interview on 1/13/16 at 9:15 a.m., with the Director of Nursing and Corporate Nurse Consultant present, the Director of Nursing indicated preventative measures were in place prior to him developing pressure ulcers. The Corporate Nurse Consultant indicated the interventions in place to prevent Resident B from developing pressure ulcers did not prevent the Resident from developing pressure ulcers. She indicated she believed the facility had done everything they could to prevent the skin breakdown and indicated the pressure ulcers were unavoidable. The Corporate Nurse Consultant indicated Resident B refused to be turned from side to side and indicated the facility documented times when the refused repositioning and indicated he had been provided with education regarding the risks of refusing repositioning. Documentation of the refusals was requested, but not provided before the survey was exited. During an interview on 1/13/16 at 11:08, Physician #90 indicated the only intervention that would have prevented pressure ulcers on Resident B's back side was to keep him off his back. He indicated in the past, when Resident B was obese, the facility staff had difficulty keeping him positioned off his back. The physician indicated Resident B declined nutritionally and had muscle wasting. He indicated the wound treatments ordered were appropriate and the only other possible intervention would be surgical repairs of the wounds. The physician indicated Resident B was on hospice and not a candidate for surgery. He indicated he recently observed staff reposition Resident B and indicated he experienced pain and could not tolerate the repositioning. He went on to indicate he believed the most important thing was to keep him comfortable. The physician indicated he believed pressure ulcers were unavoidable for residents who had end stage [MEDICAL CONDITION]. During an interview, on 1/13/15 at 11:30 a.m., the Administrator indicated documentation which indicated Resident B had refused interventions to heal/prevent pressure ulcers was not available. 2. During an interview on 1/5/2016 at 10:38 a.m., Licensed Practical Nurse (LPN) #61 indicated Resident C had an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely observed by slough and/or eschar in the wound bed) pressure ulcer to his right great toe. During an observation on 1/7/2016 from 2:05 p.m. to 2:17 p.m., Resident C was observed with his right great toe pressure ulcer positioned flat against his composure mattress before his dressing change. LPN #61 changed a dressing to Resident C's unstageable pressure ulcer to his right great toe. She measured the wound as 1.0 centimeter (cm) x 0.1 cm with depth unable to be determined. The wound was a pink scabbed area, with white slough visible at the edges encompassing the scab. Resident C was observed positioned on his left side with his bilateral legs contracted upward, as both legs laid on top of one another. The area of pressure to his right great toe was placed flat against the composure mattress upon completion of his dressing change. Resident C was not observed to have bunny boots applied to both feet before or after the dressing change. The resident's heels were not observed to be floated before or after the dressing change. During a continuous observation on 1/8/2016 from 9:29 a.m. to 10:53 a.m., Resident C was observed sitting up in his broda chair. Orthotic braces were applied to both legs without the abductor bar of the orthotics present. The area of pressure to his right great toe was observed lying against the brace to his left leg. During a dining observation on 1/08/2016 at 1:11 p.m., Resident C was sitting up in his broda chair with his brace orthotics placed on both legs. The abductor bar of the orthotics was not observed. The area of pressure to his right great toe was observed lying against his left foot. During an observation on 1/8/2016 from 2:38 p.m. to 3:11 p.m., Resident C was observed in bed positioned on his right side with his knees bent and legs contracted upward. His right foot was lying flat on the composure mattress with his left foot placed directly on top of his right foot. His left great toe was observed rubbing against the area of pressure to his right great toe. Resident C's pants were pulled down around his ankles. Resident C was not observed with soft boots to his feet or his heels floated. A pillow was not observed in between his contracted legs. During an observation on 1/8/2016 at 4:09 p.m., Resident C was observed lying in bed and positioned on his right side. His legs were bent with his knees toward the ceiling. His left foot was lying on top of his right foot flat on the composure mattress. His heels were not observed to be floated and soft boots were not observed on his feet. Resident C's record was reviewed on 1/7/2016 at 3:00 p.m. Resident C's [DIAGNOSES REDACTED]. A Certified Nursing Assistant (CNA) Assignment sheet, dated 1/4/2015, indicated Resident C should be turned and repositioned every hour, laid down after meals, wear Bunny Boots while in bed, and wear orthotics to bilateral lower extremities. A Minimum Data Set assessment (MDS), dated [DATE], indicated Resident C was totally dependent with assistance of 1 staff person with bed mobility, dressing, and locomotion on the unit. The resident was totally dependent and required assistance of 2 staff members for transfers. The record indicated Resident C was at risk of developing pressure ulcers, had an unstageable pressure ulcer with measurements of 0.2 cm x 0.2 cm, and did not have a venous or arterial ulcer present. The record indicated Resident C's skin and ulcer treatments included: pressure reducing device for chair, pressure reducing device for bed, pressure ulcer care, and applications of ointments/medications other than to feet. The record lacked indication Resident C received a turning and repositioning program or applications of dressings to feet (with or without topical medications). A Pressure Ulcer Risk care plan, dated 10/13/2015, indicated Resident C was at risk for the development of pressure ulcers due to: dependent on staff for bed mobility and all activities of daily living (ADL's) and transfers, current pressure ulcer to his right medial great toe, decreased mobility, impaired ROM (range of motion) in lower extremities and his history of healed pressure ulcers. The care plan goal indicated Resident C would be free from pressure ulcers by next review. Current interventions included: head to toe skin assessment at least weekly by a licensed nurse, staff to observe skin condition while providing care, pressure redirecting mattress to bed, treatment to pressure ulcers as ordered, Z-flow cushion to elevate heels and check each shift while in bed, encourage and assist resident with turning and repositioning at least every two hours and as needed, monitor labs as ordered, and avoid lying on right side. A Pressure Area care plan, dated 10/13/2015, indicated Resident C has a pressure area located on his right medial foot and right medial great toe. The care plan goal indicated Resident C's pressure areas will decrease in size or heal without complications through the next review. Interventions included: daily skin inspection by nursing assistants, head to toe skin assessments by licensed nurse weekly and as needed, provide pressure redistribution mattress to bed, monitor for treatment efficacy if area is not improving and consult with the physician for further instruction, and assist with turning and repositioning at least every two hours and as needed. A physician's telephone order, dated 12/9/2015, indicated, PT (physical therapy) to evaluate right great toe medial likely venous stasis ulcer. A Nurse Practitioner (NP) progress note, dated 12/9/2015, indicated, Chief Complaint: Venous stasis ulcer .This is a new problem, is acute .Resident is a highly contracted male, bed bound, concern that ulcer is 2/2 (secondary) to [MEDICAL CONDITIONS]. Will request therapy to evaluate and monitor. Will observe but given patient's chronic condition, unlikely to improve. Interested in therapy's evaluation and care plan, problem unlikely to resolve quickly if at all, patient unlikely surgical candidate unless toe becomes necrotic .Diagnosis: [REDACTED]. A physician's telephone order, dated 12/11/2015, indicated, Order clarification: 1. PT wound care eval (evaluation) completed. 2. PT skilled intervention not recommended at this time via electrical stimulation due to wound stage and status. 3. Nursing to perform saline flush, xeroform (wound dressing) application, cover with gauze daily and as needed for soilage. 