Every finding on record at Evergreen Crossing and the Lofts

Based on observation, interview, and record review, the facility failed to ensure eggs were pasteurized and foods were stored safely during 1 of 3 kitchen observations. This deficient practice had the potential to affect 97 of 99 residents who received food from the kitchen. Findings include:During an initial kitchen observation, on 4/13/26 at 6:45 a.m., the following was observed with [NAME] 12. The walk-in cooler's door was propped open, and the floor was wet. [NAME] 12 indicated the floor in the walk-in was wet because the door was propped open, and it had been propped open for about 30 minutes. [NAME] 12 indicated the temperature in the walk-in was 55 degrees Fahrenheit (F) per the electronic temperature reading. [NAME] 12 was unable to find a second thermometer inside the walk-in cooler. A box of eggs with 18 remaining was observed in the walk-in cooler. The eggs were not noted to be pasteurized. There was no stamped p on the eggs and no note on the box to indicate they were pasteurized. [NAME] 12 observed the eggs and the box and confirmed there was no documentation to indicate the eggs were pasteurized. [NAME] 12 indicated eggs were sometimes cooked to order, and some residents requested eggs with the yolks not completely cooked. A pizza, dated 3/4/26, was observed in the walk-in cooler. [NAME] 12 indicated the pizza should have been removed. During an observation, on 4/13/26 at 8:06 a.m., the walk-in cooler was observed with [NAME] 12. The electronic temperature reading indicated 33 degrees F. [NAME] 12 also checked a thermometer inside the walk-in cooler, hanging from a shelf near the door, and indicated it also read a temperature of 33 degrees F. During an observation, on 4/15/26 at 9:27 a.m., the walk-in cooler was observed with [NAME] 12. There were no eggs in the cooler. At the same time, [NAME] 12 indicated if they ran out of eggs, and there was no delivery coming, then someone would go purchase eggs from the store. On 4/15/26 at 9:45 a.m., the Administrator provided a receipt, dated 4/3/26, which indicated a case of pasteurized eggs was delivered. The Administrator was unable to provide documentation of where the box of eggs observed upon entrance came from. During an interview, on 4/15/26, the Dietary Manager indicated the pizza should have been discarded about a week after the date indicated on the pizza. The door to the walk-in cooler should not have been left open, and 55 degrees F was too warm for the cooler. As far as he knew, all the eggs were pasteurized. The Dietary Manager indicated maybe the dye on the eggs that indicated P for pasteurized had been rubbed off or maybe the box was not labeled correctly. On 4/16/26 at 11:30 a.m., the walk-in cooler was observed with the Corporate Dietary Support. The new case of eggs were in a box with PASTEURIZED in large letters across the side of the box. Each egg had a clearly stamped P. At the same time, the Corporate Dietary Support indicated maybe the other eggs had been placed in an ice bath and the P had come off each egg. On 4/16/26 at 2:16 p.m., the Administrator provided a policy titled, Food: Preparation, last revised in February 2026, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures.4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F.8. Only pasteurized egg products will be used for soft cooked egg items. On 4/16/26 at 2:16 p.m., the Administrator provided a document titled, Food Storage: Cold Foods, last revised in February 2026, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures.2. All perishable foods will be maintained at a temperature of 41 degrees F or below, except during necessary periods of preparation and service. On 4/16/26 at 2:16 p.m., the Administrator provided a document titled, Cold Food Storage Chart, last revised on 9/19/23, and indicated it was the policy currently being used by the facility. The policy indicated leftover pizza was able to be stored in the refrigerator for three to four days. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident received person-centered dementia specific care and services for 1 of 1 residents reviewed for dementia care services (Resident 72). Findings include:On 4/13/26 at 11:35 a.m., Resident 72 was initially observed. She was lying in bed with her eyes closed and appeared to be asleep. She wore a hospital gown, her hair was tangled, flattened on one side, and appeared to be greasy. There was a band aide on her upper right forehead with a dried dark substance around the edges and into her scalp at her hairline. Her fingernails were long and observed to have dark debris under them. Her television was on a news station. No other sensory stimulation for the resident was observed in the room. On 4/14/26 at 9:12 a.m., the Wound Nurse Practitioner (W-NP) exited Resident 72's room. She indicated they had just finished assessing and dressing a pressure, located on her sacrum. She indicated Resident 72 had experienced a significant decline since her return from the hospital. She was confused and often refused turning/repositioning care, as well as medications, specifically, insulin. The W-NP indicated Resident 72's dementia seemed to have progressed quite a bit and she was no longer able to have mildly coherent conversation. Instead, she just repeated, help help, please help me, even when all of her needs had been met. On 4/14/26 at 12:37 p.m., Resident 72 was observed. She remained in bed. She wore a hospital gown. Her hair had been done in two neat French braids, but the soiled band aide with dried dark substance remained. She called out repeatedly, help, help, help. Although her television was on a news station. No other sensory stimulation for the resident was observed in the room. On 4/14/26 at 12:40 p.m., Licensed Practical Nurse (LPN) 7 entered Resident 72's room. At that time she indicated Resident 72 had severe dementia which seemed worse since her return from the hospital. She used to be able to answer some yes/no questions, but now all she seemed to say was help help help. Her television was on a news station. No other sensory stimulation for the resident was observed in the room. LPN 7 indicated she did not know what kind of activities Resident 72 would like besides just visiting with her. On 4/15/26 at 8:45 a.m., Resident 72 remained in bed. She called out, help, help, help me please repeatedly. She closed her eyes between her calls for help. In between her bouts of drowsiness and calls for help, she appeared more alert than the previous days. Resident 72 indicated she was from Bulgaria, she moved to America when she was young, she had been a librarian and library director for over 30 years and gave the title of her favorite book. She indicated she could not see the TV or books anymore because she was totally blind with diabetic blindness. On 4/15/26 at 9:36 a.m., Resident 72 was up out of bed. She was seated in a regular wheelchair in her room with her over-bed table locked in place in front of her. Her eyes were closed, her head was tucked down and she leaned far forward in her chair, her forehead nearly resting on the arm rest of the chair. She remained in a hospital gown, which was untied at the neck and allowed the material to slip off her shoulder revealing her entire upper back, her left shoulder, and left upper arm. During an interview on 4/15/26 at 10:28 a.m., LPN 8 indicated Resident 72 was easily overstimulated and preferred a lot of one-on-one time with staff. Once anyone went into her room it was hard to leave without her getting upset. LPN 8 indicated she usually waited until last to administer Resident 72's medications for the morning since getting her cleaned up, out of bed, and her eating breakfast often caused increased anxiety and distress for her. Resident 72 most enjoyed someone sitting with her or holding her hand at all times. During an interview on 4/15/26 at 12:03 p.m., LPN 7 and Certified Nursing Aide (CNA) 9 exited Resident 72's room. They indicated she had just been put back in bed. Resident 72 was heard from the hallway calling out help, help, help, per her baseline. LPN 7 and CNA 9 indicated they did not know what else to do to ease her anxiety. Resident 72 was observed at this time. She remained in a hospital gown, the soiled band aide remained in place on her forehead. The television was on. No other sensory stimulation for the resident was observed in the room. On 4/15/26 at 12:38 p.m., LPN 8 entered Resident 72's room to administer medication and check her blood glucose. Initially Resident 72 refused her insulin, but with patience and encouragement, LPN 8 was able to get Residet 72 to accept her insulin. Resident 72 called out for help continuously, even though LPN 8 was in the room. LPN 8 indicated Resident 72 really needed one-on-one and she wished she could stay with her longer, but needed to finish her duties. When LPN 8 left the room, the television was on, but no other sensory stimulation for the resident was observed in the room. On 4/16/26 at 8:45 a.m., Resident 82 remained in bed in a hospital gown. Her eyes were closed and she appeared to be asleep. There was a breakfast tray on the over-bed table beside her. Her breakfast tray was observed to have zero of the scrambled eggs eaten, less than 25 percent (%) of the oatmeal eaten, and zero of the muffin eaten. The television was on, but no other sensory stimulation for the resident was observed in the room. On 4/16/26 at 11:31 a.m., the IP was in Resident 72's room and observed her band aide and fingernails. She indicated there should not be a band aide in place so that staff could monitor for signs/symptoms of infection and her fingernails needed to be trimmed and cleaned. On 4/16/26 at 11:50 a.m., Resident 72 was observed out of her room and sat in her wheelchair at the end of a table in the main activity/dining area. The area she sat was densely populated and had high foot-traffic patterns of residents, staff and visitors walking talking and passing by. Current popular songs were playing on a speaker. Resident 72 was heard calling for help per her baseline, but more loudly, and with more anxiety in her voice. On 4/16/26 at 11:52 a.m., the Assistant Business Office Manager (ABOM) indicated, she was Resident 72's Angel and knew her well. She indicated Resident 72 needed to be in a memory care setting, something that was less overstimulating and able to meet her needs with more attention. Big activities like the one she was sitting in, often overwhelmed her and she would ask to go back to her room, but now all she could say was help. On 4/17/26 at 10:20 a.m., Resident 72 was observed. She had been brought back to the main dining/activity room. She sat at the end of a table. At the opposite end sat two of her peers, Residents 13 and 79. When Resident 72 called out, help, help me, please, help me, Residents 13 and 79 mimicked her please in a mocking tone. There was a slight altercation between two male peers at the same table, and when one of the men were redirected and taken away from the table, Resident 13 and 79 indicated, they should have taken her away instead, pointing to Resident 72. On 4/14/26 at 12:40 p.m., Resident 72's record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, type II diabetes mellitus with diabetic neuropathy, unspecified dementia with agitation, and anxiety disorder. A nursing progress note, dated 12/18/25 at 1:17 p.m., indicated Resident 72's guardian and the facility agreed that another facility with an all-female dementia care unit was better suited for the resident's needs and behaviors. A nursing progress note, dated 1/13/26 at 12:16 p.m., indicated Resident 72 would benefit from a dementia unit. That was discussed with facility staff who were in agreement with the social worker. A nursing progress note, dated 2/19/26 at 1:38 p.m., indicated Resident 72 was a long term care resident who will possibly transition to a dementia unit once her Medicaid was approved. Her team was working on finalizing her assets. The resident enjoyed classical music and she preferred to stay in her room. She had an active care plan, initiated on 7/20/25 and revised on 8/11/25, which indicated, she was self-directed for activities in and out of room daily, and indicated the resident was dependent on staff for activities, cognitive stimulation or social interaction due to her disease process. She had a conflicting care plan, initiated on 3/6/26, which indicated she engaged in self-initiated leisure activities and preferred independent leisure pursuits. Neither activity care plans were revised to include some of her person-centered preferences such as the Beatles, classical music, one-on-one discussion approaches, or other sensory interventions. On 4/16/26 at 10:52 a.m. the one-on-one activity binder was reviewed. Resident 72 had not been placed one-on-one activities and was therefore not included in individual activity rounds. Resident 72 activity participation log in the electronic record for activity participation was reviewed. No activities for the previous 30 days were coded. Resident 72 was not observed in activities on 4/13/26, 4/14/26, or 4/15/26. During an interview on 4/16/26 at 11:02 a.m., the Social Service Director (SSD) with her Regional Support Staff present, indicated Resident 72 really needed to be in a special memory care unit, but because she had been private pay for so long, no one would accept her with the amount of money she owed. In the meantime, the SSD indicated they were just waiting for her to be approved for Medicaid, so she could be transferred to a more appropriate setting. In the meantime, the SSD indicated she did not know of any other dementia-specific interventions which were in place for her besides routine activities. At that time, the Regional Support Staff reviewed Resident 72's activity care plans and agreed that they were contradicting as one care plan indicated she was self-directed for activities, while the second indicated she was dependent on staff for activities. During an interview on 4/16/26 at 1:20 p.m., Resident 72's guardian indicated she and the facility had been trying to get her into a memory care unit for a while, but due to the amount of money she owed from being private pay while trying to get on Medicaid, no one would accept her. While staff were very kind and patient with her, the [NAME] indicated, they needed to be more proactive and dementia-aware and instead of giving up the first time she says no to something, they should try to encourage her, or redirect with a different options. Instead of going into her room and asking do you want to take a shower? staff should take the approach to go in and say things like, it's time to get a shower. The guardian indicated, she had multiple conversations with the staff to just stop asking her if and what she wants and help her do them instead, especially considering the severity of her dementia they need to just go in and say, hey it's time for . or let's go ahead and get up to do . Resident 72 did better in small quiet environments, she loved the Beatles, classical music, and traditional Bulgarian music. She used to be a librarian, and although she was legally blind, she might like to hold books, or have her favorite book read to her. On 4/17/26 at 11:13 a.m., the Administrator provided a copy of current, but undated, facility policy titled, Dementia Care, Resident Rights and Privileges. The policy indicated, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Residents with dementia and/or dementia-related diagnosis will be treated with the same respect and dignity and afforded the same resident rights regardless of diagnosis, severity of condition or payment source. Residents will receive care to maintain grooming and health including bathing/showering, nail grooming, oral care, and clean clothing. Individual goals will be addressed on the care plan that meet the needs of the resident for quality of life and quality of care. 410 Indiana Administrative Code (IAC) 16.2-3.1-37.