4. Unit staff to strictly adhere with orthotic application as scheduled. A Physical Therapy Plan of Care (Evaluation Only), dated 12/11/2015 and signed by the physician on 12/18/2015, indicated, .Reason for Referral: non healing pressure ulcer to right dorsal (back)) aspect of 1st DIP (distal interphalangeal joint) of foot .Therapy Necessity: Wound care skilled intervention via electrical stimulation is not recommended at this time d/t (due to) current wound stage and status however wound care treatment to be performed by nursing is recommended .2. Strict adherence to orthotic application and schedule to alleviate progression of contractures and pressure wound and prevent new onset of contractures and pressure wound .Discharge Plans: RNP (Restorative Nursing Program) will be in place to delay progression and new onset contractures and pressure sores .Underlying Impairments Other: Pt (patient) presents with stage 2 pressure wound to dorsal 1st DIP of R (right) foot with 100% granular tissue (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) measuring 1 cm x 0.9 cm x no depth with minimal exudate, no odor and intact periwound (tissue surrounding the wound) A physician's orders [REDACTED].cleanse R (right) great toe medial with NS (normal saline), pat dry, Xeroform (dressing) application and cover with gauze and secure QD (daily) and PRN (as needed) for soilage. A Braden Scale for Predicting Pressure Ulcer Risk, dated 12/23/15, indicated Resident C had a score of 11, indicating he was at a high risk for skin breakdown. The Certified Nursing Assistant (CNA) Shower Book, dated January 2016, indicated Resident C was to receive showers on Wednesday and Saturday evenings. The record lacked documentation the CNAs had performed a skin assessment for Resident C during his assigned showers for 1/2/2016 and 1/6/2016. Resident C's Medication Administration Record [REDACTED]. The record lacked indication Resident C had worn his orthotics to his legs on 1/2/2016 from 4 p.m. to 8 p.m., 1/3/2016 from 12 a.m. to 4 a.m., 1/5/2016 from 4 p.m. to 8 p.m., 1/5/2016 from 12 a.m. to 4 a.m., 1/6/2016 from 7 a.m. to 11 a.m., 4 p.m. to 8 p.m., or 12 a.m. to 4 a.m., and 1/7/2016 from 4 p.m. to 8 p.m. The record lacked indication Resident C had used a Z-flow cushion to elevate his bilateral heels while in bed on 1/2/2016 from 3 p.m. to 11 p.m., 1/5/2016 from 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m., 1/6/2016 from 3 p.m. to 11 p.m., 11 p.m. to 7 a.m., and 1/7/2016 from 3 p.m. to 11 p.m. The record lacked indicated Resident C had been turned every 2 hours on 1/2/2016 from 4 p.m. to 10 p.m., 1/3/2016 from 12 a.m. to 6 a.m., 1/5/2016 from 12 a.m. to 6 a.m. and 4 p.m. to 10 p.m., 1/6/2016 from 12 a.m. to 6 a.m. and 4 p.m. to 10 p.m. The record lacked indicated Resident C had a weekly skin assessment performed on Wednesday, 1/6/2016, and a skin sheet had been charted. The record did not indicate a reason Resident C had not received the nursing measures or dressing change. An undated Weekly Skin Assessment, reviewed in the January 2016 Treatment Administration Record (TAR), indicated, Directions: A head-to-toe assessment of each resident is to be completed. Should a new skin alteration be identified, the appropriate assessment and ongoing monitoring tool shall be initiated and noted below. Weekly assessment shall continue in an effort to identify any additional areas thereafter The record lacked documentation a weekly skin assessment had been performed by a nurse for Resident C during the month of January 2016. A physician's orders [REDACTED]. 12 a.m. to 4 a.m., for his [DIAGNOSES REDACTED]. A Podiatry Exam progress report, dated 1/6/2016, did not indicate Resident C had vascular conditions, cyanosis (poor circulation or inadequate oxygenatio of the blood), or claudication (condition in which cramping pain the the leg can be caused by obstruction of arteries). A Pressure Ulcer care plan, dated 1/7/2016, indicated Resident C had a pressure ulcer to his right great toe. The care plan indicated a goal for Resident C's ulcer to decrease in size/heal without complications by next review. The care plan included undated interventions of: treatment as ordered, monitor per Skin Management Program and SWAT (facility's wound monitoring) protocol, monitor for treatment efficacy, pressure reducing devices to bed and chair, assist/encourage to turn and reposition at least every two hours and as needed, Xeroform (dressing change) per order, boots on bilateral feet when braces are off. A Contracture care plan, dated 1/7/2016, indicated Resident C suffers with contractures to bilateral knees and is at risk for further contractures. The goal indicated Resident C will be free from further contractures. Undated care plan interventions include: ensure that splints are placed as per orders and patient to wear BLE Bilateral lower extremities) daily for four hours each shift for his contractures. An undated Restorative Program document was provided by the Physical Therapist (PT) #66 on 1/8/2016 at 1:55 p.m. This document indicated, .Program #1 Special Instructions: Apply RLE (right lower extremity) and LLE (left lower extremity) splint daily. Leave on for 5 hours each shift then remove. The record indicated a picture with instructions that an abductor bar is to be placed medial (inside) the orthotics. A Wound Care Evaluation, dated 12/21/15, indicated Resident C had a stage 3 (full thickness skin loss) wound to his right greater toe, measuring 0.4 cm x 0.4 cm with depth of 0.1 cm. The date of the wound's onset was 8/8/2014 and had been facility acquired. SWAT program documentation titled,Ongoing Assessment of Pressure Ulcer, measurements indicated Resident C's pressure ulcer to his right medial great toe had been identified as a Stage 3 pressure ulcer on 12/31/2014 with measurements of 0.7 cm x 0.4 cm and depth of 0.1 cm. The wound continued as a stage 3 pressure ulcer with increase in length and width until it progressed to an unstageable wound on 7/16/2015 with measurements of 2.6 cm x 2.8 cm and depth of 0.1 cm. The wound was then classified down as a stage 3 pressure ulcer on 7/24/2015 with measurements of 3 cm x 3 cm and depth 0.1 cm. Resident C's wound was classified down as a stage 2 (partial thickness loss of dermis) pressure ulcer on 8/14/2015 with measurements of 3 cm x 3 cm and depth less than 0.1 cm. The wound progressed to an unstageable pressure ulcer with measurements of 0.3 cm x 0.3 cm and depth unable to be determined on 9/3/15. Resident C's wound was classified on 10/8/2015 as a stage 2 pressure ulcer with measurements of 1.7 cm x 1.6 cm and depth less than 0.1 cm. From 10/16/2015 to 11/6/2015, measurements indicated Resident C's pressure ulcer to his right great toe was classified as a stage 2 pressure ulcer with depth unable to be determined. On 11/13/2015, the wound continued as a stage 2 pressure ulcer with measurements less than 0.1 cm x less than 0.1 cm and no depth. The wound progressed to a stage 3 pressure ulcer on 12/18/2015 with measurements of 2.5 cm x 2.0 cm and depth of 0.2 cm. The wound progressed to an unstageable pressure ulcer on 12/22/2015 with measurements of 1 cm x 1 cm and depth unable to be determined. Resident C's pressure ulcer to his right great toe remained at an unstageable pressure ulcer on 12/30/2015 with measurements of 1 cm x 1 cm and depth unable to be determined. During an interview on 1/7/2016 at 2:17 p.m., LPN #61 indicated Resident C currently had a composure (therapeutic) mattress and used to have a low air loss mattress. She indicated he wore orthotic braces to his legs from 8 a.m. to 2 p.m. She indicated the staff experience difficulty floating his heels due to his contracted legs. During an interview on 1/8/2016 at 9:34 a.m., CNA #65 indicated Resident C had orders to wear his orthotic braces to his lower legs for 4 hours each shift. She indicated she did not float his heels with a Z-flow cushion while in bed and indicated his room did not contain a cushion to float his heels with. She indicated he is repositioned in bed every 2 hours and she did not always float his heels with a pillow while in bed. She indicated he had a pair of Bunny Boots in his closet and he did not wear them during the day shift. She indicated the CNAs monitor the residents' skin conditions during each shower day by filling out a skin sheet and placing it in the shower binder. She indicated the