Based on observation, interview, and record review, the facility failed to ensure medications were not left at residents' bedside for 2 of 32 residents observed for potential accidents (Residents 60 and 3). Findings include:1. On 4/13/26 at 10:08 a.m., Resident 60 was observed lying in bed. There was a cup with several oral medication pills on his bedside table. At the same time, the resident indicated the nurse brought the medications about 15 minutes earlier, and he had told them he would take them later. Resident 60's record was reviewed on 4/15/26 at 11:45 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 3/29/26, indicated the resident was cognitively intact. A care plan, last revised on 2/5/26, indicated the resident had behaviors, included but not limited to, refusing medications. Interventions included, but were not limited to, administer medications as ordered. An admission nursing assessment, dated 3/25/26, indicated the resident was able to self-administer his inhaler, but not his oral medication pills. The resident's electronic record lacked documentation the resident was assessed as safe to self-administer medication, other than the inhaler. The Medication Administration Record (MAR), dated April 2026, indicated the resident was scheduled to receive allopurinol (lowers uric acid), aspirin, cholecalciferol (supplement), empagliflozin (lowers blood glucose), famotidine (treats excess stomach acid), gabapentin (nerve pain medication), lisinopril (blood pressure medication), metformin (lowers blood glucose), metoprolol (blood pressure medication), on 4/13/26 at 8:00 a.m. The MAR indicated the resident was scheduled to receive sertraline (antidepressant), spironolactone (diuretic), Xarelto (blood thinner) on 4/13/26 in the AM (morning). During an interview, on 4/16/26 at 9:42 a.m., Licensed Practical Nurse (LPN) 15 indicated medications should not have been left at residents' bedsides. The nurses were supposed to watch the residents take their medications. If a resident asked to take their medication later, then the nurse should have removed the medication from the room and returned at a later time. LPN 15 was not aware of any residents who were able to safely self-administer their oral medication pills. Residents normally were able to self-administer things like inhalers. 2. On 4/13/25 at 7:32 a.m., Resident 3 was observed sitting in her chair with her bedside table over her legs. She was eating breakfast and had a medicine cup containing 9 different oral medications pills, sitting next to her breakfast tray, along with a medicine cup of an orangish liquid. On 4/15/26 at 9:47 a.m., a record review was completed for Resident 3. She had the following diagnoses which included, but were not limited to, diabetes type 2, hyperlipidemia (high cholesterol), hypertension (high blood pressure), acute kidney failure, major depressive disorder. A review of her Medication Administration Record (MAR), dated April 2026, revealed she was prescribed the following morning medications: a. Cilostazol (used to improve blood flow and leg pain from limited circulation)100 milligrams (mg) b. Eliquis (used as a blood thinner) 5 mg c. Famotidine (used to stomach concerns)20 mg d. Ferrous Sulfate (used as a supplement) 325 mg e. Lyrica (used to treat pain) 100 mg f. Potassium Chloride Extended Release (used as a supplement) 20 milliequivalents (meq) g. Vitamin C (a supplement) 500 mg h. Vitamin E (a supplement) 180 mg i. Zinc Sulfate (a supplement) 220 mg There was no current medication order found on the April MAR for the cup of orangish cup of liquid. The medical record lacked a self-administration of medication assessment. The medical record lacked a care plan indicating the resident could self-administer her medications. On 4/15/26 at 1:32 p.m., the [NAME] President of Risk Management indicated the orangish liquid was Pro-Stat (a supplement) and she did not require an order to take it. A policy titled, Bedside Medication Storage, dated September 2025, was provided by the Administrator on 4/16/26 at 9:22 a.m. The policy indicated, Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been evaluated and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)

Based on interview and record review, the facility failed to code a Minimum Data Set (MDS) correctly when a resident was not taking an antidepressant and failed to code a resident who was edentulous (no teeth or dentures) for 2 of 20 residents reviewed for MDS accuracy (Residents 2 and 7).Findings include:1. On 4/15/26 at 1:18 p.m., a record review was completed for Resident 2. He had the following diagnoses which included, but were not limited to, dementia, anxiety, diabetes, major depressive disorder, traumatic brain injury, insomnia, and kidney disease.Resident's medication orders did not include an antidepressant.Resident's MDS, dated [DATE], indicated he was prescribed an antidepressant.On 4/15/26 at 2:02 p.m., the Corporate MDS Coordinator indicated she corrected the MDS.2. During an interview, on 4/13/26 at 8:57 a.m., Resident 7 indicated he had dentures, but they had broken.Resident 7's record was reviewed on 4/16/26 at 12:24 a.m. A nursing admission assessment, dated 10/31/25, indicated the resident did not have natural teeth or tooth fragments and was edentulous.A comprehensive Minimum Data Set (MDS) assessment, dated 11/7/25, indicated the resident was not edentulous (no teeth or tooth fragments).During an interview, on 4/17/26 at 10:20 a.m., the [NAME] President (VP) of Risk Management indicated the resident was edentulous.During an interview, on 4/17/26 at 11:04 a.m., the Regional MDS Coordinator indicated the staff member who completed the resident's assessment was not able to physically assess him because he was out of the building often. The resident's assessment should have indicated he was edentulous. If the MDS Coordinator was unable to assess a resident they should code as unable to assess. The facility used the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual for their policy on MDS coding.The CMS MDS RAI Manual, version 3.0, dated October 2025, indicated, .Section L: Oral/Dental Status. Intent: This item is intended to record any dental problems present in the 7-day look-back period. Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth or parts of teeth.410 IAC (Indiana Administrative Code) 16.2-3.1-31(c)(9)

Based on interview and record review, the facility failed to ensure a resident's code status and resident representative information was appropriately communicated during a transfer to the hospital for 1 of 5 residents reviewed for hospitalization (Resident 59).Findings include:During an interview on [DATE] at 9:31 a.m. Resident 59's legal guardian indicated the facility called Resident 59's nephew, not her, to notify a resident representative of Resident 59's transfer to the hospital. The resident's legal guardian was not notified of Resident 59's transfer until the following Monday when the social worker from the facility called to get an update on the resident. Resident 59's legal guardian indicated once she talked to the hospital staff they indicated to her that they were told Resident 59 was a full code.On [DATE] at 11:59 a.m. Resident 59's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a progressive, incurable lung disease) and dementia. Resident 59 had a legal guardian. Resident 59 had an active order for a Do Not Resuscitate (DNR) code status.On [DATE] a Physicians Order for Scope of Practice (POST) form signed by Resident 59's legal guardian was scanned into the resident's medical chart. That form indicated Resident 59 had elected a code status of DNR and the form was signed on [DATE].A progress note, dated [DATE] at 3:16 p.m., indicated Resident 59 had been transferred to the hospital at 12:00 p.m. that day for complaints of shortness of breath.A physician's note, dated [DATE] at 1:00 a.m., indicated during Resident 59's hospitalization on [DATE] she had respiratory failure and underwent a Rapid Sequence Intubation (RSI) (an emergency procedure used to quickly induce unconsciousness and paralysis to secure an airway in patients at risk of aspiration) which required 4 attempts due to stenotic airway (a serious, often acquired narrowing of the trachea or larynx, restricting airflow to the lungs).A transfer form, dated [DATE] at 2:54 p.m., indicated Resident 59 had been transferred to the local hospital at 12:00 p.m. for shortness of breath via ambulance. The form indicated Resident 59's code status was Cardiopulmonary Resuscitation (CPR). The form also indicated the resident representative who was notified of Resident 59's transfer to the hospital was a male family member of the resident.During an interview on [DATE] at 12:22 p.m. the [NAME] President of Risk Management indicated the transfer form that was in the resident's medical record was not accurate. She indicated it was filled out at 2 p.m. but the resident had been transferred at 12 p.m. The [NAME] President of Risk Management indicated they always sent a packet of paperwork with the resident when they were transferred to the hospital and that packet would include a POST form if applicable. She indicated she would find the packet and show that the facility provided the appropriate paperwork to the ambulance staff.On [DATE] at 1:26 p.m. a copy of a current facility policy titled, Transfer and Discharge Policy, undated, was provided. That policy indicated, .7. Emergency Transfer/Discharges. e. A copy of any Advance Directive,. DNR. forms should be sent with the resident. F. The original copies of the transfer form and Advance Directive accompany the resident. Copies are retained in the medical record.At the time of exit additional time was allotted to the facility to submit documentation related to the deficient practice. The facility was asked to submit any additional documentation by end of business day on [DATE].At the end of business day [DATE] no additional documentation had been provided from the facility related to this deficient practice. A copy of the packet sent with the resident to the hospital was not provided.410 IAC (Indiana Administrative Code) 16.2-3.1-80

Based on observation and record review, the facility failed to ensure medications were properly labeled and stored in 3 of 6 carts reviewed for appropriate storage and labeling of medications (Residents 100 and 112).Findings include:On 4/16/26 at 8:50 a.m. [NAME] Medication Cart 1 was observed. Resident 100 had a bottle of Sevelamer Carbonate (a prescription medication used to control high phosphorus levels in adults with chronic kidney disease) 800 milligrams (mg) that did not have a written or prescription label on it.On 4/16/26 at 9:10 a.m. [NAME] Medication Cart 2 was observed. Resident 112 had an open Budesonide and Formoterol inhaler (a combination inhaler used to manage asthma and chronic obstructive pulmonary disease) with an open date of 11/15/26.On 4/16/26 at 9:30 a.m. Heritage Medication Cart 2 was observed. An unknown resident had a bottle of liquid guaifenesin (an expectorant used to relieve chest congestion by thinning and loosening mucus in the airways) that had a pharmacy label that had been ripped off the bottle. Only a small portion of the top left corner of the label was left on the bottle.On 4/17/26 at 10:23 a.m. a copy of a current facility policy titled, Storage of Medications, dated 9/2025, was provided. That policy indicated, .C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label.H. Outdated. or deteriorated medications. are immediately removed from inventory, disposed of according to procedures for medication disposal . And reordered from the pharmacy. if a current order exists.F. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.On 4/17/26 at 10:23 a.m. a copy of a current facility reference guide untitled, dated 8/2025, was provided. That guide indicated, .Budesonide/Formoterol. Discard 90 days after removal from protective pouch.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 interview and record review, the facility failed to ensure a resident received showers and bathing per their preference for 1 of 32 residents reviewed for choices (Resident 7). Findings include:During an interview, on 4/13/26 at 8:46 a.m., Resident 7 indicated he received showers twice weekly. Resident 7 indicated he wanted three showers a week. The resident did not remember the staff asking him about his shower and bathing preferences. Resident 7's record was reviewed on 4/16/26 at 12:24 p.m. Census information indicated the resident was admitted to the facility on [DATE]. A nursing admission assessment, dated 10/31/25, indicated the resident's bathing preference was to receive a bed bath three times weekly. A care plan, last revised on 11/10/25, indicated the resident had an activities of daily living (ADL) self-care performance deficit. Interventions included, but were not limited to, staff provide substantial/maximal assistance with showering/bathing. A quarterly Minimum Data Set (MDS) assessment, dated 2/7/26, indicated the resident was cognitively intact. Bathing documentation in the electronic record, dated 3/1/26 to 4/16/26, indicated the resident was scheduled for and received showers twice weekly. During an interview, on 4/17/26 at 11:25 a.m., the [NAME] President (VP) of Risk Management indicated the resident received showers twice weekly. If a resident told the admitting nurse they wanted a shower three times a week then it should have been scheduled accordingly. On 4/17/26 at 11:45 a.m., the VP of Risk Management provided an undated document titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. a. Residents have a Right to.Be treated with respect 1. Including make their own schedule. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(v)(1)

Based on interview and record review, the facility failed to maintain a system for the reconciliation of controlled medications from 4 of 4 nursing units (Health, Heritage, [NAME] 1 and [NAME] 2), resulting in diversion of at least 60 Norco (hydrocodone-acetaminophen - a Schedule II narcotic medication) tablets from 1 of 4 nursing units reviewed for diversion of narcotics (Heritage hallways). This deficient practice was corrected by [DATE] prior to the start of the survey and was therefore Past Noncompliance.Findings include: A Facility Reported Incident (FRI), indicated on [DATE], 2 cards of Resident L's narcotic medications, for a total of 60 tablets, were found missing from the medication cart. The Executive Director (ED), local law enforcement, consulting pharmacy, and Nurse Practitioner (NP) were notified. Licensed Practical Nurse (LPN) 10 was suspended pending investigation and subsequently terminated. A pharmacy packing slip, dated [DATE] at 6:00 a.m., indicated Registered Nurse (RN) 11 signed for receipt of 4 cards of 30 hydrocodone-acetaminophen 5-325 mg (a total of 120 tablets) for Resident L. A progress notes, dated [DATE], indicated at 6:00 a.m. Resident L was found unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated but unsuccessful and the resident was pronounced dead at 6:15 a.m. A Witness Statement by Licensed Practical Nurse (LPN) 6, dated [DATE], indicated she had last seen Resident L's hydrocodone-acetaminophen on [DATE] at the end of her shift. On [DATE] when she returned to work, she found there were 2 cards of the medication missing, but the count was correct. A narcotic count sheet for Resident L, for hydrocodone-acetaminophen 5-325 mg tablets, was signed as having 45 tablets on [DATE], 19 days after the resident died. Shift Change/Controlled Substance Inventory Tracker sheets (kept on each medication cart in a narcotic tracking binder), indicated Every controlled medication and count sheet added or removed from the medication cart MUST be documented by 2 nurses on the left side. The Shift Change/Controlled Substance Inventory Trackers sheets, dated [DATE] - 12/2925, from 6 of the 6 medication carts utilized on the Health hallways, Heritage hallways, the [NAME] 1 or the [NAME] 2 hallways, indicated 2 nurses had not signed as the 1st nurse initials or the verified by a 2nd nurse initials, when cards and count sheets for narcotic medications had been added or removed per instructions on the bottom of the sheet. During an interview on [DATE] at 12:55 p.m., the [NAME] President of Risk Management (VPRM) indicated, on Saturday [DATE], QMA 14 was on call for the facility. QMA 14 was notified by LPN 6 that Resident L's hydrocodone-acetaminophen count was correct, but she and RN 13 both remembered the day before there being more cards of the medication in the cart. LPN 6 had questioned if the 2 cards of medication had already been destroyed. QMA 14 then called the ED who was the abuse coordinator, the DON, and all upper management staff were notified. QMA 14 had contacted the VPRM again, and guidance was given to include counting the narcotic book, cards and sheets. Subsequently staff found there was a page missing in the narcotic count book (the pages were numbered in sequential order), and a new page for counts had been started in the book. When interviewed, LPN 10 indicated the prior evening the narcotic counts had been correct between evening and night shift. The night shift person had only a new narcotic sheet to go by that had been started by LPN 10, and had no idea there were missing cards. The next morning, [DATE], when LPN 6 and the night shift nurse counted the cart, LPN 6 questioned the number of medication cards. LPN 10 denied the extra cards of medications for Resident L had been in the cart. But the nurse from the evening shift the night before remembered the extra cards had been in the cart. LPN 10 eventually admitted starting a new narcotic count sheet, but indicated the narcotic sheet had already been missing, and the numbers on the narcotic count sheet were gained by counting the medications in the cart. LPN 10 did not admit to ripping the count sheet page out of the narcotic book or taking the 2 cards of narcotics. LPN 10 had been suspended pending investigation, the police had been contacted, and when LPN stopped taking phone calls or cooperating with the investigation, she had been terminated. During an interview on [DATE] at 12:55 p.m., the VPRM indicated the DON was responsible for destruction of narcotic medications. There had been a delay in destruction of Resident L's narcotic medications after the resident died as the facility had been in transition between DON's in [DATE]. The nursing staff had since been educated to include receiving narcotics from the pharmacy, chain of custody, the chain of custody book, shift count of narcotics, and destruction of narcotics. The UM was responsible for notifying the DON when a resident discharged or died, and nurses were supposed to notify the DON again if narcotics remained on the cart more than a few days. The UM would monitor the medication cart and pull narcotics the next day after a resident discharge and take them to the DON if the DON had not retrieved them, monitor for proper documentation on the narcotic tracking sheets, and monitor for drug diversion. The regional staff would provide additional monitoring. On [DATE] at 1:25 p.m., the Regional Director of Clinical Operations provided a Controlled Substance Disposal policy, dated [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, .Medications included in the Drug Enforcement Administration [DEA] classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations.C. All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of: a. In the facility by the director of nursing and the consultant pharmacist [or other licensed personnel.F. Accountability records or controlled substances that are disposed of or destroyed are maintained with the unused supply until destruction or disposal and then stored for five [5] years or per applicable law or regulation. On [DATE] at 2:03 p.m., the VPRM provided a Medication Controlled Drugs and Security policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, .Narcotics will be kept under double lock and will be counted by off-going nurse at the end of the shift and before keys are passed to next shift.III. d. Narcotics will be counted at change of shift and upon being relieved from duty.IV. a. Controlled drugs as well as the controlled drug count sheets and cards, are counted every shift change by the nurse reporting on duty with the nurse reporting off duty. b. The inventory of the controlled drugs count sheets and number of cards must be recorded on the narcotic records and signed for correctness of count. c. The controlled drug record must be signed by the nurse coming on duty and going off duty to verify that the count of all controlled drugs is correct after the count has been completed.V. c. If the cause of the discrepancy cannot be located and/or the count does not balance, report the matter to the supervisor for immediate investigation. d. Nurses, or qualified medication aides may not leave the unit until directed to do so by the immediate supervisor.VII. a. When the prescribed drug is discontinued, or the resident discharged , the container and control sheet must be removed for drug destruction. A Nurse Shift Change and Walking Rounds policy, undated, indicated, .4. Nurse rounding and report includes but not limited to: a. Medication count for legally accepting the chain of command for drugs. b. A shift audit of the MAR and TAR records with reconciliation if needed. c. The MAR will be audited and reconciled with the narcotics count and PRN medications, as applicable. i. For a drug discrepancy that cannot be resolved, the Director of Nursing/designee will be notified immediately. Ii. Nurses will remain on the unit until the DON/designee releases them.5. Nurses will accept/reject current status of residents, medications and orders and be accountable on his/her shift; reconciliation will be achieved prior to the off-going nurse being released. A Maintaining Chain of Custody Destruction Sheet, effective [DATE], indicated, When narcotics are discontinued, pull from the med cart and are unable to be given for any reason, they must be destroyed to ensure the chain of custody. The medication must be listed on this form or an appropriate log from the pharmacy. Once the drug is destroyed, it must be in the presence of 2 nurses and/or pharmacist or per state regulations. Both signatures must be next to the item destroyed on this form. This form must be kept in the facility for a minimum of 2 years. This deficient practice was corrected by [DATE] prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included monitoring delivery, storage and counting of narcotic medications, staff education regarding accurate narcotic counts and policy and procedures for medication destruction, and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI). Cross reference F602. This citation relates to Intake 2701568. 3.1-25(e)(2) 3.1-25(e)(3) 3.1-25(s)

Based on interview and record review, the facility failed to ensure residents' narcotic medications were protected from diversion resulting in 60 missing Norco (a Schedule II narcotic medication) tablets, for 1 of 3 residents reviewed for misappropriation (Resident L). This deficient practice was corrected by [DATE] prior to the start of the survey and was therefore Past Noncompliance.Findings include: A Facility Reported Incident (FRI) indicated, on [DATE], two cards of Resident L's narcotic medications, for a total of 60 tablets, were found missing from the medication cart. The Executive Director (ED), local law enforcement, consulting pharmacy, and Nurse Practitioner (NP) were notified. Licensed Practical Nurse (LPN) 10 was suspended pending investigation and subsequently terminated. Resident L's clinical record was reviewed on [DATE] at 12:31p.m. Diagnoses on Resident L's profile included, but were not limited to, radiculopathy in the cervical region (pinched nerve in the neck), fibromyalgia (chronic condition causing widespread body pain), carpal tunnel syndrome of an unspecified upper limb (painful condition caused by compressed nerves in the wrist), and intervertebral disc degeneration of lumbar region (lower back). The most recent pain assessment documented on a Pain Observation Tool, dated [DATE], indicated Resident L verbalized severe pain. A physician's order for Resident L, dated [DATE], indicated hydrocodone-acetaminophen (Norco) 5-325 milligrams (mg) give 1 tablet by mouth every 6 hours for pain. A pharmacy packing slip, dated [DATE] at 6:00 a.m., indicated Registered Nurse (RN) 11 signed for receipt of four cards of 30 hydrocodone-acetaminophen 5-325 mg (a total of 120 tablets) for Resident L. A progress note, dated [DATE], indicated at 6:00 a.m. Resident L was found unresponsive. Cardiopulmonary Resuscitation (CPR) was initiated but unsuccessful and the resident was pronounced dead at 6:15 a.m. A Witness Statement by Licensed Practical Nurse (LPN) 6, dated [DATE], indicated she had last seen Resident L's hydrocodone-acetaminophen on [DATE] at the end of her shift. On [DATE] when she returned to work, she found there were two cards of the medication missing, but the count was correct. A narcotic count sheet for Resident L, for hydrocodone-acetaminophen 5-325 mg tablets, was signed as having 45 tablets on [DATE], 19 days after the resident died. Shift Change/Controlled Substance Inventory Tracker sheets (kept on each medication cart in a narcotic tracking binder), indicated Every controlled medication and count sheet added or removed from the medication cart MUST be documented by 2 nurses on the left side. The Shift Change/Controlled Substance Inventory Trackers sheets, dated [DATE] - 12/2925, from 6 of the 6 medication carts utilized on the Health hallways, Heritage hallways, the [NAME] 1 or the [NAME] 2 hallways, indicated two nurses had not signed as the 1st nurse initials or the verified by a 2nd nurse initials, when cards and count sheets for narcotic medications had been added or removed per instructions on the bottom of the sheet. An Employee Corrective Action Form, dated [DATE], indicated LPN 10 was terminated due to performance/policy violation. The violation statement indicated LPN 10 failed to cooperate in an investigation related to drug diversion. In-Service Education sign-in logs, dated [DATE] - [DATE], indicated the topics of the narcotic medication log, counting narcotics, and medication administration. Nursing staff documented as having received the education. The interim ED indicated she and Regional Director of Clinical Operations had not been working in the facility when Resident L's narcotic medication had been found missing on [DATE] and therefore were not part of the entire follow-up investigation. During an interview on [DATE] at 11:22 a.m., Unit Manager (UM) 15 indicated she had been involved in the search for the missing narcotic medications on the Heritage hallway. Resident L had died on [DATE] and his hydrocodone-acetaminophen 5-325 mg tablets were found missing on [DATE]. UM 15 indicated she had not worked in the facility at the time of the medications were found missing, but to her knowledge, the narcotics were not recovered. An investigation had been initiated and the evidence gathered pointed to LPN 10 who was a floater nurse in the facility. LPN 10 had been terminated. UM 15 indicated nurses and Qualified Medication Aides (QMAs) were required to count the number of narcotic pills/tablets, the number of cards the narcotic medications were on, and the number of narcotic medication count sheets. During an interview on [DATE] at 11:33 a.m., LPN 6 indicated she and the other nurses routinely worked the same resident assignment and medication cart on the Heritage hallway. On [DATE] while counting the medication cart with a peer, she identified missing cards of medications for deceased Resident L. The number of medications matched the narcotic count sheets, but she knew there had been more cards of hydrocodone-acetaminophen and corresponding count sheets when she had left the prior day. LPN 6 indicated she had immediately notified the prior ED, provided a statement when asked, and management had opened an investigation. LPN 6 indicated as part of the follow-up investigation, nursing staff had been educated on the storage, administration, counting and destruction of narcotic medications. LPN 6 indicated when a resident discharged , the charge nurse or UM notified the DON, and it was the responsibility of the DON to destroy narcotic medications. Narcotics were never destroyed by the nurses working on the hallways. LPN 6 indicated she could not answer as to why Resident L's medication had remained on the medication cart for 15 days after his death, but to her knowledge the missing narcotics were never found. During an interview on [DATE] at 12:55 p.m., the [NAME] President of Risk Management (VPRM) indicated, on Saturday [DATE], QMA 14 was on call for the facility. QMA 14 was notified by LPN 6 that Resident L's hydrocodone-acetaminophen count was correct, but she and RN 13 both remembered the day before there being more cards of the medication in the cart. LPN 6 had questioned if the two cards of medication had already been destroyed. QMA 14 then called the ED who was the abuse coordinator, the DON, and all upper management staff were notified. QMA 14 had contacted the VPRM again, and guidance was given to include counting the narcotic book, cards, and sheets. Subsequently staff found there was a page missing in the narcotic count book (the pages were numbered in sequential order), and a new page for counts had been started in the book. When interviewed, LPN 10 indicated the prior evening the narcotic counts had been correct between evening and night shift. The night shift person had only a new narcotic sheet to go by that had been started by LPN 10, and had no idea there were missing cards. The next morning, [DATE], when LPN 6 and the night shift nurse counted the cart, LPN 6 questioned the number of medication cards. LPN 10 denied the extra cards of medications for Resident L had been in the cart. But the nurse from the evening shift the night before remembered the extra cards had been in the cart. LPN 10 eventually admitted starting a new narcotic count sheet, but indicated the narcotic sheet had already been missing, and the numbers on the narcotic count sheet were gained by counting the medications in the cart. LPN 10 did not admit to ripping the count sheet page out of the narcotic book or taking the two cards of narcotics. LPN 10 had been suspended pending investigation, the police had been contacted, and when LPN stopped taking phone calls or cooperating with the investigation, she had been terminated. During an interview on [DATE] at 12:55 p.m., the VPRM indicated the DON was responsible for destruction of narcotic medications. There had been a delay in destruction of Resident L's narcotic medications after the resident died as the facility had been in transition between DON's in [DATE]. The nursing staff had since been educated to include receiving narcotics from the pharmacy, chain of custody, the chain of custody book, shift count of narcotics, and destruction of narcotics. The UM was responsible for notifying the DON when a resident discharged or died, and nurses were supposed to notify the DON again if narcotics remained on the cart more than a few days. The UM would monitor the medication cart and pull narcotics the next day after a resident discharged and take them to the DON if the DON had not retrieved them, monitor for proper documentation on the narcotic tracking sheets, and monitor for drug diversion. The regional staff would provide additional monitoring. On [DATE] at 1:25 p.m., the Regional Director of Clinical Operations provided a Controlled Substance Disposal policy, dated [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, Medications included in the Drug Enforcement Administration [DEA] classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations.C. All controlled substances remaining in the facility after a resident has been discharged , or the order is discontinued, are disposed of: a. In the facility by the director of nursing and the consultant pharmacist [or other licensed personnel.F. Accountability records or controlled substances that are disposed of or destroyed are maintained with the unused supply until destruction or disposal and then stored for five [5] years or per applicable law or regulation. On [DATE] at 2:03 p.m., the VPRM provided a Medication Controlled Drugs and Security policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, .Narcotics will be kept under double lock and will be counted by off-going nurse at the end of the shift and before keys are passed to next shift.III. d. Narcotics will be counted at change of shift and upon being relieved from duty.IV. a. Controlled drugs as well as the controlled drug count sheets and cards, are counted every shift change by the nurse reporting on duty with the nurse reporting off duty. b. The inventory of the controlled drugs count sheets and number of cards must be recorded on the narcotic records and signed for correctness of count. c. The controlled drug record must be signed by the nurse coming on duty and going off duty to verify that the count of all controlled drugs is correct after the count has been completed.V. c. If the cause of the discrepancy cannot be located and/or the count does not balance, report the matter to the supervisor for immediate investigation. d. Nurses, or qualified medication aides may not leave the unit until directed to do so by the immediate supervisor.VII. a. When the prescribed drug is discontinued, or the resident discharged , the container and control sheet must be removed for drug destruction. A Nurse Shift Change and Walking Rounds policy, undated, indicated, .4. Nurse rounding and report includes but not limited to: a. Medication count for legally accepting the chain of command for drugs. b. A shift audit of the MAR and TAR records with reconciliation if needed. c. The MAR will be audited and reconciled with the narcotics count and PRN medications, as applicable. i. For a drug discrepancy that cannot be resolved, the Director of Nursing/designee will be notified immediately. Ii. Nurses will remain on the unit until the DON/designee releases them.5. Nurses will accept/reject current status of residents, medications and orders and be accountable on his/her shift; reconciliation will be achieved prior to the off-going nurse being released. A Maintaining Chain of Custody Destruction Sheet, effective [DATE], indicated, .When narcotics are discontinued, pull from the med cart and are unable to be given for any reason, they must be destroyed to ensure the chain of custody. The medication must be listed on this form or an appropriate log from the pharmacy. Once the drug is destroyed, it must be in the presence of 2 nurses and/or pharmacist or per state regulations. Both signatures must be next to the item destroyed on this form. This form must be kept in the facility for a minimum of 2 years. This deficient practice was corrected by [DATE] prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included monitoring delivery, storage, and counting of narcotic medications; staff education regarding accurate narcotic counts; policy and procedures for medication destruction; and ongoing monitoring by Quality Assurance and Performance Improvement (QAPI). This citation relates to Intake 2701568. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure all medications, painting supplies, and cleaner/degreaser sprays were secured for 3 of 3 random observations for potential accidents. This deficient practice had the potential to affect 2 of 2 residents randomly observed (Residents G and N). Findings include: 1. On 12/30/25 at 11:15 a.m. Resident G was observed lying on his bed closing his eyes on and off. There was a medication cup of 5 unidentified pills observed on the over-the-bed table among the resident's personal items. The resident indicated the staff had left the medications for him to take when he wanted, and this was his usual routine. The resident deflected and changed the topic when he was asked to identify the medications. There was also a medication cup containing 2 unidentified white tablets on the bedside stand between the resident's BiPAP machine (a non-invasive ventilator used to help people breathe easier) and a push-button desk telephone, out of reach and sight of the resident. On 12/30/25 at 12:33 p.m., a second observation of Resident G lying on the bed scrolling on his cellphone. The medication cup of 2 unidentified white tablets remained on the bedside stand between the resident's BiPAP machine and a push-buttoned desk telephone, out of reach and sight of the resident. On 12/30/25 at 3:55 p.m., a third observation of Resident G lying on the bed scrolling on his cellphone. The medication cup of 2 unidentified white tablets remained on the bedside stand between the resident's BiPAP machine and a push-buttoned desk telephone, out of reach and sight of the resident. On 12/30/25 at 3:58 p.m., the Regional Nurse Consultant and Director of Nursing Services were informed that medications had been observed at Resident G's bedside. Nursing staff were observed in the resident's room but had not removed the medications. Resident G's clinical record was reviewed on 12/31/25 at 1:30 p.m. Diagnoses on Resident G's profiled included osteomyelitis of lumbar vertebra, respiratory failure, and dependence on renal dialysis. An entry Minimum Data Set (MDS) assessment, completed on 10/4/25, assessed Resident G as having moderately impaired cognition. Resident G's clinical record lacked a physician's order or care plan for self-administration of medications. On 12/31/25 at 2:15 p.m., the Regional [NAME] President of Risk Management provided a Medication Administration policy, undated, and indicated the policy was the one being used by the facility. The policy indicated, The purpose of this policy guidance for general medication administration .w. Never leave medications unattended .cc. Do not leave medications at bedside . 2. On 12/30/25 at 11:38 a.m., a utility cart was observed at the end of the hallway, parked in an alcove beside Resident N's room. Resident N was observed in a manual wheelchair (WC) rolling himself up and down the hallway unsupervised. The resident was carrying a bible, confused, wandering aimlessly around the unit, and muttering to himself. The resident was observed stopping next to the utility cart for extended periods of time. Painting supplies on the cart included 2 buckets of wall putty, an opened tube of caulking in a metal holder ready for use, an opened bottle of M1 Tough Job remover (used to strip latex paint - a hazardous statement indicated highly flammable liquid and vapor, caused serious eye irritation, keep container tightly closed, and if the liquid got on skin shower immediately), an opened spray bottle of Krud [NAME] cleaner (a cleaner/degreaser - a hazardous statement indicated caused eye irritation, potential harm if swallowed or inhaled, and avoid getting on skin or breathing), a bucket of paint, and a bucket of dirty water sitting among blankets, trash bags, trash, dirty rags, and painting supplies. There was also an opened blue 5-gallon bucket of paint with a roller inside, there was no lid on the bucket. On 12/30/25 at 11:45 a.m., Resident N was observed propelling himself from near the nurse's station in the center of the unit, to the end of the hallway and he stopped near the utility cart. Licensed Practical Nurse (LPN) 4 indicated Resident N was confused and wandered up and down the hallways all the time. On 12/30/25 at 12:30 p.m., a third observation of the utility cart with painting supplies parked near Resident N's room. Resident N's clinical record was reviewed on 12/31/25 at 2:10 p.m. Diagnoses on Resident N's profile included autistic disorder, unspecified dementia, and intellectual disabilities. A quarterly MDS, completed on 11/28/25, indicated Resident N had severe cognitive impairment. The resident required moderate to significant assistance from staff for most ADL's (activities of daily living) and could propel himself in a wheelchair after setting him up. On 12/30/25 at 3:50 p.m., the Executive Director (ED) indicated the utility cart was being used by a painter working on the vacant room next to Resident N. The cart should have been secured in the room being refurbished, not left in the hallway unsupervised. On 12/31/25 at 2:15 p.m., the Regional [NAME] President of Risk Management provided a Hazardous Material and Waste Management policy, revised 10/7/19, and indicated the policy was the one being used by the facility. The policy indicated, .8. The facility shall establish and implement processes for selecting, handling, storing, transporting, and disposing of hazardous materials .10. The facility shall ensure that all chemicals and wastes are maintained appropriately to ensure a safe environment. This citation relates to Intake 2691777. 3.1-45(a)(1)3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure insulin was administered in accordance with physician's orders and by manufacturer's instructions for 3 of 3 residents observed for insulin administration (Residents B, H, and T). Findings include:1. A concern brought up during the survey indicated Resident B had complained to the staff daily about his high blood sugar readings, not getting his insulin timely, the physician not being contacted for extra insulin coverage when his blood sugar readings were high, and not receiving the proper diet to help control his diabetes. On 12/30/25 at 12:36 p.m., Resident B was observed returning to his room. The resident indicated his blood sugar readings were always high due to not getting his insulin correctly. That morning at 4:00 a.m., his blood sugar had read high which meant over 600, he had cold sweats, and the staff had responded by turning on the air conditioner but had refused to call the physician and get insulin coverage. The resident indicated until this past week he had worn an electronic glucose monitoring device on his arm, but it had come apart when he was removing his shirt last week. The facility was supposed to have got him a replacement, but that had not yet happened. On 12/30/25 at 12:42 p.m., Registered Nurse (RN) 6 was observed to enter Resident B's room with an electronic pad so the resident could participate in a telehealth visit with the attending physician's Nurse Practitioner (NP) about his pain medication. Resident B was overheard reporting his blood sugar reading of 399, and the NP recommended administering an additional 9 units of insulin to supplement the noon insulin he'd already received. The resident indicated his A1C (a lab test to measure the average blood sugar over the past 2-3 months) was running over 9 and going up, and in the past, it had never been over 6.5 (normal range 4.8 - 5.6). The resident indicated he was currently managing his diet, but the nurses were not listening to him and refused to call the MD/NP when he knew he needed additional insulin. On 12/31/25 at 8:59 a.m., Resident B was observed to be upset and voicing his displeasure to Licensed Practical Nurse (LPN) 8 as she prepared to administer his Lantus insulin 20 units and Humalog insulin 3 units that were ordered for 8:00 a.m. Resident B also indicated that the night nurse had not taken his blood sugar reading before he went to breakfast. LPN 8 performed a finger stick blood sugar with a reading of 410, and an additional 9 units of Humalog insulin was administered. Resident B indicated, he was supposed to have his insulin administered 15 - 30 minutes before meals to get a proper reading as getting the blood sugar reading after he ate would affect the amount of sliding scale coverage he received, but that rarely happened. LPN 8 responded that she had other residents with diagnoses of diabetes that required insulin, and she would get them all when she had time. Resident B asked when his electronic glucose monitoring device for his arm would be available, and LPN 8 indicated she would call the pharmacy for an update. Resident B indicated this was a daily fight he had with the nurses, of his blood sugar being high, the nurses giving his insulins late, and them refusing to notify the MD/NP of high readings to get additional insulin coverage. Resident B's clinical record was reviewed on 12/30/25 at 2:25 p.m. Diagnoses on Resident B's profile included type 2 diabetes mellitus with hyperglycemia. A care plan for Resident 8, dated 9/18/25, indicated the resident had diabetes. The goal was for the resident to be able to articulate potential complications of not following prescribed regimen and to be free from signs and symptoms of hypoglycemia and hyperglycemia. Interventions included administering insulin injections per orders, administering medications per medical provider's orders, and monitoring symptoms of hyperglycemia and hypoglycemia. The resident's care plan lacked documentation it had been updated after his admission on [DATE]. A Nursing admission Evaluation, dated 11/25/25, indicated Resident B's admitting diagnoses was ketoacidosis (a life-threatening medical emergency where the body was unable to use glucose). The resident was cognitively intact and had no behaviors or rejection of care. The resident did not have a CGMD (Continuous Glucose Monitoring Device) he choose to self-manage. Physician's orders included:a. On 11/25/25, a consistent carbohydrate diet (CCD diet - designed to help manage high blood sugar levels). The order was discontinued on 11/26/25 and the diet order changed to a regular diet with thin consistency liquids.b. On 11/25/25, perform a fingerstick blood glucose test before meals and at bedtime. If the blood glucose is less than 70 or greater than 410, staff were to notify the primary care physician. c. On 11/25/25, monitor for signs or symptoms of hypoglycemia/hyperglycemia (i.e. sweating, tremor, pallor, tachycardia, palpitations, nervousness, headache, confusion, lightheadedness, slurred speech, lack of concentration, irritability, staggering gait etc.) every shift.d. On 11/25/25, an order for a FreeStyle Libre 3 Reader Device (Continuous Glucose System Receiver) e. On 11/25/25, Humalog insulin inject subcutaneously before meals and at bedtime for diabetes per sliding scale: if blood sugar is 140 - 170 = 1 unit; 171 - 200 = 2 units; 201 - 230 = 3 units; 231 - 260 = 4 units; 261 - 290 = 5 units; 291 - 320 = 6 units; 321 - 350 = 7 units; 351 - 380 = 8 units; 381 - 410 = 9 units. If Blood sugar is greater than (>) 410 Call MD. f. On 12/5/25, Lantus insulin inject 20 units subcutaneously in the morning for diabetes.g. On 12/11/25, Humalog insulin inject 3 units subcutaneously before meals for diabetes, hold if blood sugar was below 180. Medication Administration Records (MARs), dated November and December 2025, indicated documentation Resident B consistently received his Humalog insulin after meals, not before meals as per the physician's orders. Review of Resident B's blood sugar readings, dated 11/25/25 - 12/28/25, documented 158 blood sugar readings to include,Normal range of 74 - 106, 7 times107 - 400, 133 times401 - 499, 16 times500 - 582, 2 times Progress notes that indicated the physician/NP had been notified of Resident B having high blood sugar readings included on 11/26/25 at 9:02 p.m. the blood sugar reading was 509, and on 12/11/25 at 6:30 p.m., blood sugar reading was 582. Orders were obtained to administer additional insulin coverage. A physician's progress note, dated 12/22/25 at 6:44 a.m., indicated Resident B stated, he'd been diabetic since 2012. He was very frustrated, he stated his insulin was poorly controlled, and he was not getting as much insulin as he needed. The resident had orders for Lispro Insulin 3 units plus sliding scale coverage before meals, and Lantus insulin 20 units in the a.m. The resident was very upset that he was not getting the carbohydrate count with his meals. The physician's note indicated he was going to place orders for a dietary consultation, and to give an additional Lispro 10 units and re-check the blood sugar in an hour. Notify the in-house provider of elevated blood sugars. A nursing behavioral progress notes, dated 12/22/25 at 8:06 p.m., indicated Resident B was noted yelling down the hall and cursing at staff about his dinner tray. Staff member told resident, they thought he had eaten in the dining room since he was seen there at mealtime. The resident was escorted to the dining room to eat his dinner. The resident had called the police. Resident B's MAR indicated his blood sugar reading at 4:59 p.m. was 275 and his evening insulin had been administered at 6:30 p.m. During an interview on 12/31/25 at 8:45 a.m., LPN 8 indicated Resident B was upset that his [NAME] electronic glucose monitoring machine had not been working for several days, and she needed to contact the pharmacy that morning to figure out where the new monitor was. During an interview on 12/31/25 at 12:40 p.m., Unit Manager (UM) 9 indicated she had been the nurse dealing with Resident B's concerns regarding his blood sugars and insulin administration. Resident B voiced daily, if not multiple times daily, to staff his being upset, his opinion of mismanagement of blood sugars, the food, and insulin administration. The MD/NP were notified almost daily about the resident's concerns and nurses would receive a 1-time order to cover high blood sugars as needed. UM 9 indicated, Resident B was often out of his room or off the unit and it was hard for nurses to find him when time for medication administration. The resident would get upset at not getting his medications by 9:00 a.m. and sometimes would refuse to take the medications until someone else attempted. Staff had tried to explain the 1-hour before and after window for medication administration, but Resident B did not care. Resident B's Dexcom electronic glucose reader was not broken, but the sensor had come off and needed replaced. UM 9 indicated, the facility did not utilize electronic glucose monitoring sensors to monitor blood sugars, instead the nurse's would stick the resident's finger and use a glucometer to read. All diabetic residents that received insulin were supposed to have parameters for when to notify the physician, especially if they had a sliding scale insulin order. 2. On 12/31/25 at 9:10 a.m., Resident H was observed lying on his bed watching television. His breakfast tray sat on the over-the-bed table at bedside, and the food had all been eaten. LPN 8 looked at the resident's electronic glucose reader and recorded his blood sugar as 122. LPN 8 then administered Lantus insulin 8 units. Resident H's clinical record was reviewed on 12/31/25 at 2:18 p.m. Diagnoses on Resident H's clinical record included type 2 diabetes mellitus (DM). A care plan for Resident H, dated 12/13/24, indicated the resident had diabetes and diabetic neuropathy. The goal was for the resident to be free from any signs or symptoms of hyper or hypoglycemia. Interventions included administering insulin injections per orders, administering medications per medical providers orders, and observe for signs and symptoms of hyperglycemia. Physician's orders included:a. On 12/13/24, indicated perform a fingerstick blood glucose test before meals and at bedtime. If the blood glucose is less than 70 or greater than 350, notify the primary care physician. b. On 12/13/24, monitor for signs and symptoms of hypoglycemia/hyperglycemia (IE: sweating, tremor, pallor, tachycardia, palpitations, nervousness, headache, confusion, lightheadedness, slurred speech, lack of concentration, irritability, staggering gait, etc.) every shift for diabetes.c. On 4/11/25, Metformin HCI ER (extended release) 500 milligrams (mg) give 1 tablet by mouth in the morning, related to type 2 DM with hyperglycemia.d. On 4/11/25, Jardiance 25 mg (Empagliflozin) give 1 tablet by mouth one time a day for DM.e. On 7/11/25, FreeStyle Libre 2 Sensor (Continuous Glucose System Sensor) inject 1application subcutaneously every day shift every 10 day(s) for diabetes.f. On 10/13/25 Trulicity insulin, inject 4.5 mg subcutaneously every Monday day shift for diabetes.g. On 12/4/25 Lantus insulin, inject 8 unit subcutaneously in the morning for diabetes. Blood sugar monitoring, dated December 2025, indicated Resident H's daily blood sugar readings fluctuated from 69 - 297. 