Based on observation, interview, and record review, the facility failed to identify changes in skin condition and ensure effective pressure reducing interventions for 3 of 3 residents reviewed for pressure ulcers. This deficient practice resulted in a resident's existing pressure ulcers deteriorating to stage IV (full thickness tissue loss with exposed bone, tendon or muscle) or unstagegable pressure ulcers and development of additional pressure ulcers on the buttocks and bilateral, medial knees. This deficient practice also resulted in a resident with a stage III pressure ulcer (full thickness tissue loss where bone, tendon or muscle is not exposed) on the right great toe worsening to an unstageable pressure ulcer and resulted in lack of wound healing for a resident with a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying tissue) to the right heel (Residents B, C and D). Findings include: 1. During an observation on 1/11/15 at 4:00 p.m., Resident B was seated in a reclined broda chair by the C wing nursing station without a pressure reducing cushion in place. The resident had bilateral heel protectors on and his right and left knees had wound dressings in place. The knees were positioned against one another. During an observation on 1/12/16 at 11:29 a.m., with Qualified Medication Aide (QMA) # 98, Licensed Practical Nurse (LPN) #96, and LPN #99 present, Resident B's wounds were observed during a dressing change. QMA #98 and LPN #99 positioned Resident B on his left side. There was a stage IV pressure ulcer on the coccyx with a yellow and dark brown wound bed. The wound edges were reddened and yellow crusted. No drainage was observed. The left buttock wound was a stage IV pressure ulcer with a yellow wound bed with a moderate amount of continuous brownish colored drainage. The wound edges were reddened. The right buttock wound was observed as a stage IV pressure ulcer with a yellow wound bed with some red tissue. No drainage was observed and the wound edges were intact. The right lower buttock wound was observed as an unstageable pressure ulcer with a dark brown center and yellow tissue surrounding the dark center. During an observation on 1/12/16 at 10:00 a.m., Resident B was positioned on his back on a low air loss mattress. During observations on 1/12/16 at 12:33 p.m., 12:50 p.m., and 1:00 p.m., Resident B was lying in bed on his back. His legs were covered with a thin sheet and a blue foam knee protector pad was at the end of the bed. During an observation on 1/12/16 at 1:08 p.m., with LPN #96 present, Resident B was observed on his back, foam knee protector was at the end of the bed. Resident B had a stage two pressure ulcer with yellow wound bed and reddened wound edges on his right inner knee and a stage two pressure ulcer with a yellow wound bed and reddened wound edges on his left inner knee. During an observation on 1/13/16 at 10:14 a.m., with Certified Nursing Assistant (CNA) #92 present, Resident B was lying in bed on his back with a regular bed pillow positioned under his left hip. The pillow was compressed flat and did not position the Resident to reduce pressure to his coccyx and buttock wounds. Resident B's record was reviewed on 1/12/16 at 10:05 a.m. and indicated [DIAGNOSES REDACTED]. An admission assessment, dated 9/26/14, indicated Resident B was admitted to the facility without pressure ulcers. Laboratory tests results, dated 1/5/15, indicated Resident B had a total protein level of 6.8 gm/dL (reference range 6.0-8.2) and an [MEDICATION NAME] (helps tissue growth ad healing) of 3.7g/dl (reference range 3.2-5.7). The record lacked indication levels were monitored after this date. A hospice certification note, dated 1/12/15, indicated Resident B qualified for hospice due to his [DIAGNOSES REDACTED]. A pressure ulcer assessment record, dated 3/25/15, indicated Resident B developed a stage III (full thickness loss) pressure ulcer which measured 5.0 x 5.0 x 0.1 (length X width X depth in centimeters) on his left buttock. The record indicated the wound was measured weekly and indicated the wound became unstageable and measured 6.0 x 6.0 with an undetermined depth on 5/1/15. The wound bed was 100 percent necrotic and the wound edges were red. On 5/28/15, the wound stage was documented as stage 3 and the wound measured 5.0 X 5.0 with 0.1 depths. The wound bed was 10 percent slough and 90 percent beefy red. On 6/12/15, the wound stage was documented as unstageable and measured 2.6 x 2.4 with the depth undetermined. The wound bed was 100 percent slough and the wound edges were red. On 1/8/15, the wound stage was documented as stage IV and measured 3 x 3.2 x 5.2 with a moderate amount of serosangineous drainage with no tunneling. Wound associated pain was rated 7 out of 10, the wound bed was red, and the wound edges were red. On 1/11/16, the wound measured 2.7 x 3.2 x 1.5, had moderate amount of serous drainage, 5.4 cm (centimeters) tunneling at 12:00. Wound associated pain was 8 out of 10 and the wound bed was red with red/dark edges. A pressure ulcer assessment record, dated 4/23/15, indicated Resident B developed an unstageable pressure ulcer which measured 4 x 2 x undetermined depth to his right buttock. The wound bed was 100 percent necrotic with red wound edges. The record indicated weekly wound measurements and indicated on 6/8/15 the wound stage was documented as stage III and measured 1.6 x 1.2 x undermined depth. The wound bed was 100 percent slough with red wound edges. On 6/12/15 the wound stage was documented as unstageable and measured 1.4 x 1.0 x undetermined depth. The wound bed was 100 percent slough with red wound edges. On 1/8/15, the wound stage was documented as stage IV and measured 5 x 3 x 3.6 with no tunneling. Wound associated pain was a 7/10 and the wound bed was red with red wound edges. On 1/11/16 the wound measured 4 x 3.3 x 1.5, had a moderate amount of serous exudates, with 2 cm tunneling/undermining at 11:00-12:00 locations of a clock face. The wound associated pain was rated a 5/10, with a red wound bed and red wound edges. A pressure ulcer assessment record, dated 10/16/15, indicated Resident B developed a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a res-pink wound bed without slough) on his sacrum which measured 1.2 x 0.4 x less than 0.1. The wound had no tunneling and no pain. The wound bed was red and the wound edges had redness. The record indicated wounds were measured weekly and on 12/18/15 the wound stage declined to a stage III and measured 2.5 x 2 x 0.2. Wound associated pain was rated at a 4/10. The wound bed was red and the edges were red. On 1/8/16, the wound stage declined to a stage IV and measured 3.9 x 3.6 x 2.8, had a moderate amount of serosanginous drainage, no tunneling, wound associated pain rated 7/10, wound bed was red, and the wound edges were red. On 1/11/16 the wound measured 5.7 x 3.7 x 3, had a moderate amount of serous exudates, 4 cm of tunneling/undermining located at 3:00-4:00 on a clock face, wound associated pain was rated 5/10, with a red wound bed with red wound edges. A Minimum Data Set (MDS) assessment, dated 8/5/15, indicated Resident B was at risk for developing pressure ulcers and had one stage II pressure ulcer, 2 stage III pressure ulcers, and no stage IV pressure ulcers. The assessment indicated the resident was totally dependent on staff for bed mobility. A pressure sore care plan, initiated on 3/29/15, and last updated 10/30/15, indicated Resident B had a pressure ulcer. A goal indicated the pressure ulcer would decrease in size or heal by the next review. Interventions to meet this goal included: apply treatment as ordered, monitor per skin management program, monitor for signs/symptoms of infection, monitor for treatment efficacy and consult the physician if the ulcer did not improve. Additional interventions included pressure reducing devices to the bed and chair, low air loss mattress, encourage consumption of meals, fluids, and supplements, assist/encourage to turn and reposition at least every two hours and as needed, educate the resident and responsible party on factors of skin breakdown and interventions as needed, use the bed pad/sheets for bed mobility and positioning, and refer to incontinence, dietary, and pressure risk care plans. The record lacked indication Resident B refused interventions to prevent or promote healing of pressure ulcers. A pressure ulcer risk care plan, originally dated 5/13/15, and last updated 12/12/15, indicated Resident B was at risk for the development of pressure ulcers due to: dependence on staff for bed mobility, functional limitation in range of motion to bilateral upper extremities and bilateral lower extremities, bedfast, frequently slides down in bed, bowel incontinence, use of s/p (suprapubic) catheter, impaired cognition, use of [MEDICAL CONDITION] and narcotic pain medications, pain, increased pain with repositioning, use of oxygen, significant weight loss, current pressure ulcers, [DIAGNOSES REDACTED]. A goal indicated he would be free from pressure ulcers by the next review. Interventions included: weekly head to toe skin assessments, observation of skin condition during care, notification of skin problems to the charge nurse for further assessment and possible physician notification, pressure redirecting cushion to chair, pressure reducing mattress to be, low air loss mattress, encourage and assist with turning and repositioning at least every two hours and as needed, application of preventative topical medication as ordered, monitor labs as ordered, encourage food and fluid intake, refer to dietician as indicated, dietary supplements as ordered, hospice visits as scheduled, educate him on the risks of non adherence as needed and encourage him to comply. The record lacked indication Resident B refused interventions to prevent or promote healing of pressure ulcers A physician's orders [REDACTED]. The order indicated, not on his back. A physician's orders [REDACTED]. A Minimum Data Set (MDS), dated [DATE], indicated Resident B was totally dependent on two staff for bed mobility, had range of motion limitations in upper and lower extremities, had unhealed pressure ulcers, was at risk for developing additional pressure ulcers, and did not exhibit