3. On 12/31/25 at 9:40 a.m., the Resident T was observed lying in bed speaking with 2 therapists. LPN 5 was observed to look at the resident's electronic glucose reader and recorded her blood sugar as 117. LPN 5 then administered Lantus 8 units. Resident T's clinical record was reviewed on 12/31/25 at 3:00 p.m. Diagnoses on Resident T's profile included type 2 DM with hyperglycemia. An annual MDS, completed on 9/19/25, assessed the resident as having moderate cognitive impairment, she had no signs or symptoms of behaviors and no rejection of care. Physician's orders included: a. On 6/13/25, Glargine insulin, inject 8 unit subcutaneously in the morning for diabetes.b. On 8/28/25, FreeStyle Libre 3 Sensor Miscellaneous (Continuous Glucose System Sensor) 1 unit every day shift every 14 day(s) for diabetes.c. On 9/12/24, perform a fingerstick blood glucose test (accucheck) before meals for DM, notify provider if blood sugar is less than 70 or greater than 350. Blood sugar monitoring, dated December 2025, indicated Resident T's daily blood sugar readings fluctuated from 75 - 279. During an interview on 12/31/25 at 9:31 a.m., LPN 4 indicated on the Heritage hallways the night nurse started checking blood sugars at 6:30 a.m., and the day shift nurse would finish them as needed. Morning insulin was administered at the time the blood sugar was taken if the reading was high. If blood sugar reading was within normal range for the resident, the insulin was administered when the breakfast trays come out at approximately 7:30 a.m. - 7:45 a.m. During an interview on 12/31/25 at 9:42 a.m., LPN 5 indicated on the Health hallways the 2 residents on her assignment that required morning insulin both wore a FreeStyle [NAME] electronic glucose monitoring system. The electronic reader was used to determine if the resident's blood sugar was normal or if additional insulin coverage was needed. LPN 5 would look at the reader, and if she did not think it was correct according to that resident's normal reading, or how they were acting, she would retake their blood sugar by poking their finger. LPN 5 indicated she administered her 2 residents' insulin according to when the resident requested, usually around 8:00 a.m. If the resident received long-acting insulin the timing of the insulin administration was not as important, but if the resident received short acting insulin she preferred to wait until the breakfast or lunch trays were served to prevent the blood sugar from dropping too low. On 12/31/25 at 3:40 p.m., the [NAME] President of Risk Management indicated medication administration times on the MAR included, Early am = 4:00 a.m. - 7:00 a.m.AM = 6:00 a.m. - 11:00 a.m.Afternoon = 12:00 p.m. - 3:00 p.m.PM = 4:00 p.m. - 7:00 p.m. HS = 8:00 p.m. - 11:00 p.m. Humalog Insulin prescribing information, at www.humalog.com (5/20/25), was provided by the Regional [NAME] President of Risk Management on 12/31/25 at 3:15 p.m. The manufacturers instruction indicated administer Humalog insulin, (a rapid acting insulin designed for quick action to match mealtime glucose), by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. Lantus Insulin prescribing information (6/2022), the Food and Drug Administration, at https://www.fda.gov/drugsatfdawww.humalog.com for the latest approved by the FDA, was provided by the Regional [NAME] President of Risk Management on 12/31/25 at 3:15 p.m. The manufacturers instruction indicated, administer Lantus insulin, (a long-acting insulin was designed to provide a slow, steady release of insulin to manage blood sugar levels between meals and overnight), by subcutaneous injection into the abdominal area, thigh, or deltoid once daily at any time of day, but at the same time every day. On 12/31/25 at 2:15 p.m., the Regional [NAME] President of Risk Management provided a Medication Administration policy, undated, and indicated the policy was the one being used by the facility. The policy indicated, 1. a. The purpose of this policy guidance for general medication administration Administer medications only as prescribed by the provider.f. Observe the [five rights] in giving each medication: i. the right resident ii. the right time . This citation relates to Intake 2691777. 3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to identify wounds, and complete skin assessments for 1 of 3 residents resulting in harm when the resident developed skin breakdown on her buttocks that progressed to an unstageable pressure ulcer/injury (a full thickness tissue loss where the extent of the damage is hidden by dead tissue) that required surgical debridement and the facility failed to assess and treat a Deep Tissue Injury (a pressure-related injury to sub-cutaneous tissue under intact skin, as a result of prolonged compression of bony prominences on underlying soft tissue, particularly muscle) to the right heel for 1 of 3 residents reviewed for pressure ulcers (Resident B). This deficient practice was corrected by 10/31/25 prior to the start of the survey and was therefore Past Noncompliance. Findings include: A confidential interview conducted during the survey indicated a resident representative had been upset when Resident B had developed pressure wounds on her bottom and right heel. Staff had not kept the resident representative informed regarding the extent of the wounds on the resident's bottom, or that the resident had acquired a wound on her right heel. Resident B's clinical record was reviewed on 11/7/25 at 2:00 p.m. Diagnoses on Resident B's profile included hemiplegia and hemiparesis (paralysis) following a cerebral infarction (stroke - death of brain tissue caused by a lack of blood flow) affecting the left dominant side, type 2 diabetes mellitus with diabetic neuropathy, Parkinson's disease, encephalopathy (disfunction of the brain that caused confusion and memory loss), and dysphagia (difficulty swallowing). A Nursing admission Evaluation, dated 9/5/25, indicated there were no skin areas noted, and the resident had no skin issues in the past year. Resident B was unresponsive to painful stimuli due to diminished level. The skin was occasionally moist, and she was bedfast. Mobility was very limited, and she could make occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. During a move skin probably slid to some extent against sheets, chair, restraints or other devices. The resident maintained relatively good position in a chair or bed most of the time but occasionally slid down. A care plan for Resident B, dated 9/5/25, indicated the resident was at risk for altered skin integrity related to impaired mobility, and type 2 diabetes mellitus. The goal was for the resident to have improved skin or maintain the current skin status through the next review. Interventions included, complete a skin at risk assessment upon admission / readmission, quarterly, and as needed; complete weekly skin checks; encourage the resident to turn and reposition or assist as needed as resident allows; and to provide an appropriate off-loading mattress and off-loading cushion, if applicable. Physician's orders, dated 9/8/25, included weekly skin assessments to be completed every Thursday, and that the resident was to be on a standard facility mattress that was supposed to be pressure reducing/relieving. Wound Assessment Reports, documented by Wound Nurse Practitioner (NP) 13, dated 9/8/25, indicated there were no pressure ulcers noted. A Physician's order, dated 9/9/25, indicated to apply Triad cream (a multipurpose skin protectant) to the buttocks every shift and as needed after incontinent episodes. A Weekly Skin assessment, dated 9/12/25, indicated Resident B had skin areas noted that were not new since the last documented skin assessment. A nursing progress note, dated 9/17/25 at 4:04 p.m., indicated there had been skin breakdown observed on Resident B's buttocks. A physician's order, dated 9/19/25, indicated to cleanse the coccyx with soap and water, then pat dry, apply Triad paste to the coccyx affected area three times a day (TID) for wound care and as needed for soilage, and leave open to air. A Dietary Progress note, dated 9/19/25 at 2:09 p.m., indicated Resident B had no skin issues notes. A Post Wound Round report, dated 9/19/25, indicated new full thickness dermatosis on the coccyx, measured 3.5 centimeters (cm) by (x) 2.5 cm x 0.1 cm. Wound Assessment Reports, documented by Wound NP 13, dated 9/19/25, indicated the resident had an open area to the coccyx, and scarring to the peri wound suggestive of gluteal dermatosis, that measured 3.5 cm x 2.5 cm x 0.10 cm. A Skin Grid Non-Pressure assessment, dated 9/22/25, indicated Resident B had a non-pressure area on the sacrum (situated just above the crack of the butt and coccyx/tailbone) that was not new. Gluteal dermatosis (general term for skin diseases) was first been observed on 9/19/25 and measured 3.5 cm x 2.5 cm x 0.1cm, with full thickness skin loss. The assessment did not indicate if the primary care physician had been notified. A Post Wound Round report, dated 9/26/26, indicated a new in-house acquired unstageable (full thickness skin and tissue loss where the wound depth is obscured by dead tissue) pressure ulcer on the coccyx, that measured 6.5 cm x 8 cm x 0.1cm. A nursing progress notes by the prior in-house wound nurse, Licensed Practical Nurse (LPN) 15, dated 9/26/25 at 2:19 p.m., indicated she had called Resident B's representative regarding skin issues, and informed her the resident's buttocks was improving with the current treatment. The resident was being turned every 2 hours and on a low air loss mattress (LAM). Wound Assessment Reports, documented by Wound NP 13, dated 9/26/25, indicated the resident had an unstageable pressure ulcer/injury to the coccyx, that measured 6.5 cm x 8.0 cm x 0.1 cm. There was 80% eschar (brown or black colored dead tissue), no slough (yellow colored dead tissue), and wound status was stable. Physician's orders, dated 9/26/25, included cleanse the coccyx with wound cleanser then apply medical grade honey and cover with boarder foam every shift for wound care and as needed for soilage or dislodgement. Staff were to do daily wound assessment and document abnormalities in the progress notes to include drainage, necrotic tissue, signs of infection, odor, surrounding skin, pain level, and if the dressing was dry and intact. A Post Wound Round report, dated 10/3/25, indicated the in-house acquired unstageable pressure ulcer on the coccyx, measured 10 cm x 3.5 cm x 0.1 cm. A Physician's order, dated 10/3/25, indicated using a low air loss mattress, and checking every shift for placement and function. Wound Assessment Reports, documented by Wound NP 13, dated 10/4/25, the resident had an unstageable pressure ulcer/injury to the coccyx, that measured 10.0 cm x 3.5 cm x 0.1 cm. There was 80% eschar, no slough, and the wound was stable. A local hospital Physician's Progress Notes, dated 10/6/25 at 3:18 p.m., indicated Resident B presented to the hospital with concerns for hypoxia (low oxygen saturations) and difficulty breathing. The resident was subsequently admitted to the Intensive Diagnostic Treatment Unit (IDTU) to receive treatment for pneumonia (PNA) and a change in mental status. On 10/7/25 at 8:40 a.m., orders were received to initiate the skin and wound care protocol. The reason for the consultation was an unstageable pressure injury on the sacrum and a Deep Tissue Injury (DTI, a type of pressure injury beneath the skin's surface that often appears as a dark red, purple, or maroon area of intact skin or a blood-filled blister) on the right heel. On 10/8/25 at 4:22 p.m. hospital wound care consult documentation and photos included,a. A general assessment indicated, the patient's left heel, bilateral ears, and elbows were intact. The left ear and knee had some hyperpigmentation.b. An unstageable sacral/bilateral buttocks pressure ulcer, that measured 8.1 cm x 9.3 cm x 0.4 cm. A minimal amount of tissue was removed with sharps, but remaining necrosis was crosshatched to allow for deeper dressing penetration.c. An unstageable right heel pressure injury was firm and intact with adherent eschar. d. There was a small oval area on the left lateral lower exterior, that presented like an old wound with a hard scab, and measured approximately 3.0 cm x 1.0 cm. e. Nursing was to turn the patient every 2 hours using 2 pillows as wedges, no pillow to the sacrum/buttocks only back and posterior legs, and no back time. Waffle boots were in place to assist with offloading while in bed. A nursing progress note by LPN 15, dated 10/10/25 at 1:50 p.m., indicated Resident B had returned on a stretcher from a nearby hospital. The resident was alert to herself only and non-verbal per her baseline. The resident had a hard calloused area on the left heel and boots were applied as preventative. A Nursing admission Evaluation by LPN 15, dated 10/10/25, indicated the resident had an unstageable pressure area on the sacrum, and a suspected DTI on the left heel. There were no descriptions or measurements of either wound. Physician's orders, dated 10/10/25, included weekly skin assessments were to be completed every Friday, wound care consult, the resident was to be on a standard facility mattress that was supposed to be pressure reducing/relieving, and daily wound assessment and document abnormalities. Cleanse the sacral wound daily with wound cleanser, apply medical grade honey, and cover with a bordered foam daily and as needed for soiling and as needed. A Post Wound Round report, dated 10/14/25, indicated the in-house acquired unstageable pressure ulcer on the coccyx, measured 9.5 cm x 4 cm x 2 cm. Wound Assessment Reports, documented by Wound NP 13, dated 10/14/25, indicated the resident had an unstageable pressure ulcer/injury on the coccyx, that measured 9.5 cm x 4.0 cm x 2.0 cm. There was 80% eschar, 20% slough, and the wound was stable. Surgical excisional debridement of the wound was performed with a scalpel, forceps, and scissors at bedside. An e-mail statement from Wound NP 13 indicated, results of Resident B's skin examination on 10/14/25 were as follows, Unstageable pressure injury to her sacrum, long thick toenails. Her intact skin was dry and ashy, including both heels. Prior to completing her assessment, I reviewed her hospital documentation, and they noted she had DTI's to her left knee, ear, lower leg, and right heel. All those areas were dry, ashy, and intact. While those areas are included in the comprehensive skin exam, I double-checked them, along with double-checking both heels to confirm. I also double-checked both heels as she was bedbound to ensure they were intact as those are high pressure injury areas. Nurse Practitioner 12, who represented Resident B's Primary Care Physician (PCP), assessed Resident B upon admission 9/5/25 and weekly throughout the resident's stay. NP 12 documented on the resident's each weekly assessment, no rashes or skin breakdown, and there are no pressure ulcers noted. On 10/13/25, NP 12 documented a Post Hospital Visit, and indicated there are no pressure ulcers noted. The skin is warm and dry. There are no obvious suspicious lesions. A History and Physical, documented by PCP 16 on 10/15/25, lacked documentation of Resident B having skin breakdown to include a pressure ulcer/injury to the sacral area or a DTI on the right heel. A Post Wound Round report, dated 10/21/25, indicated the in-house acquired unstageable pressure ulcer on the coccyx, measured 7 cm x 9 cm x 3 cm. Wound Assessment Reports, documented by Wound NP 13, dated 10/22/25, indicated the resident had an unstageable pressure ulcer/injury on the coccyx, that measured 7.0 cm x 9.0 cm x 3 cm. There was 0% eschar, 50% slough, and the wound was stable. Surgical excisional debridement of the wound was performed with a scalpel, forceps, and scissors at bedside. A Concern Form, dated 10/23/25, indicated Resident B's representative had concerns with the resident's wounds, and had indicated she was not aware of the treatment being done or that it would cause the area to look like a hole in her mother's butt. The resident representative indicated while she was washing her mother, she had also found a discolored area on her heel. The Executive Director (ED) reviewed with the resident representative that a new Wound NP had assessed the resident's heel on 10/24/25, stated it was a DTI, and indicated it was believed the wound was present upon her return from the hospital on [DATE]. The resident representative indicated she was moving forward with hospice and intended to take Resident B home. The concern was documented as resolved on 10/24/25. A Post Wound Round report, dated 10/24/25, a right heel DTI was covered in eschar, and measured 1.8 cm x 1.5 cm x 0.1 cm. The DTI on the resident's heel was identified on 10/8/25 when the resident was in the hospital, but was not identified for the Wound Round report until 10/24/25. A Care Plan Note, dated 10/24/25 at 11:12 a.m., indicated the Social Service Director (SSD), ED, Director of Nursing Services (DNS), Unit Manager (UM), and Resident B's representative met to discuss her concerns with the team. The care plan note focused on the resident representative's behaviors the previous day when she'd been upset, and how in the future she would converse regarding concerns about her mother. The note indicated the team discussed Resident B going home with hospice service, and the plan was for the resident to discharge the following week. The care plan note lacked documentation about the resident representative's specific concerns or interventions that were put into place to reach a resolution about her concerns. A Wound Assessment Report for Resident B, documented by Wound NP 14, who provided a contracted service from a wound care company, dated 10/24/25 at 2:49 p.m., indicated the resident had a DTI pressure ulcer/injury on the right heel, that measured 1.8 cm x 1.5 cm x 0.1 cm. The wound had 100% stable eschar. Resident B's clinical record lacked documentation of when or how the right heel pressure injury was identified, the right heel