behaviors of rejecting care. A Certified Nursing Assistant assignment sheet, dated 1/4/16, indicated Resident B was dependent for activities of daily living, confused at times, needed encouraged to lay on his side, turned every two hours, and checked every 30 minutes. An initial pressure ulcer assessment, dated 1/5/16, indicated Resident B developed a stage 2 pressure ulcer which measured 2 x 2.5 x less than 0.1 on his right knee and a stage 2 pressure ulcer which measured 1 x 0.9 x 0.1 on his left knee. An initial pressure ulcer assessment, dated 1/11/16, indicated Resident B developed a stage III pressure ulcer to his right lower buttock which measured 2 x 1.9 x 0.1, with a dark brown wound bed and red edges. An initial pressure ulcer assessment, dated 1/11/16, indicated Resident B developed a stage 1 pressure ulcer on his left heel which measured 2.5 x 5.5, had a dark red wound bed with red wound edges. A physician's orders [REDACTED]. A care plan, dated 1/11/16, and updated on 1/12/16, indicated Resident B had pressure ulcers located on his left and right buttocks, coccyx, left and right knees, lower right buttock, and his left heel. A goal indicated the pressure ulcers would decrease in size/heal without complications by the next review. Interventions to meet this goal included: administer treatments as ordered, monitor skin management program, monitor for signs and symptoms of infection, monitor for treatment efficacy and notify physician if not improving, pressure reducing devices to bed and the chair, encourage consumption of meals, fluids and supplements, assist/encourage to turn and reposition at least every two hours and as needed, turn on his left and right only, turn every two hours, dressing changes as ordered, notify hospice nurse as needed, bunny boots to bilateral feet, abductor pillow (knee) at all times may remove for bathing and care. During an interview, on 1/11/2016 at 4:00 p.m., Licensed Practical Nurse #96 indicated the chair in which Resident B was seated did not have a pressure reducing cushion. During an interview, on 1/12/16 at 1:08 p.m., LPN #96 pointed to a foam cushion at the end of Resident B's bed and indicated she did not know when the resident got the foam cushion and indicated it was to prevent his skin from breaking down between his knees. During an interview on 1/13/16 at 10:14 a.m., CNA #92 indicated she was assigned to Resident B and indicated she repositioned Resident B every two hours. The CNA indicated Resident B wasn't supposed to be on his back too much and indicated she didn't want to position him on his side because he wouldn't have anything to look at but the wall. She indicated she placed a pillow under his left hip to help relieve the pressure. She indicated she should probably get more pillows to help relieve the pressure and indicated Resident B complained of pain when she moved him, but he did not refuse repositioning. During an interview on 1/13/16 at 9:15 a.m., with the Director of Nursing and Corporate Nurse Consultant present, the Director of Nursing indicated preventative measures were in place prior to him developing pressure ulcers. The Corporate Nurse Consultant indicated the interventions in place to prevent Resident B from developing pressure ulcers did not prevent the Resident from developing pressure ulcers. She indicated she believed the facility had done everything they could to prevent the skin breakdown and indicated the pressure ulcers were unavoidable. The Corporate Nurse Consultant indicated Resident B refused to be turned from side to side and indicated the facility documented times when the refused repositioning and indicated he had been provided with education regarding the risks of refusing repositioning. Documentation of the refusals was requested, but not provided before the survey was exited. During an interview on 1/13/16 at 11:08, Physician #90 indicated the only intervention that would have prevented pressure ulcers on Resident B's back side was to keep him off his back. He indicated in the past, when Resident B was obese, the facility staff had difficulty keeping him positioned off his back. The physician indicated Resident B declined nutritionally and had muscle wasting. He indicated the wound treatments ordered were appropriate and the only other possible intervention would be surgical repairs of the wounds. The physician indicated Resident B was on hospice and not a candidate for surgery. He indicated he recently observed staff reposition Resident B and indicated he experienced pain and could not tolerate the repositioning. He went on to indicate he believed the most important thing was to keep him comfortable. The physician indicated he believed pressure ulcers were unavoidable for residents who had end stage [MEDICAL CONDITION]. During an interview, on 1/13/15 at 11:30 a.m., the Administrator indicated documentation which indicated Resident B had refused interventions to heal/prevent pressure ulcers was not available. 2. During an interview on 1/5/2016 at 10:38 a.m., Licensed Practical Nurse (LPN) #61 indicated Resident C had an unstageable (full thickness tissue loss in which actual depth of the ulcer is completely observed by slough and/or eschar in the wound bed) pressure ulcer to his right great toe. During an observation on 1/7/2016 from 2:05 p.m. to 2:17 p.m., Resident C was observed with his right great toe pressure ulcer positioned flat against his composure mattress before his dressing change. LPN #61 changed a dressing to Resident C's unstageable pressure ulcer to his right great toe. She measured the wound as 1.0 centimeter (cm) x 0.1 cm with depth unable to be determined. The wound was a pink scabbed area, with white slough visible at the edges encompassing the scab. Resident C was observed positioned on his left side with his bilateral legs contracted upward, as both legs laid on top of one another. The area of pressure to his right great toe was placed flat against the composure mattress upon completion of his dressing change. Resident C was not observed to have bunny boots applied to both feet before or after the dressing change. The resident's heels were not observed to be floated before or after the dressing change. During a continuous observation on 1/8/2016 from 9:29 a.m. to 10:53 a.m., Resident C was observed sitting up in his broda chair. Orthotic braces were applied to both legs without the abductor bar of the orthotics present. The area of pressure to his right great toe was observed lying against the brace to his left leg. During a dining observation on 1/08/2016 at 1:11 p.m., Resident C was sitting up in his broda chair with his brace orthotics placed on both legs. The abductor bar of the orthotics was not observed. The area of pressure to his right great toe was observed lying against his left foot. During an observation on 1/8/2016 from 2:38 p.m. to 3:11 p.m., Resident C was observed in bed positioned on his right side with his knees bent and legs contracted upward. His right foot was lying flat on the composure mattress with his left foot placed directly on top of his right foot. His left great toe was observed rubbing against the area of pressure to his right great toe. Resident C's pants were pulled down around his ankles. Resident C was not observed with soft boots to his feet or his heels floated. A pillow was not observed in between his contracted legs. During an observation on 1/8/2016 at 4:09 p.m., Resident C was observed lying in bed and positioned on his right side. His legs were bent with his knees toward the ceiling. His left foot was lying on top of his right foot flat on the composure mattress. His heels were not observed to be floated and soft boots were not observed on his feet. Resident C's record was reviewed on 1/7/2016 at 3:00 p.m. Resident C's [DIAGNOSES REDACTED]. A Certified Nursing Assistant (CNA) Assignment sheet, dated 1/4/2015, indicated Resident C should be turned and repositioned every hour, laid down after meals, wear Bunny Boots while in bed, and wear orthotics to bilateral lower extremities. A Minimum Data Set assessment (MDS), dated [DATE], indicated Resident C was totally dependent with assistance of 1 staff person with bed mobility, dressing, and locomotion on the unit. The resident was totally dependent and required assistance of 2 staff members for transfers. The record indicated Resident C was at risk of developing pressure ulcers, had an unstageable pressure ulcer with measurements of 0.2 cm x 0.2 cm, and did not have a venous or arterial ulcer present. The record indicated Resident C's skin and ulcer treatments included: pressure reducing device for chair, pressure reducing device for bed, pressure ulcer care, and applications of ointments/medications other than to feet. The record lacked indication Resident C received a turning and repositioning program or applications of dressings to feet (with or without topical medications). A Pressure Ulcer Risk care plan, dated 10/13/2015, indicated Resident C was at risk for the development of pressure ulcers due to: dependent on staff for bed mobility and all activities of daily living (ADL's) and transfers, current pressure ulcer to his right medial great toe, decreased mobility, impaired ROM (range of motion) in lower extremities and his history of healed pressure ulcers. The care plan goal indicated Resident C would be free from pressure ulcers by next review. Current interventions included: head to toe skin assessment at least weekly by a licensed nurse, staff to observe skin condition while providing care, pressure redirecting mattress to bed, treatment to pressure ulcers as ordered, Z-flow cushion to elevate heels and check each shift while in bed, encourage and assist resident with turning and repositioning at least every two hours and as needed, monitor labs as ordered, and avoid lying on right side. A Pressure Area care plan, dated 10/13/2015, indicated Resident C has a pressure area located on his right medial foot and right medial great toe. The care plan goal indicated Resident C's pressure areas will decrease in size or heal without complications through the next review. Interventions included: daily skin inspection by nursing assistants, head to toe skin assessments by licensed nurse weekly and as needed, provide pressure redistribution mattress to bed, monitor for treatment efficacy if area is not improving and consult with the physician for further instruction, and assist with turning and repositioning at least every two hours and as needed. A physician's telephone order, dated 12/9/2015, indicated, PT (physical therapy) to evaluate right great toe medial likely venous stasis ulcer. A Nurse Practitioner (NP) progress note, dated 12/9/2015, indicated, Chief Complaint: Venous stasis ulcer .This is a new problem, is acute .Resident is a highly contracted male, bed bound, concern that ulcer is 2/2 (secondary) to [MEDICAL CONDITIONS]. Will request therapy to evaluate and monitor. Will observe but given patient's chronic condition, unlikely to improve. Interested in therapy's evaluation and care plan, problem unlikely to resolve quickly if at all, patient unlikely surgical candidate unless toe becomes necrotic .Diagnosis: [REDACTED]. A physician's telephone order, dated 12/11/2015, indicated, Order clarification: 1. PT wound care eval (evaluation) completed. 2. PT skilled intervention not recommended at this time via electrical stimulation due to wound stage and status. 3. Nursing to perform saline flush, xeroform (wound dressing) application, cover with gauze daily and as needed for soilage. 4. Unit staff to strictly adhere with orthotic application as scheduled. A Physical Therapy Plan of Care (Evaluation Only), dated 12/11/2015 and signed by the physician on 12/18/2015, indicated, .Reason for Referral: non healing pressure ulcer to right dorsal (back)) aspect of 1st DIP (distal interphalangeal joint) of foot .Therapy Necessity: Wound care skilled intervention via electrical stimulation is not recommended at this time d/t (due to) current wound stage and status however wound care treatment to be performed by nursing is recommended .2. Strict adherence to orthotic application and schedule to alleviate progression of contractures and pressure wound and prevent new onset of contractures and pressure wound .Discharge Plans: RNP (Restorative Nursing Program) will be in place to delay progression and new onset contractures and pressure sores .Underlying Impairments Other: Pt (patient) presents with stage 2 pressure wound to dorsal 1st DIP of R (right) foot with 100% granular tissue (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) measuring 1 cm x 0.9 cm x no depth with minimal exudate, no odor and intact periwound (tissue surrounding the wound) A physician's orders [REDACTED].cleanse R (right) great toe medial with NS (normal saline), pat dry, Xeroform (dressing) application and cover with gauze and secure QD (daily) and PRN (as needed) for soilage. A Braden Scale for Predicting Pressure Ulcer Risk, dated 12/23/15, indicated Resident C had a score of 11, indicating he was at a high risk for skin breakdown. The Certified Nursing Assistant (CNA) Shower Book, dated January 2016, indicated Resident C was to receive showers on Wednesday and Saturday evenings. The record lacked documentation the CNAs had performed a skin assessment for Resident C during his assigned showers for 1/2/2016 and 1/6/2016. Resident C's Medication Administration Record [REDACTED]. The record lacked indication Resident C had worn his orthotics to his legs on 1/2/2016 from 4 p.m. to 8 p.m., 1/3/2016 from 12 a.m. to 4 a.m., 1/5/2016 from 4 p.m. to 8 p.m., 1/5/2016 from 12 a.m. to 4 a.m., 1/6/2016 from 7 a.m. to 11 a.m., 4 p.m. to 8 p.m., or 12 a.m. to 4 a.m., and 1/7/2016 from 4 p.m. to 8 p.m. The record lacked indication Resident C had used a Z-flow cushion to elevate his bilateral heels while in bed on 1/2/2016 from 3 p.m. to 11 p.m., 1/5/2016 from 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m., 1/6/2016 from 3 p.m. to 11 p.m., 11 p.m. to 7 a.m., and 1/7/2016 from 3 p.m. to 11 p.m. The record lacked indicated Resident C had been turned every 2 hours on 1/2/2016 from 4 p.m. to 10 p.m., 1/3/2016 from 12 a.m. to 6 a.m., 1/5/2016 from 12 a.m. to 6 a.m. and 4 p.m. to 10 p.m., 1/6/2016 from 12 a.m. to 6 a.m. and 4 p.m. to 10 p.m. The record lacked indicated Resident C had a weekly skin assessment performed on Wednesday, 1/6/2016, and a skin sheet had been charted. The record did not indicate a reason Resident C had not received the nursing measures or dressing change. An undated Weekly Skin Assessment, reviewed in the January 2016 Treatment Administration Record (TAR), indicated, Directions: A head-to-toe assessment of each resident is to be completed. Should a new skin alteration be identified, the appropriate assessment and ongoing monitoring tool shall be initiated and noted below. Weekly assessment shall continue in an effort to identify any additional areas thereafter The record lacked documentation a weekly skin assessment had been performed by a nurse for Resident C during the month of January 2016. A physician's orders [REDACTED]. 12 a.m. to 4 a.m., for his [DIAGNOSES REDACTED]. A Podiatry Exam progress report, dated 1/6/2016, did not indicate Resident C had vascular conditions, cyanosis (poor circulation or inadequate oxygenatio of the blood), or claudication (condition in which cramping pain the the leg can be caused by obstruction of arteries). A Pressure Ulcer care plan, dated 1/7/2016, indicated Resident C had a pressure ulcer to his right great toe. The care plan indicated a goal for Resident C's ulcer to decrease in size/heal without complications by next review. The care plan included undated interventions of: treatment as ordered, monitor per Skin Management Program and SWAT (facility's wound monitoring) protocol, monitor for treatment efficacy, pressure reducing devices to bed and chair, assist/encourage to turn and reposition at least every two hours and as needed, Xeroform (dressing change) per order, boots on bilateral feet when braces are off. A Contracture care plan, dated 1/7/2016, indicated Resident C suffers with contractures to bilateral knees and is at risk for further contractures. The goal indicated Resident C will be free from further contractures. Undated care plan interventions include: ensure that splints are placed as per orders and patient to wear BLE Bilateral lower extremities) daily for four hours each shift for his contractures. An undated Restorative Program document was provided by the Physical Therapist (PT) #66 on 1/8/2016 at 1:55 p.m. This document indicated, .Program #1 Special Instructions: Apply RLE (right lower extremity) and LLE (left lower extremity) splint daily. Leave on for 5 hours each shift then remove. The record indicated a picture with instructions that an abductor bar is to be placed medial (inside) the orthotics. A Wound Care Evaluation, dated 12/21/15, indicated Resident C had a stage 3 (full thickness skin loss) wound to his right greater toe, measuring 0.4 cm x 0.4 cm with depth of 0.1 cm. The date of the wound's onset was 8/8/2014 and had been facility acquired. SWAT program documentation titled,Ongoing Assessment of Pressure Ulcer, measurements indicated Resident C's pressure ulcer to his right medial great toe had been identified as a Stage 3 pressure ulcer on 12/31/2014 with measurements of 0.7 cm x 0.4 cm and depth of 0.1 cm. The wound continued as a stage 3 pressure ulcer with increase in length and width until it progressed to an unstageable wound on 7/16/2015 with measurements of 2.6 cm x 2.8 cm and depth of 0.1 cm. The wound was then classified down as a stage 3 pressure ulcer on 7/24/2015 with measurements of 3 cm x 3 cm and depth 0.1 cm. Resident C's wound was classified down as a stage 2 (partial thickness loss of dermis) pressure ulcer on 8/14/2015 with measurements of 3 cm x 3 cm and depth less than 0.1 cm. The wound progressed to an unstageable pressure ulcer with measurements of 0.3 cm x 0.3 cm and depth unable to be determined on 9/3/15. Resident C's wound was classified on 10/8/2015 as a stage 2 pressure ulcer with measurements of 1.7 cm x 1.6 cm