wound was being monitored or treated, that the PCP and resident representative had been notified of the wound, or that a care plan was implemented before the resident representative verbalized a concern on 10/23/25. An updated skin care plan for Resident B, dated 10/27/25, indicated the resident was at risk for altered skin integrity related to impaired mobility, type 2 diabetes mellitus, hemiplegia/hemiparesis, hyperlipidemia, chronic kidney disease, Parkinson's disease, insomnia, atrial fibrillation, hypertension, and obstructive + reflux uropathy. Gluteal dermatosis to the coccyx, an unstageable coccyx wound, and a right heel DTI. The goal was for the resident to have improved or maintain the current skin status through the next review date. On 9/5/25 interventions included, complete a skin at risk assessment upon admission / readmission, quarterly, and as needed. Complete weekly skin checks, encourage the resident to turn and reposition or assist as needed as resident allows, and to provide an appropriate off-loading mattress and off-loading cushion, if applicable. New interventions, dated 10/27/25, included apply barrier creams after incontinent episodes, enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri care, and providing care to wound care for skin openings that require a dressing. Ensure residents are turned and repositioned. Nutritional consult on admission, quarterly, and PRN (as needed). Provide appropriate off-loading cushion to chair. Provide appropriate off-loading mattress. Provide appropriate off-loading mattress & off-loading cushion, if applicable. Provide heel protectors per orders. During an interview on 11/7/25 at 12:04 p.m., Licensed Practical Nurse (LPN) 7 indicated there was a new in-house wound nurse, LPN 9, who rounded with Wound NP 13 every Tuesday and Friday, and they were responsible for keeping track of and documenting resident wounds. If a nurse identified or was informed of a new wound, that nurse wound notify the PCP and obtain new orders. When the aides gave showers, they would notify the nurse if there was a skin issue or concern, and that was documented on the shower sheet by the aide. Staff were taught if you see something, you say something. During an interview on 11/7/25 at 2:45 p.m., the resident representative indicated Resident B had been admitted to the nursing facility on 9/5/25 after having been hospitalized for a stroke. The resident required total assistance with a mechanical lift for transfers, and she required total care per staff for activities of daily living (ADLs), but she had no skin breakdown or wounds. On 10/6/25, the resident was readmitted to the hospital for pneumonia, and after receiving intravenous (IV) antibiotics, was returned to the nursing facility on 10/10/25. The resident representative indicated she was the health care representative (HCR) and had not been informed of the severity of the wound on the resident's bottom or that the resident had a new wound on her right heel until she was giving the resident a bath on 10/23/25. The resident representative indicated she had observed the wound on her mother's bottom to be round and about the size and depth of a cutie orange with tunneling and a small black area on the resident's right heel. The resident representative indicated she had questioned staff about the severity of the wounds, and when the aides told her they were not aware of the heel wound, and the nurse on duty indicated they had previously informed her of the severity of the sacral wound, she had went off. The healthcare representative indicated she then went to the receptionist and asked to speak with management, and was told the DNS was out, and she would have to make an appointment to speak with the ED. The healthcare representative indicated she was so upset about her mother's condition, she had acted in an inappropriate manner, and the facility called the police on her. The healthcare representative indicated, on 10/24/25, she had met with management regarding her care concerns, and the team provided no explanation about how the wounds had occurred, or what she perceived as lack of care, instead she was spoken down to in a condescending tone, and they spent their time scolding her about her behavior the day before. The management team knew they were in the wrong, as they kept repeating phases like we could have done better, or we should have done better. A corporate person called her that evening and seemed genuinely apologetic, and after she was provided with pictures of the residents wounds, assured her an investigation into the situation would start the following Monday. The resident representative indicated, on 10/30/25 she took Resident B home with her. During an interview on 11/12/25 at 2:08 p.m., the [NAME] President of Risk Management (VPRM) indicated on 10/23/25, Resident B's representative had gotten upset and acted out against the staff as she thought the resident had developed wounds in the facility. She was not sure she had understood that debridement of the wound would make it look worse before it got better. The Wound NP had assessed the resident on 9/19/25 and diagnosed her with gluteal dermatosis with scarring. The VPRM indicated, in defense of the facility, she felt the resident could have had a DTI on her coccyx before being admitted to the facility, and upon reviewing pictures, did not see scarring but instead saw what she thought was dead tissue. This could have caused the resident's bottom to be more prone to breakdown. There was no documentation of the right heel DTI before the resident was readmitted to the hospital. On 9/26/25 LPN 15 had documented she informed the resident representative Resident B's buttocks were improving with the current treatment, which was a contradiction to Wound NP 13's documentation of the wound worsening. The VPRM indicated she did not think LPN 15's documentation reflected what she meant. On 10/10/25, LPN 15 had documented both on a skin grid and in the progress notes that Resident B had a wound on the left heel versus the correct location on the right heel, but she thought the nurse knew which was the correct heel and just made a mistake when documenting. During an interview on 11/13/25 at 12:10 p.m., the VPRM indicated, while reviewing Resident B's wounds, additional lack of documentation included,a. The clinical record lacked documentation to indicate when an abscess on the right upper back had been identified, of palliative/preventative care being provided, if the staff was monitoring for pain at the site, the resident representative and PCP had been notified, and there was no care plan initiated. b. The clinical record lacked documentation before or after hospitalization, of a small oval area on the left lateral lower exterior, that had presented like an old wound with a hard scab.c. The clinical record identified a left heel suspected DTI on 10/10/25, with no description or measurements. There were no orders obtained to treat the DTI on the right heel. Wound NP 14 documented on 10/14/25 there was no DTI on the heels, and in subsequent visits did not document on the heels. There was no documentation to indicate the resident representative was aware of the DTI on the right heel, and there was no care plan initiated.d. The clinical record lacked care plan documentation of a sacral wound until 10/27/25. On 10/3/25 an order was obtained to place a LAM. The LAM order was not rewritten upon the Resident B's return from the hospital on [DATE]. During an interview on 11/13/25, the VPRM indicated she had interviewed LPN 15 regarding Resident B's wounds. LPN 15 indicated, when the resident returned to the facility on [DATE], the nurse had mistakenly documented the resident had a suspected DTI on the left versus right heel. Wound NP 13 had seen Resident B on 10/14/25 and documented the resident had no DTI's. LPN 15 had told the VPRM she did not agree with Wound NP 13's assessment of the heel, but she wound not argue as Wound NP 13 was the wound expert. Both Wound NP 13 and LPN 15 indicated it was not customary for them to document on calluses, so there was no further documentation of the right heel DTI until after the resident representative brought it to the attention of nursing staff on 10/23/25. The Divisional Director of Clinical Services had requested a different Wound NP visit, and on 10/24/25 Wound NP 14 had assessed and documented Resident B's right heel DTI. The VPRM indicated it was at this point that the facility realized there was a potential issue regarding wound documentation and a disconnect between what Wound NP 13 had documented versus what the hospital had documented, and nursing staff indicated they felt was a skin issue. During an interview on 11/14/25 at 2:36 p.m., LPN 10 indicated she was the Unit Manager (UM) for the 2nd floor hallways. LPN 10 indicated, if a resident developed a new wound, staff were supposed to relay the information to her or the nurse in charge at the time, and the nurse that was informed of a wound was responsible for documenting the information in the electronic medical record. The in-house wound nurse was then responsible for assessing the wound, documenting a description and measurement, informing Wound NP 13, and care planning the wound. If there was a change in the status of a wound, the in-house wound nurse would be informed and was again responsible for assessing and documenting the wound and making the necessary notifications. If a new wound was found in between Wound NP 13's rounds, the in-house wound nurse would enter a generic order for treatment until the resident could be seen. On 11/14/25 at 2:49 p.m., the VPRM provided documentation from a local hospital, that indicated the resident had been admitted on [DATE] for medical treatment following a cardiovascular accident (CVA-stroke). A Nurse's Note for Resident B, dated 9/5/25 at 10:00 a.m., indicated Resident B had a resolved stage 2 pressure injury (a partial-thickness skin loss where the outer layers of the skin are damaged, resulting in an open, shallow wound that may look like a blister or abrasion with a pink or red base) on the coccyx. Daily wound care included no cover dressing, and no documented treatment. The note lacked documentation of a date when the resident had acquired the pressure injury, root cause, or a description and size of the injury. During an interview on 11/14/25 at 2:50 p.m., LPN 11 indicated she was the UM for the downstairs hallways. If she was informed by staff or a family member that a resident had developed a wound, she would notify in-house NP 12, who was usually in the facility Monday through Thursday, and get orders until Wound NP 13 visited on Tues and Fri, and she would then assume care of the wound. The UM and floor nurses would only document in the progress note and on a skin grid that a wound was found if wound nurse LPN 9 and Wound NP 13 were unavailable and then reach out to the tele-health NP for treatment orders. LPN 9, or the floor nurse in her absence, was responsible for notifying the resident representative and PCP of a new or worsening wound. The floor nurse was responsible for completing weekly skin assessments, and for documenting nursing wound interventions. The Minimum Data Set (MDS) nurse was responsible for care planning for a new or worsening wound. During an interview on 11/14/25 at 2:50 p.m., LPN 11 indicated Resident B had been admitted to the facility on [DATE]. The nurse on duty for the day documented an admission nursing assessment to include the skin, and Wound NP 13 had followed up with documentation of a head-to-toe assessment a few days, and there were no wounds documented at that time. Wound NP 13 was the facility expert for wounds. But, if the nurse identified that a resident had a skin area of concern, and the area was not documented or was staged by Wound NP 13 in a manner that she did not agree with, she would take next steps. The nurse could describe the area of concern in the progress notes, notify in-house NP 12 for direction, notify the DNS with the concern, or notify the corporate support to help intervene. On 11/14/25 at 3:20 p.m., the RVRM provided documentation she felt would prove past non-compliance to include,a. On 10/24/25, internal education was sent out to 130 staff members. Education regarding wounds included assessment of skin conditions, information to be documented to include a description and measurements, notification of the wound, where to document the wound, care planning the wound, and what to do if the nurse disagreed with the providers choice of treatment or wound description.b. On 10/24/25 - 10/27/25, nursing management met with staff in-person, and nursing staff signed to verify they had received the education, if they understood the education, and if there were questions. The clinical education for the nurses and aides included skin observation, wound documentation, wound assessments, and who was to be notified of a new wound. The nurses were also encouraged to notify nursing management if the nurse felt like she/he was not being heard, or if he/she felt a wound was not being managed/documented accurately by internal or external sources. c. On 10/24/25, care plan audits were completed for residents with known skin concerns/wound and updated with interventions as needed. d. On 10/25/25 a skin sweep of every resident was completed and documented on bath/skin sheets for the 97 residents residing in the facility. There were no new pressure wounds/injuries identified. Approx. 75% of known residents with wounds had their care plans updated with new interventions.e. On 10/25/25, notifications to the MD/NP, resident representatives, and wound NP were made, and treatment orders were obtained for any resident found to have a skin issue. New wound orders were obtained as needed.f. On 10/27/25, LPN 9 was hired for the in-house wound nurse position and replaced LPN 15. LPN 9 then initiated completion of a skin assessment on all new residents on her next day on shift.g. On 10/31/25, follow-up audits were initiated. Ten (10) residents with wounds were to be visually validated per week for 4 weeks to ensure family had been notified, wound treatments were completed per orders, monitoring had occurred daily, Wound NP recommendations were being followed, LAM were in place per orders, and care plans were up to date. On 11/14/25 at 2:49 p.m., the VPRM provided a Skin Care & Wound Management Overview policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, Each resident is evaluated upon admission and weekly thereafter for changes in skin condition. Resident skin condition is also re-evaluated with change in clinical condition, prior to transfer to the hospital and upon return from the hospital.Prevention: 1. Complete the Braden Scale.2. Complete an admission Observation Tool.3. Identify diagnoses or conditions to place the resident at risk for pressure ulcer development . [co-morbid conditions, cognitive impairment, decreased activity, decreased sensory perception, diabetes, poor nutrition/hydration.healed pressure ulcer, increased moisture on skin] .4. Develop a care plan with individualized interventions to address risk factors. 5. Communicate risk factors and interventions to the care giving team. 6. Evaluate for consistent implementation of interventions and effectiveness at clinical meeting. 7. Modify and document goals and interventions as indicated. 8. Communicate changes to the care giving team. This deficient practice was corrected by 10/31/25 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included staff education, skin assessments, and wound care plan audits, and ongoing monitoring was in place. This citation relates to Intake 2655006. 