and depth less than 0.1 cm. From 10/16/2015 to 11/6/2015, measurements indicated Resident C's pressure ulcer to his right great toe was classified as a stage 2 pressure ulcer with depth unable to be determined. On 11/13/2015, the wound continued as a stage 2 pressure ulcer with measurements less than 0.1 cm x less than 0.1 cm and no depth. The wound progressed to a stage 3 pressure ulcer on 12/18/2015 with measurements of 2.5 cm x 2.0 cm and depth of 0.2 cm. The wound progressed to an unstageable pressure ulcer on 12/22/2015 with measurements of 1 cm x 1 cm and depth unable to be determined. Resident C's pressure ulcer to his right great toe remained at an unstageable pressure ulcer on 12/30/2015 with measurements of 1 cm x 1 cm and depth unable to be determined. During an interview on 1/7/2016 at 2:17 p.m., LPN #61 indicated Resident C currently had a composure (therapeutic) mattress and used to have a low air loss mattress. She indicated he wore orthotic braces to his legs from 8 a.m. to 2 p.m. She indicated the staff experience difficulty floating his heels due to his contracted legs. During an interview on 1/8/2016 at 9:34 a.m., CNA #65 indicated Resident C had orders to wear his orthotic braces to his lower legs for 4 hours each shift. She indicated she did not float his heels with a Z-flow cushion while in bed and indicated his room did not contain a cushion to float his heels with. She indicated he is repositioned in bed every 2 hours and she did not always float his heels with a pillow while in bed. She indicated he had a pair of Bunny Boots in his closet and he did not wear them during the day shift. She indicated the CNAs monitor the residents' skin conditions during each shower day by filling out a skin sheet and placing it in the shower binder. She

Based on interview and record review, the facility failed to ensure recommended restorative services were provided to 1 of 3 resident reviewed for restorative therapy resulting in harm as evidenced by a decline in functional status (Resident V). Findings include: During a Stage 1 interview on, 12/15/14 at 12:03 p.m., Resident V indicated she had pain in her legs which she rated at a 6 or 7 out of 10. She indicated she was supposed to have her legs stretched as a part of her therapy and had not received those services. She indicated the leg stretches made her feel better and alleviated some of her pain. She indicated she informed the nurses and Director of Nursing (DON) of her request to have these services, but had not received them for several months. She indicated when the facility had a restorative program she routinely received stretching exercises from a restorative aide. She indicated the facility discontinued offering restorative services. During an interview with Unit Manger #34 on 12/16/14 at 11:00 a.m., she indicated she thought Resident V had a contracture to her left wrist. She indicated the resident wore a splint for her wrist at night, but was not on a restorative program. She further indicated the facility discontinued its restorative program. On 12/18/14 at 12:31 p.m., Resident V was observed sitting in her wheel chair in her room. She indicated her legs had not been exercised or stretched since the interview on 12/15/14. She further indicated she had not received massages for her pain. During an interview on 12/19/14 at 10:53 a.m., CNA #32 indicated she was not sure who provided restorative care for residents. During an interview on 12/19/2014 at 11:00 a.m., Physical Therapist # 36 indicated when a resident's therapy services were discontinued a restorative program was provided by the nurses. She indicated physical therapy set up the exercises and restorative plan. During an interview on 12/19/14 at 11:16 a.m., LPN # 37 indicated the facility's restorative program was discontinued earlier in the year. She indicated the CNA's were responsible for providing restorative care. LPN #37 indicated she had not performed massages or similar interventions for Resident V. During an interview on 12/19/14 at 11:57 a.m., Physical Therapist #36 indicated a change on the MDS assessment for functional status from limited assistance to extensive assistance indicated a decline. She indicated the restorative program exercises were to maintain or improve joint range of motion (ROM) and muscular flexibility. She indicated a decline was possible when a resident had not received recommended services. During an interview on 12/19/14 at 12:16 a.m., the Director of Nursing (DON), indicated the facility used to have a contracted restorative team. She indicated CNA's were responsible for restorative care. The DON indicated Resident #41 informed her she needed therapy and was "upset" the service was discontinued. The DON indicated CNA #37 provided restorative care for Resident V. She indicated CNA #37 worked 5 days a week and did not chart the restorative exercises she provided for Resident #41. The DON indicated CNA #37 knew what exercises to perform. During an interview on, 12/19/14 at 12:24 p.m., Resident V indicated she had not received restorative services from CNA #37. During a phone interview on 12/19/14 at 12:36 p.m., CNA #37 indicated she cared for Resident V a " couple of days every 3 weeks. " She indicated she had not cared for Resident V for 2 weeks or longer and indicated if she did ROM it consisted of bending the resident's knee and raising her knee up 5 times when the resident's legs got stiff. A chart review of Resident V's medical record was completed on 12/18/14 at 10:54 a.m. An MDS dated [DATE] indicated Resident V required limited assistance for bed mobility. A physicians order, dated 9/13/14, indicated, "PT (Physical Therapy)/Restorative (Resident V) is requesting stretching and standing exercises legs 10 minutes to 15 minutes 3 times per week to prevent cramps." A Restorative Program plan, dated 9/26/14, indicated the resident was quadriplegic and at risk for contractures related to decreased mobility. The resident was to have Passive Range of Motion (PROM) exercises to her bilateral lower extremities (ble) at the rate of 25 reps to each joint 6 days a week. The order also indicated the resident was to have lotion applied as needed, pain monitoring, resistance monitoring and monitoring for swelling and or redness. A Minimum Data Set (MDS) assessment, dated 10/26/14, indicated Resident V was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and required extensive assistance for mobility. A pain care plan dated, 11/13/14, indicated interventions of light therapeutic massage of the afflicted areas An undated "CNA Assignment Sheet" did not indicate Resident V received restorative services. . A physicians order for December of 2014 indicated the resident, "May participate in restorative nursing program." The record indicated the last date the facility documented the resident received restorative ROM services was February 28, 2014. A policy and procedure entitled, "Restorative Nursing Services," received from the Administrator on 12/19/14 at 3:32 p.m., indicated, "The facility shall be responsible to ensure that residents receive restorative nursing programs in an effort to assist them in maintaining/attaining their highest practicable level of physical independence...." This Federal tag relates to Complaint IN 538. 3.1-42(a)(2)

Based on closed record review and interview, the facility failed to ensure 1 of 4 sampled residents who entered the facility without pressures did not develop stage 2 pressure ulcers (skin breaks open and the sore expands into deeper layers of the skin) on the right and left buttocks (Resident B). Findings include: Resident B closed clinical record was reviewed, on 09/23/13 at 2:15 p.m., and indicated Resident B was admitted from the hospital to the facility. Resident B had [DIAGNOSES REDACTED]. Hospital records, dated 06/28/13, indicated Resident B was in the hospital from March 21, 2013 to June 28, 2013, and had no pressure sores. Resident B's Nursing Admission Assessment, dated 06/28/13, indicated "no skin issues." Resident B's Braden Scale Assessment, dated 06/28/13, indicated a score of "16" which represents a high risk for pressure sores. Resident B's initial care plan, dated 06/28/13, indicated, "At risk for alteration in skin integrity R/T (related to): incontinence decreased mobility (bedrest)" had as a goal, "Resident will be free from skin breakdown thru next review." Interventions included: "*Assess skin daily for signs of breakdown & report to MD and responsible party PRN (as needed). *Resident to be monitored by SWAT weekly for 30 days. *Assist with turning & repositioning at least every 2 hours. *Peri care per policy after each incontinent episode." Review of Resident B's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] Cream 2% - Apply to peri-area & coccyx BID...." This medication was for a yeast infection and the MARs lacked documentation as being administered. House barrier cream to peri area & buttocks prn redness as a preventative measure was also ordered on [DATE]. This was documented as done on the MAR indicated [REDACTED] Review of the "WEEKLY SKIN ASSESSMENT", dated 07/02/13, indicated, "Head to toe skin assessment completed & no skin alterations noted." Physician telephone orders, dated 07/06/13 at 2:00 p.m., indicated an order for [REDACTED]." Resident B's clinical record lacked documentation of a schedule for positioning. The "PRESSURE ULCER FLOWSHEET", dated 07/08/13, indicated a stage II pressure ulcer was found on the right and left buttocks. The measurements, dated 07/09/13, indicated the right buttock pressure ulcer was 7 centimeters (cm) x 4 cm x <0.1 cm and the left buttock pressure ulcer was 8 cm x 6 cm x <0.1 cm. Small brown areas on the right buttock measured 1.0 cm x 1.0 cm on the upper part of the open area and the mid brown area measured 1.0 cm x 1.0 cm. The left buttock had a small brown area in the middle of pressure ulcer which measured 1.0 cm x 2.0 cm. Last measurements for the right buttocks was 6.5 cm x 3.0 cm x <0.1 cm which showed improvement. The left buttock ulcer stayed the same in size. Resident B's admission Minimum Data Set (MDS) assessment, dated 07/09/13, indicated Resident B was severely cognitively impaired and was a high risk for pressure sores. The skin assessment, dated 07/09/13, indicated, "Head to toe skin assessment completed. New skin alteration found. See: Pressure Ulcer flowsheet." Resident B's record lacked documentation of Resident B having any problems on his buttocks prior to the finding of the stage II pressure sores which were large in size when found. Review of the Nutritional Assessment Form, dated 06/28/13, indicated the current formula for the tube feeding was meeting 100% of estimated needs at this time. There were no new interventions when Resident B developed his pressure sores. Documentation on the admission MDS assessment, dated 07/09/13, indicated the resident had a problems with friction and shearing per observation during assessment period and Braden, dated 07/05/13. The resident's care plans lacked documentation of using a bed sheet to pull resident up in bed. Physician telephone orders, dated 07/09/13 indicated, "order clarification [MEDICATION NAME] to pink areas of wound (L) & (R) buttocks, Santyl to brown areas of wound. Cover with nonstick [MEDICATION NAME] then 4 x 4's and ABD pad secure with Medifix tape qd (every day) and prn soilage." Resident B's care plan, dated 07/11/13, for at risk for development of pressure ulcers indicated a goal of "The resident will be free from pressure ulcers. (sic) By (sic) next review." Interventions included, head to toe skin assessment at least weekly by a licensed nurse, staff to observe skin condition while providing care, notify the charge nurse of any skin problems for further assessment and possible MD and responsible party notification, pressure redirecting cushion to chair, pressure redirecting mattress to bed, encourage and assist resident with turning and repositioning at least every two hours and as needed, apply preventative topical medication as ordered, monitor labs as ordered, encourage food and fluid intake as diet permits, refer to dietician as indicated, strict turn every 2 hours 07/06/13, administer medication per physician orders, treatment to pressure ulcers per physician orders. Resident B's care plan, dated 07/11/13 with update of 07/16/13, indicated, "The resident has a pressure area located: right buttocks" indicated goal of "The pressure area will decrease in size or heal without complications thru next review." Interventions included: Notify physician and responsible party of area and as needed, apply treatment as ordered, daily skin inspection by nursing assistants, head to toe skin assessment by licensed nurse weekly and PRN, provide pressure redistribution mattress to bed, provide pressure redistribution cushion for wheel chair, refer to Registered Dietician as indicated, monitor for treatment efficacy, if area is not improving, consult physician for further instruction, Braden risk assessment to be completed per policy and procedure, assist with turning and repositioning at least every two hours and as needed, therapy referral as needed, educated resident and responsible party on risk factors of skin breakdown and interventions, also see incontinence care plan, also see dietary care plan, administer nutrition or hydration interventions as ordered, [MEDICATION NAME] & Santyl per physician orders, D/C Santyl, [MEDICATION NAME] only 7/16/13. Resident B also had a care plan for the left buttock with the same interventions, but the Santyl was not discontinued. Physician telephone orders, dated 07/16/13, indicated, "[MEDICATION NAME] 0.5 mg DC (discontinue) [MEDICATION NAME] 1 gm x 1 - may use [MEDICATION NAME] (2 cc) DT (due to) possible URI (Upper Respiratory Infection) CXR (chest x-ray) - DT possible URI CBC (complete blood count), BMP (blood metabolic panel) - DT possible URI." According to documentation found on the Admission MDS assessment, [MEDICATION NAME] increases the risk for pressure sore development and was not discontinued until 07/16/13. The record lacked laboratory test results. Physician telephone orders, dated 07/17/13, indicated, "Transfer to ____ (name of hospital) ER (emergency room ) Pneumonia on cxr (chest x-ray) Increased lethargy, etc." Interview with Resident B's daughter, on 09/23/13 at 8:08 p.m., indicated Resident B was in the hospital several days prior to coming to the facility and had no pressure sores upon admission to the facility. Resident B's daughter indicated she called the medical doctor due to her father was not himself, was more lethargic, had run a temperature, and not in the same condition as he was upon admission to the facility where he was talking, joking, and much more alert. Resident B's daughter indicated her father had double pneumonia and was sent to the hospital and was started on 4 different antibiotics at the hospital. Resident B's daughter indicated the resident improved and was moved to another facility and his pressure ulcers were like new skin before he passed away. Interview with the Administrator, Director of Nursing (DON), and Corporate Nurse at exit, on 09/24/13 at 3:45 p.m., indicated the resident was in bad shape and staff was in his room all the time. The Corporate Nurse indicated the resident had a yeast infection on his peri area, which could have contributed to his skin breakdown. Review of the facility's policy for "INTERVENTIONS TO REDUCE THE RISK OF PRESSURE ULCER DEVELOPMENT & PRESSURE ULCER MANAGEMENT", dated 01/10/10, indicated, to add multivitamin with minerals daily. This deficiency is related to Complaint IN 291. 3.1-40(a)(1)

Based on record review and interview, the facility failed to ensure the nurses provided and documented accurate and ongoing assessment, in that when a resident was identified with a history of [MEDICAL CONDITION], pneumonia and lower extremity [MEDICAL CONDITION] and required additional diuretics to treat the resident's signs and symptoms, the nursing staff failed to recognize the resident's ongoing respiratory distress and decline in condition over a period of 11 days which resulted in the resident being transferred to the hospital with volume overload and [MEDICAL CONDITIONS]. This deficient practice effected 1 of 3 residents reviewed for [MEDICAL CONDITION] in a sample of 10. (Resident "A"). Findings include: The record for resident "A" was reviewed on 09-09-11 at 9:45 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had physician orders [REDACTED]. (milligrams) 3 tablets (120 mg) by mouth every morning and 2 tablets (80 mg) every evening. Review of the resident's plan of care, dated 06-29-11, indicated the resident "requires use of oxygen at 2 liters per nasal cannula due to [MEDICAL CONDITIONS] and pneumonia to keep sats (oxygen saturation) level greater that 90 %." Interventions to this plan of care included [MEDICATION NAME] (a respiratory treatment) every 6 hours, use oxygen at 2 liters per nasal cannula." The plan of care related to [MEDICAL CONDITION], and dated 06-30-11, indicated the resident was at risk for respiratory distress. Interventions included "observe for signs and symptoms of respiratory distress, elevate HOB (head of bed) as needed to facilitate respiratory effort, administer oxygen as ordered, administer medications as ordered, advise the charge nurse if signs or symptoms are noted for further evaluation and possible physician and responsible party notification." Review of the nurses notes, dated 08-17-11 at 1:00 p.m., indicated the following:"Res. (resident) c/o (complained of) leggs <sic> being tight, upon assessment legs were swollen and tight. Called MD (Medical Doctor), new orders for increased [MEDICATION NAME] (a diuretic) to 10 mg (milligrams) BID (two times a day) times 3 days. POA (power of attorney) notified about medication changes, resident aware. Will continue to monitor for s/s (signs and symptoms) of infection and adverse reactions. Will follow plan of care." The next nurses note entry was dated 08-28-11 at 5:00 a.m., 11 days later, which indicated the following:"Pt. (patient) states having spell. c/o stomach hurting. tylenol (an [MEDICATION NAME]) given for pain, was effective." Nurses note 08-29-11 1:00 a.m., "Pt. c/o stomach <sic> pain and not being able to lay in bed. Resident was given tylenol and sat in wheelchair. Resident also given (illegible word). Both meds (medications) were effective." Review of the Respiratory therapist notations for 08-30-11 at 6:30 a.m., indicated the resident's oxygen saturation level was 69 - 70 %. The therapist placed oxygen on the resident and turned to level to 5 lpm (liters per minute). The therapist documented the resident's oxygen level was checked 30 minutes later and the oxygen level had increased to 88 % and then a later notation indicated oxygen level was recorded at 92 %. Breath sounds were "diminished." Nurses note dated 08-30-11 at 8:00 a.m. Awake, up in wheelchair. O2 (oxygen) saturation 84 % on RA (room air). Lungs course/dim. (diminished). O2 (oxygen) places <sic. at 2L (liters). Slight confusion. 