3.1-40(a)(1)3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure care plan interventions were personalized, implemented, and updated to include changes to wound management for 1 of 3 residents reviewed for care plans (Resident B). This deficient practice was corrected by 10/31/25 prior to the start of the survey and was therefore Past Noncompliance. Findings include:Resident B's clinical record was reviewed on 11/7/25 at 2:00 p.m. Diagnoses on Resident B's profile included hemiplegia and hemiparesis (paralysis) following a cerebral infarction (stroke - death of brain tissue caused by a lack of blood flow) affecting the left dominant side, type 2 diabetes mellitus with diabetic neuropathy, Parkinson's disease, encephalopathy (disfunction of the brain that caused confusion and memory loss), and dysphagia (difficulty swallowing). A care plan for Resident B, dated 9/5/25, indicated the resident was at risk for altered skin integrity related to impaired mobility, and type 2 diabetes mellitus. The goal was for the resident to have improved skin or maintain the current skin status through the next review. Interventions included, complete a skin at risk assessment upon admission / readmission, quarterly, and as needed. Complete weekly skin checks, encourage the resident to turn and reposition or assist as needed as resident allows, and to provide an appropriate off-loading mattress and off-loading cushion, if applicable. Physician's order, dated 9/9/25, indicated to apply Triad cream (a multipurpose skin protectant) to the buttocks every shift and as needed after incontinent episodes. A nursing progress notes, dated 9/17/25 at 4:04 p.m., indicated there had been skin breakdown observed on Resident B's buttocks. A Post Wound Round report, dated 9/19/25, indicated a new full thickness dermatosis on the coccyx, measured 3.5 cm x 2.5 cm x 0.1 cm. Physician's order, dated 9/19/25, indicated to cleanse the coccyx with soap and water, then pat dry. Apply Triad paste to the coccyx affected area three times a day (TID) for wound care and as needed for soilage. Leave open to air. A Post Wound Round report, dated 9/26/26, indicated a new in-house acquired unstageable pressure ulcer on the coccyx, that measured 6.5 cm x 8 cm x 0.1cm. Physician's order, dated 9/26/25, indicated to cleanse the coccyx with wound cleanser then apply medical grade honey and cover with boarder foam every shift for wound care and as needed for soilage or dislodgement. Daily wound assessment and document abnormalities in the progress notes to include drainage, necrotic tissue, signs of infection, odor, surrounding skin, pain level, and if the dressing was dry and intact. Physician's order, dated 10/3/25, indicated to use a low air loss mattress, and check every shift for placement and function. A Post Wound Round report, dated 10/3/25, indicated the in-house acquired unstageable pressure ulcer on the coccyx, measured 10 cm x 3.5 cm x 0.1 cm. A local hospital Physician's Progress Notes, dated 10/6/25 at 3:18 p.m., indicated Resident B presented to the hospital with concerns for hypoxia (low oxygen saturations) and difficulty breathing. The resident was subsequently admitted to the Intensive Diagnostic Treatment Unit (IDTU) to receive treatment for pneumonia (PNA) and a change in mental status. On 10/7/25 at 8:40 a.m., orders were received to initiate the skin and wound care protocol. The reason for the consultation was an unstageable pressure injury on the sacrum and a DTI on the right heel. On 10/8/25 at 4:22 p.m. wound care consult photos included,a. A general assessment indicated the patient's left heel, bilateral ears, and elbows were intact. The left ear and knee had some hyperpigmentation.b. An unstageable sacral/bilateral buttocks pressure ulcer, that measured 8.1 cm x 9.3 cm x 0.4 cm. A minimal amount of tissue was removed with sharps, but remaining necrosis was crosshatched to allow for deeper dressing penetration.c. An unstageable right heel pressure injury was firm and intact with adherent eschar. d. There was a small oval area on the left lateral lower exterior, that presented like an old wound with a hard scab, and measured approximately 3.0 cm x 1.0 cm.e. Nursing was to turn the patient every 2 hours using 2 pillows as wedges, no pillow to the sacrum/buttocks only back and posterior legs, and no back time. Waffle boots were in place to assist with offloading while in bed. A nursing progress notes by LPN 15, dated 10/10/25 at 1:50 p.m., indicated Resident B had returned on a stretcher from a nearby hospital. The resident was alert to herself only and non-verbal per her baseline. The resident had a hard calloused area on the left heel and boots were applied as preventative. Physician's order, dated 10/10/25, indicated weekly skin assessments were to be completed every Friday, wound care consult, the resident was to be on a standard facility mattress that was supposed to be pressure reducing/relieving, and daily wound assessment and document abnormalities. Cleanse the sacral wound daily with wound cleanser, apply medical grade honey, and cover with a bordered foam daily and as needed for soiling and as needed. A Post Wound Round report, dated 10/14/25, indicated the in-house acquired unstageable pressure ulcer on the coccyx, measured 9.5 cm x 4 cm x 2 cm. A Post Wound Round report, dated 10/21/25, indicated the in-house acquired unstageable pressure ulcer on the coccyx, measured 7 cm x 9 cm x 3 cm. A Post Wound Round report, dated 10/24/25, indicated a right heel DTI was covered in eschar, and measured 1.8 cm x 1.5 cm x 0.1 cm. The wound round report indicated the DTI was identified on 10/8/25, when the resident was in the hospital, but had not been identified for this report until 10/24/25. An updated skin care plan for Resident B, dated 10/27/25, indicated the resident was at risk for altered skin integrity related to impaired mobility, type 2 diabetes mellitus, hemiplegia/hemiparesis, hyperlipidemia, chronic kidney disease, Parkinson's disease, insomnia, atrial fibrillation, hypertension, and obstructive + reflux uropathy. Gluteal dermatosis to the coccyx, an unstageable coccyx wound, and a right heel DTI. The goal was for the resident to have improved or maintain the current skin status through the next review date. On 9/5/25 interventions included, complete a skin at risk assessment upon admission / readmission, quarterly, and as needed. Complete weekly skin checks, encourage the resident to turn and reposition or assist as needed as resident allows, and to provide an appropriate off-loading mattress and off-loading cushion, if applicable. New interventions, dated 10/27/25, included apply barrier creams after incontinent episodes, enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri care, and providing care to wound care for skin openings that require a dressing. Ensure residents are turned and repositioned. Nutritional consult on admission, quarterly, and PRN (as needed). Provide appropriate off-loading cushion to chair. Provide appropriate off-loading mattress. Provide appropriate off-loading mattress & off-loading cushion, if applicable. Provide heel protectors per orders. On 11/14/25 at 2:49 p.m., the VPRM provided documentation from a local hospital, that indicated the resident had been admitted on [DATE] for medical treatment following a cardiovascular accident (CVA-stroke). A Nurse's Note for Resident B, dated 9/5/25 at 10:00 a.m., indicated Resident B had a resolved stage 2 pressure injury (a partial-thickness skin loss where the outer layers of the skin are damaged, resulting in an open, shallow wound that may look like a blister or abrasion with a pink or red base) on the coccyx. Daily wound care included no cover dressing, and no documented treatment. The note lacked documentation of a date when the resident had acquired the pressure injury, root cause, or a description and size of the injury. During an interview on 11/14/25 at 2:50 p.m., LPN 11 indicated, the Minimum Data Set (MDS) nurse was responsible for care planning new or worsening wounds. On 11/14/25 at 3:20 p.m., the RVRM provided documentation she felt would prove past non-compliance to include,a. On 10/24/25, care plan audits were completed for residents with known skin concerns/wounds (Residents B, F, L, P, Q, R, S, T, U, V, W, and X). The RVRM indicated, approximately 75% of those residents required their care plans to be updated, but she did not know the names of the residents who had care plans revised. b. On 10/25/25 a skin sweep of every resident was completed and documented on bath/skin sheets for the 97 residents residing in the facility. To her knowledge there were no new pressure ulcer/injuries identified, but residents were found with undocumented skin tears, bruises, and other skin issues.c. On 10/31/25, follow-up audits were initiated. Ten (10) residents with wounds were to be visually validated per week for 4 weeks to ensure family had been notified, wound treatments were completed per orders, monitoring had occurred daily, Wound NP recommendations were being followed, LAM were in place per orders, and care plans were up to date. On 11/14/25 at 2:49 p.m., the [NAME] President Risk Management provided a Plan of Care Overview policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, The facility will: i. Provide an RN assessment of the resident as on on-going, periodic review that provides the foundation for resident focused care and the care planning process.iii. Review care plans quarterly and/or with significant changes in care.vii. Support and encourage resident/representative participation including but not limited to working cooperative to.3. Schedule meetings to accommodate a resident's representative that may include conference calls, video conference sessions or live sessions.II. Care Plan Team.b. Members of the care planning team will coordinate care to meet resident preferences and care needs utilizing a holistic approach of care. On 11/14/25 at 2:49 p.m., the [NAME] President Risk Management provided a Skin Care & Wound Management Overview policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, 4. Develop a care plan with individualized interventions to address risk factors. 5. Communicate risk factors and interventions to the care giving team. 6. Evaluate for consistent implementation of interventions and effectiveness at clinical meeting. 7. Modify and document goals and interventions as indicated. 8. Communicate changes to the care giving team. This deficient practice was corrected by 10/31/25 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included staff education, skin assessments and wound care plan audits, and ongoing monitoring was in place. Cross reference tag F686. This citation relates to Intake 2655006. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to provide comfortable water temperatures of more than 100 degrees Fahrenheit (F) and less than 120 degrees F in 16 of the 16 residents' bathrooms on the [NAME] 1 hallway reviewed for comfortable temperatures (Rooms 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, and 215) . Findings include: During the initial tour, on 8/6/25 at 12:03 p.m., Resident N indicated that the water in her bathroom was cold, she could not take a shower in her room, and CNA 8 had to warm up water in a basin at the nurse's station so she could be washed. A visitor observed the water being cold after having been turned on for 5 minutes. The resident indicated she had notified management more than once that her water did not always warm up after being turned on for 20 minutes.Documentation of water temperature monitoring included:a. On 7/7/25, water temperatures were 120 Fahrenheit (F) in the Health hallway nurse's station, Heritage hallway nurse's station, [NAME] 1 hallway, and [NAME] 2 hallway.b. On 7/14/25, water temperatures were 120 F in the Health hallway nurse's station, Heritage hallway nurse's station, [NAME] 1 hallway, [NAME] 2 hallway, and the frill (upstairs dining area).c. On 7/21/25, water temperatures ranged from 115 - 120 F in the Health hallway, Heritage hallway, [NAME] 1 hallway, [NAME] 2 hallway, and the frill.d. On 7/28/25, water temperatures ranged from 110 - 112 F in the Health hallway, Heritage hallway, [NAME] 1 hallway, [NAME] 2 hallway, and the frill.e. On 8/4/25, water temperatures ranged from 110 - 120 F in the Health hallway, Heritage hallway, [NAME] 1 hallway, [NAME] 2 hallway, and the frill.A grievance documented from Resident N on 8/5/25, indicated she had water concerns.The facility lacked documentation resident specific room water temperatures were being monitored before 8/6/25.Documentation of water temperature monitoring on [NAME] 1 hallway included,a. On 8/6/25, rooms 200 - 215 ranged from 76 - 82 F.b. On 8/7/25, rooms 200 - 215 ranged from 64 - 76 F.c. On 8/8/25 in the morning, rooms 202 - 215 ranged from 76 - 80 F.d. On 8/8/25 in the afternoon, rooms 203 - 211 ranged from 63 - 98 F.A service report, dated 8/6/25, indicated a heat sensor was not working properly, and a replacement part was ordered.During an interview on 8/11/25 at 9:57 a.m., the Administrator indicated, on 8/5/25, it was brought to her attention that water temperatures on [NAME] 1 were intermittently not hitting proper temperatures. On 8/6/25 the residents/resident representatives in rooms 205 - 209 were offered rooms. The residents in rooms 203, 204, 210, and 211 were offered room moves on 8/8/25 after daily water temperature monitoring had identified hot water concerns in their rooms. Residents had declined a room move and were not made to make a room change as there was no threat of them getting burned, and the facility knew the problem was in the process of being fixed.During an interview on 8/11/25 at 3:30 p.m., the Administrator indicated the facility did not have a specific policy for monitoring hot water temperatures but followed current state regulation regarding water temperatures. The regulation indicated, Hot water temperatures for all bathing and hand washing facilities shall be controlled by an automatic control valve. Water temperature at point of use must be maintained between one hundred [100] degrees Fahrenheit and one hundred twenty [120] degrees Fahrenheit.This citation relates to Intake 2581409.3.1-19(r)(1)3.1-19(r)(2)

Based on observation, interview, and record review, the facility failed to provide or document showers for 4 of 11 residents reviewed for bathing preferences (Residents C, K, L, and N). Findings include:During the initial facility tour on 8/6/25 at 10:45 a.m., the following residents complained of not getting showers.a. On 8/6/25 at 11:22 a.m., Resident K was observed lying in bed watching TV. The resident indicated she required assistance with ADL's (activities of daily living) to include bathing, transfers out of the bed, and wheelchair (WC) mobility.On 8/8/25 at 10:52 a.m., electronic shower documentation for Resident K, dated 7/1/25 - 8/6/25, indicated the resident had received a shower on 7/23, 8/4, and 8/6. Licensed Practical Nurse (LPN) 9 indicated, the resident had moved upstairs from Heritage hallway 2 days prior. There was no documentation to indicate Resident K had refused to have a shower.b. On 8/6/25 at 11:37 a.m., Resident L was observed wheeling herself into her room in a manual WC and stopped at the end of her bed. Certified Nursing Assistant (CNA) 8 indicated the resident required assistance with bathing, dressing, and toileting.On 8/7/25 at 10:45 a.m., Resident L was observed being brought out of her bathroom after having received a shower. CNA 8 indicated this was the first time in more than a month she had been able to shower the resident in her room due to not having hot water on the unit, and in her opinion, that was not fair to the residents. The shower was observed to be wet and water dripping from the shower head.On 8/8/25 at 2:38 p.m., electronic shower documentation for Resident L, dated 7/1/25 - 8/7/25, indicated the resident had a shower on 7/8, 7/12, 7/17, 7/29, and 7/31. There was no documentation the Resident L had received or refused a shower in August.c. On 8/6/25 at 12:03 p.m., Resident N was observed in an electric WC at bedside applying makeup. The resident indicated the water in her bathroom was cold, she could not take a shower in her room, and CNA 8 had to warm up water in a basin at the nurse's station so she could be washed.On 8/8/25 at 10:52 a.m., electronic shower documentation for Resident N, dated 7/1/25 - 8/8/25, indicated the resident was not documented as having received or refused a shower. d. On 8/6/25 at 12:50 p.m., Resident C was observed sitting in a reclining geriatric chair at bedside. The resident indicated she was dependent on staff for bed mobility, transfers, bathing, and propelling her chair.On 8/8/25 at 2:38 p.m., electronic shower documentation for Resident C, dated 7/1/25 - 8/8/25, indicated the resident had received a shower on 7/12. There was no documentation Resident C had refused showers.During an interview on 8/6/25 at 12:40 p.m., LPN 9 indicated, there were days the water in certain residents' rooms would get only lukewater. When this happened, she had notified the maintenance department of the issue electronically. During an interview on 8/6/25 at 12:44 p.m., CNA 8 indicated she was routinely assigned to work on [NAME] 1. On that morning, she had to get warm water at the nurse's station for most of her residents' baths.During an interview on 8/7/25 at 10:38 a.m., CNA 8 indicated there had been some hot water that morning in [NAME] 1 rooms, and her residents had received showers in their rooms for the first time in several weeks.During an interview on 8/8/25 at 10:52 a.m., LPN 9 indicated staff were supposed to document showers in POC (Point of Care - an electronic documentation system) when completing their daily charting. But there were staff that would document showers on skin/shower sheets or in nursing progress notes.During an interview on 8/8/25 at 11:30 a.m., CNA 14 indicated nursing staff were required to document showers both on paper and in POC for the same day of service. It was double documentation, but that was the expectation.During an interview on 8/11/25 at 9:57 a.m., the Administrator indicated, on 8/5/25, it was brought to her attention that water temperatures on [NAME] 1 were intermittently not hitting proper temperatures. There was no centralized shower room in the Lofts 1 hallway. All resident rooms had a shower in their private bathrooms, and on 8/5/25 an empty resident room had been designated as a shower room where residents could be taken for showers.On 8/11/25 at 12:37 p.m., the Administrator (ADM) provided a Daily Skin Care policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, skin care included bathing.1. Discuss the resident/patient preferences for bathing and skin care. 2. Document preferences on the care plan. 3. Communicate resident/patient preferences to the care giving staff. 4. Monitor resident/patient's ability to care for self, including appropriate skin care. Offer assistance or provide care as needed.This citation relates to Intake 2581409.3.1-3(v)(1)