1+ pedal [MEDICAL CONDITION]. O2 sat recheck <sic> at 1 hr. (hour) 89% - O2 at 2L. MD (Medical Doctor) notified. Family notified. N.O. (new order) received to send out to (name of local area hospital)." A respiratory therapist notation on 08-30-11 at 11:30 a.m., also indicated the resident's breath sounds remained "diminished." "Pt. (patient) continues to "de sat (unable to keep oxygen level up) Resident is going to the hospital." During an interview on 09-14-11 at 12:30 p.m., Respiratory Therapist- Employee #21 indicated the following:"I went in to do a treatment and I put the probe on (resident's name) finger. (Resident) O2 Sat. (oxygen saturation level) was 69 % - 70 %. I put the oxygen on (resident) at 2 liters. I rechecked the O2 Sat. and it came up to 88 % - 90 %. It kept dropping a little bit. I went out to tell the nurses, they were in report. She (in reference to the nurse) went to call the MD (Medical Doctor). I worked with (name of resident) 30 - 40 minutes. I finally got it (in reference to the oxygen saturation level) up in normal range and I left and went on to do what I had to do - the next treatment. After that I went back. Toward the end of the treatment (resident's family member) came in and the nurse said that after (name of resident) ate lunch she was going to send (resident) out (in reference to the hospital). I told (name of nurse) that (name of resident) wasn't acting right." During an interview on 09-14-11 at 10:12 a.m., a concerned family member indicated, "(Resident) kept coughing and coughing. It was a real deep cough. This happened before in April and it seemed just like the same thing all over again. They told me they would give (resident) additional [MEDICATION NAME], but it didn't seem to help." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the hospital History and Physical, dated 08-30-11, indicated the following:"... presents to hospital via EMS (emergency medical system) from the nursing home with worsening dyspnea and lower extremity [MEDICAL CONDITION]. (Resident) is short of breath ... coughing ... was hypoxic and has been placed on [MEDICAL CONDITION] (breathing treatments) per the emergency room physicians. the chest x-ray show bibasilar infiltrates and [MEDICAL CONDITIONS] ... is grossly volume overloaded ...has an elevated white count. There is concern for coexistent pneumonia and had abdominal discomfort as well. (Resident) has progressive lower extremity [MEDICAL CONDITION] and abdominal swelling. Lungs: very coarse and crackly without wheezes, very diminished in the bases bilaterally. Abdomen: markedly distended but non tender. Probably has ascites - and most likely related to [MEDICAL CONDITION]. (Resident) has abdominal wall [MEDICAL CONDITION]. Extremities: There is 3+ lower extremity [MEDICAL CONDITION] to the thighs bilaterally. Assessment: The patient has acute on chronic [MEDICAL CONDITION]. The etiology is not quite clear and is probably multifactorial, including at least in part some component of [MEDICAL CONDITION], [MEDICAL CONDITIONS], pleural effusions, possible superimposed pneumonia and [MEDICAL CONDITION] exacerbation." Review of the hospital cardiology consult report, dated 08-30-11, indicated "Today (resident) is short of breath ... coughing. (Resident) is grossly volume overloaded. On admission, (resident) blood pressure was tenuous with systolics running in the 80's to 90's. (Resident) has abdominal discomfort as well. In addition, has an elevated white count and a venous [MEDICATION NAME] of 3. This would raise concern for [MEDICAL CONDITION] as well." This federal deficiency relates to Complaint IN 814. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident was free from pressure ulcers in that when a resident was identified as incontinent of bowel and bladder, relied on the nursing staff for repositioning needs, and was at risk for pressure ulcers, the facility failed to ensure the resident was kept clean, dry and repositioned which resulted in new pressure areas/skin breakdown for 1 of 3 residents reviewed for risk of pressure ulcers in a sample of 10. (Resident "J"). Findings include: During the Initial tour of the facility on 09-08-11 at 10:30 a.m., Resident "J" was assessed by the Unit Manager, Licensed Practical Nurse- Employee #4 as "total care." The record for Resident "J" was reviewed on 09-09-11 at 2:15 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set assessment, dated 08-09-11, indicated the resident required total care for transfer, ambulation, dressing, eating, hygiene and incontinent needs. In addition, the assessment indicated the resident did not have a previous history of pressure ulcers. Review of the resident's plan of care, dated 08-18-11, indicated the resident required assistance with Activities of Daily Living due total dependence for bed mobility, transfers, eating and toilet use. The resident's plan of care for Urinary Incontinence, dated 08-18-11, indicated the resident was incontinent of bladder and required the nursing staff to "approach resident at least every two hours and ask and or check for evidence of incontinence." Interventions to this plan of care included "encourage and assist resident with turning and repositioning at least every two hours. Provide incontinent care after each incontinent episode." The plan of care, dated 08-10-11, with the identified problem "risk for the development of pressure ulcers due to incontinence, spends all/lost of time in bed/chair, impaired communication, impaired cognition, and dependence on staff for transfers, repositioning and bed mobility. " Interventions to this plan of care included "apply preventative topical medication as ordered - [MEDICATION NAME] every shift, provide incontinence care after each incontinent episode, encourage and assist resident with turning and repositioning at least every two hours." During observation on 09-09-11 at 8:15 a.m., the resident was observed seated in wheelchair and remained seated in the wheelchair until 10:10 a.m. A request was made to check the resident for incontinence. CNA- Employee #16 indicated the resident was "up and in the wheelchair since about 7:30 a.m." The CNA pulled down the front of the resident's slacks and indicated the resident was "dry." A request was made to transfer the resident in to bed to check skin. CNAs- Employees #14 and #16 exited the resident's room and approximately 10 minutes later returned with the mechanical lift. The CNA's positioned the lift in front of the wheelchair, fastened the appropriate hooks onto the sling that was already positioned beneath the resident, and then transferred the resident to bed. The CNA's removed the resident's slacks, unfastened the incontinent brief, and a strong smell of urine permeated the air. The resident was wearing one incontinent brief inside of the other and the inner brief was saturated and heavy with urine. The CNA's indicated they were unaware the resident had been placed in two incontinent briefs. During observation on 09-14-11 at 9:30 a.m., the resident was observed lying supine (on their back) in bed. Further observation on 09-14-11 at 12:00 p.m., the resident remained in the supine position. A request was made to check the resident for incontinence. The Licensed Practical Nurse-Employee #26 pulled the bed linens down to the end of the bed, looked at the brief and indicated the resident was "dry." A request was made to turn the resident and check the resident's skin. Licensed Practical Nurse- Employee #26 enlisted the assistance of Licensed Practical Nurse-Employee #27, and both turned the resident to the left side. The incontinence brief was unfastened and the resident was observed with two incontinent briefs on. The inner brief was wet with urine. As the resident was turned to the left side, two open areas were observed. Licensed nurse-Employee #27 verified the areas were pressure areas and measured each one. Area #1 on the right buttocks measured 1 cm (centimeter) "around and 0.2 cm. in width by 0.8 cm. in length, while area #2 located on the left buttocks/coccyx measured 0.1 centimeter "around" and 0.5 cm in width by .4 cm in length. 3.1-40(a)(1) 3.1-40(a)(2)