Based on observation, and interview, the facility failed to maintain a clean and sanitary environment on 4 of 4 hallways (Health Heritage, [NAME] 1, and [NAME] 2 hallways) observed for cleanliness. Findings include:1. A confidential interview during the survey process indicated family members had visited to find the resident's room in complete filth. The resident had multiple sheets with urine and bowel movement, and the mess had been covered up with cloth pads by the staff instead of them changing his sheets. There had been dried bowel movement on the trash can, and someone had removed the trash can liner then put a trash can liner back in on top of the dried bowel movement. There was an occurrence when the resident had a loose bowel movement, could not get staff to respond to his call light, and in attempts to clean up the mess had smeared it from the bed into the bathroom. The resident had an infectious disease, and having his bodily fluids all over the room was not hygienic. On 8/6/25 at 2:38 p.m., observation of 2 flies flying around the room near Resident D as he sat in the manual WC on the back side of the bed using a remote to change the TV channel. The resident gestured to a tray on his over-the-bed table, and indicated staff had yet to pick up his lunch tray. Observation of 2 opened boxes of cereal sitting on top of a bedside dresser, and food sitting on the windowsill among skin treatments. The resident's bed was unmade with a gown thrown on the foot of the bed, clothing overflowed a tall plastic clothes hamper onto the floor, there were piles of clothing stacked on the floor and a chair, and a soiled pair of pants was on the floor beside the trashcan, and a soiled pair of pants on the floor in the bathroom. Food debris, bottles of soda, and an open 1/2 gallon of green punch were observed under the bed, and 2 dirty forks, condiment packets and alcohol preps on a dresser underneath the TV. The room had a strong smell of urine, and the floor was sticky throughout the room from food and unidentified substances.On 8/7/27 at 11:04 a.m., a second observation of Resident D's room not having been cleaned. The bed was observed to be unmade, soiled bedding, and a strong foul urine odor remained in the room. A urinal with 4 inches of urine was sitting on the floor on the back side of the bed.On 8/7/25 at 12:19 p.m., Resident D indicated a family member had just visited and took his laundry to be cleaned. The resident moved a cloth pad on his bed and indicated the dark circles on the sheet were from where he sometimes had accidents with his bladder and bowel. Resident D indicated he had asked nursing staff to change his sheets that morning, and in response they had given him a pad to cover the bed where he laid. The resident indicated he wanted his room cleaned by housekeeping staff, but that did not happen, and his sheets got changed maybe twice weekly even though he was known to have accidents.On 8/7/25 at 3:00 p.m., Resident D was observed to be sleeping on his unmade bed, on top of a soiled cloth pad and sheets with dried dark circles. Housekeeping services had not yet been provided that day, and there was soiled clothing lying on the bathroom floor.On 8/11/25 at 9:12 a.m., Resident D was observed sitting up on the bed eating a muffin. Dirty eating utensils remained underneath the TV on the dresser. Food observed sitting on flat surfaces throughout the room. A strong urine smell remained in the room.Housekeeping checklists, dated August 2025, indicated Resident D's room was documented as having been cleaned daily.2. On 8/6/25 at 10:50 a.m., Resident E was observed out of the room. Soiled bedding was observed on the floor near the window, and there was a strong urine smell that permeated into the hallway.On 8/7/25 at 10:15 a.m. a second observation of Resident E's room. The bed was unmade, and a cloth pad on the bed was observed with dried yellow rings that smelled of urine.3. On 8/6/25 at 10:52 a.m., Resident F was observed ambulating in the hallway independently, then she returned to lie down on the bed. Potato chips were observed on the floor behind the bed.4. On 8/6/25 at 10:54 a.m., a shared bathroom for Residents G and H was observed, and there was dried bowel movement smeared on the raised toilet seat. An unidentified aide indicated, neither resident was independent with toileting.There was no housekeeping staff observed on the [NAME] 2 hallway during the initial tour. Trash cans in resident rooms lacked liners. 5. On 8/6/25 at 11:16 a.m., a gnat was observed flying outside Resident Z's doorway as Housekeeper 7 finished mopping the floor, then left the room and closed the door. The room was observed with Certified Nursing Assistant (CNA) 8, the bathroom sink was soiled with paper debris and hair, and the toilet soiled with dried bowel movement.6. On 8/6/25 at 11:22 a.m., Resident K was observed lying in bed watching TV. There was food and flower debris under the bed and around the room, with larger pieces of food near the door. The resident indicated she required assistance to transfer out of bed, and the staff provided wheelchair (WC) mobility. 7. On 8/6/25 at 11:37 a.m., gnats were observed flying in the resident room as Resident L was observed wheeling herself into her room in a manual WC. The resident's room had an overabundance of personal items stacked haphazardly on the floor, in and under chairs, on and under tables, on the windowsill, and sitting on shelves near the bathroom door. A protein shake with an expiration date of 6/26/25 and an opened container of coffee with tissue paper stuffed in the top, were sitting next to an opened bottle of wound spray that had a dried dark substance down the side, all sitting among additional food and personal items on her dresser. There were open containers of powdered vanilla creamer, sugar, and frosted cereal on the shelves near the bathroom door. The outside of the bathroom toilet bowl was observed soiled with a dried yellow substance, the sink dull and heavily soiled with dried food and debris, and the bathroom and shower floors were heavily soiled with loose coins, a dirty metal spoon, paper debris, unidentified substances, and hair. The flat surfaces of the room had an accumulation of dust and the floor around and under the bed were heavily littered with items that included dropped food, sugar packets, an oxygen tubing, rolled up socks, a purple beanbag, a metal fork, a gait belt, and a black WC cushion with a dried whitish substance that looked like mold. 8. On 8/6/25 at 11:57 a.m., Resident M was observed sitting in a manual WC watching beside the bed watching TV. The resident indicated he liked to get a shower but had only received 1 since his recent admission to the facility. The shower floor was observed to be heavily soiled with dust and black hair.9. On 8/6/25 at 12:03 p.m., Resident N was observed in an electric WC at bedside applying makeup. A small black refrigerator was observed sitting on a piece of wood over a pallet, and there was a visible accumulation of food debris under the pallet. Resident N indicated the water in her bathroom was cold.On 8/6/25 at 12:20 p.m., Resident N was observed asking a housekeeper to empty and replace the liners in her trashcans. A white trash can near the resident's bed was heavily soiled inside and out with dark unidentified substances. 10. On 8/6/25 at 12:20 p.m., gnats were observed flying around Resident Q's room. The bathroom toilet, floor, shower, and mirror were heavily soiled with dark substances and hair. There was 1 white sneaker and a strip of black rubber cove base under the bathroom sink. The floor throughout the room, and under the bed and dressers were littered with food, and dried liquid substances. There was a battery and 1 WC pedal lying among debris behind a bedside dresser. The top of a dresser under the tv had dried white paper stuck to the top. An over-the- bed tabletop and the entire metal stand were heavily soiled with dried food and fluids. All 4 walls of the bedroom and the top of a white kitchen sized trash can sit in a corner near the door were heavily soiled with unidentified dark substances. There was an open box of snack crackers sitting on the bedside dresser. A continuous observation, on 8/6/25 from 11:16 a.m. to 12:28 p.m., Housekeeper 7 was observed mopping resident rooms on the [NAME] 1 hallway. Housekeeper 7 indicated, [NAME] 1 was her usual assignment for cleaning, and it was her responsibility to sweep, mop, and dust the residents' rooms. Housekeeper 7 was observed to take her cart with water, mop pads and a broom and leave the floor. She was not observed dusting or removing trash from any room on the hallway. On 8/7/25 at 10:43 a.m., gnats were observed swarming around Resident Q's door to the hallway, and Housekeeper 11 indicated it was not unusual to see gnats in and around certain resident rooms in the facility. Housekeeper 11 was observed cleaning Resident Q's shower, and indicated his room and bathroom always needed extra attention. Housekeeper 11 indicated, while cleaning the bathroom, she had found an excess of filth to include a molded banana behind the toilet. During an interview on 8/11/25 at 3:00 p.m., the Administrator indicated that the resident would throw urine on the walls of his room. He did not like to have housekeeping clean his room. 11. On 8/6/25 at 11:27 a.m., observation of Resident C's room. The bathroom trashcan lacked a liner, the inside heavily soiled with dark colored unidentified sticky substances, scraps of paper, paper straw covers, and hair. An uncapped tube of hydrophilic wound dressing was on the bedside dresser among the resident's cellphone, lotions, radio, and a container of petroleum jelly with the lid off on its side. A nebulizer machine sat on the back corner of the beside dresser with the mask unbagged in the top drawer among her personal items. The top of the bedside dresser was covered in paper pieces dried to the surface. The over-the- bed stand was heavily soiled with dust and dried fluid rings, and an open bottle of hot sauce.On 8/6/25 at 12:50 p.m., multiple gnats were observed flying around the room as Resident C sat in a geriatric chair at bedside. The resident indicated she had gnats everywhere. The housekeeping staff swept and mopped her room almost every day, but she was responsible for dusting her own room. On 8/7/25 at 10:28 a.m., Resident C was observed lying in bed working on a puzzle. The flat surfaces of the resident's room remain unclean from the day before. The resident indicated she continued to have gnats flying around. 12. On 8/7/25 at 11:06 a.m., observation of tiny black ants on the floor near where Resident S was observed sitting in a manual WC at bedside watching TV. The resident's floor was observed to be sticky with visible shoe tracks, and the bathroom was not swept. There was dirty clothing wadded up and placed over incontinent products on top of a dresser. A urinal with 1 of urine was observed sitting on the floor beside the bed.13. On 8/7/25 at 11:10 a.m., Resident HH was observed propped up in bed, and an over-the- bed table over her lap had a partial cup of cold tea with a tea bag inside. The resident indicated, the prior evening, an aide had gotten her a warm cup of tea and animal crackers to snack on. There were food crumbs on the over-the-bed table and the floor around the bed.14. On 8/7/25 at 12:21 p.m., observation of a gnat flying around Resident V's head and face as she sat in a manual WC near the nurse's station, talking with staff. The resident's room was observed to have clothing stacked haphazardly in piles near the window, a soiled glove on the floor in front of a dresser, a hanger under the heating/cooling unit, a smoking vape and tub of Eucerin cream (emollient) sitting on the seat a bedside commode, and an open tube of Calmoseptine (barrier cream) on the floor under the bed. The resident indicated she used the bedside commode. A white trashcan near the doorway had no liner, and the bottom was heavily soiled with dark substances, wet sugar packets, and dark hair.15. On 8/7/25 at 11:56 a.m., Resident Y was observed in her room in a manual WC at bedside. There was soiled bedding and a soiled brief piled on the floor outside the bathroom door. At 11:58 a.m., CNA 14 was observed entering the room and she bagged the pile of bedding and brief into a clear trash bag, and left the room.Housekeeping checklists, dated 8/1 - 8/11/25, documented facility rooms as having been cleaned daily, and were signed or initialed by housekeeping staff.On 8/11/25 at 10:45 a.m., the Administrator indicated housekeeping services were contracted out, and the company supervisor was responsible for assuring residents were provided with housekeeping services.On 8/11/25 at 11:50 a.m., the Regional Director for the housekeeping group indicated there was no policy for housekeeping services instead there was a checklist for the housekeeper to sign daily for each room cleaned. The 5-step daily cleaning schedule of the resident room included pull trash/replace liner, horizonal surfaces, vertical surfaces, and dust mop and damp mop. The 7-step daily cleaning schedule for the bathroom included check/refill supplies, pull trash/replace liner, dust mop/sweep, clean sink area/tub, clean commode/basin, clean wall/particians, and damp mop.This citation relates to Intakes 1835279, and 2581409.3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure resident rooms and common areas were free of flying and crawling insects, and subsequently into and landing on open food and drinks in the resident's room on 4 of 4 nursing units during random observation of resident rooms (Health, Heritage, [NAME] 1, and [NAME] 2 hallways). Findings include:On 8/6/25 at 11:16 a.m., a gnat was observed flying outside Resident Z's doorway as Housekeeper 7 mopped the floor.On 8/6/25 at 11:37 a.m., gnats were observed flying in Resident L's room as she was wheeling herself into her room in a manual WC (wheelchair). A protein shake with an expiration date of 6/26/25 and an opened container of coffee with tissue paper stuffed in the top, were sitting next to an opened bottle of wound spray that had a dried dark food substance down the side, all sitting among additional food and personal items on her dresser. There were open containers of powdered vanilla creamer, sugar, and frosted cereal on the shelves near the bathroom door. On 8/6/25 at 12:20 p.m., gnats were observed flying around Resident Q's room, with an open box of snack crackers sitting on a bedside dresser. On 8/6/25 at 12:50 p.m., gnats were observed flying around Resident C's room as she sat in a geriatric chair at bedside, indicating she had gnats everywhere. An open bottle of hot sauce was observed sitting next to the resident on the top of a bedside dresser. On 8/6/25 at 2:38 p.m., observation of 2 flies flying around the room near Resident D as he sat in the manual WC on the back side of the bed using a remote to change the TV channel. The resident gestured to a tray on his over-the-bed table, and indicated staff had yet to pick up his lunch tray. Observation of 2 opened boxes of cereal sitting on top of a bedside dresser, and food sitting on the windowsill among skin treatments. Food debris, bottles of soda, and an open 1/2 gallon of green punch were observed under the bed, and 2 dirty forks, condiment packets and alcohol preps on a dresser underneath the TV. The room had a strong smell of urine, and the floor was sticky throughout the room from food and unidentified substances. On 8/7/25 at 10:28 a.m., Resident C indicated she continued to have gnats flying around her room.On 8/7/25 at 10:30 a.m., observation of gnats flying inside the [NAME] 1 nurse's station with LPN 10.On 8/7/25 at 10:43 a.m., gnats were observed swarming around Resident Q's doorway to the hallway, and Housekeeper 11 indicated it was not unusual to see gnats in and around certain resident rooms in the facility. Housekeeper 11 indicated, while cleaning the bathroom, she had found a molded banana behind the toilet.On 8/7/25 at 11:06 a.m., tiny black ants were observed crawling on the floor under the window near where Resident S was sitting in a manual WC at bedside watching TV.On 8/7/25 at 11:39 p.m., observation of 2 flies and several gnats flying around the Heritage nurse's station.On 8/7/25 at 12:13 p.m., observation of CNA 12 swatting at a gnat as she dipped ice into a resident's styrofoam cup in the Heritage nurse's station.On 8/7/25 at 12:21 p.m., observation of a gnat flying around Resident V's head and face as she sat in a manual WC near the nurse's station, talking with staff.On 8/8/25 at 9:50 a.m., observation of Licensed Practical Nurse (LPN) 17 waving a bingo medication card around his head as he set up medications in the [NAME] 2 nurse's station. LPN 17 indicated, he was swatting the gnats away.On 8/8/25 at 10:11 a.m., a gnat was observed flying around Resident F's head as she took medications near the [NAME] 2 nurse's station. Resident F indicated, the gnats were bad, and she had spiders in her shower. Registered Nurse (RN) 20 and LPN 17 indicated, the gnats drove them nuts.On 8/8/25 at 11:05 a.m., gnats were observed flying around the [NAME] 1 nurse's station. LPN 9 indicated, she saw the most problem with gnats when residents had food in their trash cans.On 8/8/25 at 12:29 p.m., Qualified Medication Aide (QMA) 19 was observed swatting a gnat away from Resident FF as she administered his medication at a table in the bistro. On 8/8/25 at 12:37 p.m., a gnat was observed flying around Resident JJ's head as she sat in a manual WC outside her doorway in Heritage hallway.On 8/8/25 at 3:21 p.m., observation of gnats in the medical records office with the Director of Nursing (DON).On 8/11/25 at 9:45 a.m., gnats observed flying around the kitchen, dietary staff was observed to swat them away from a food prep station near cut up wedges of potatoes.Documentation of contracted pest control services, dated 7/3/25 - 8/5/25, indicated routine services to treat for gnats and/or ants, and spiders, had been provided on 7/3, 7/17, and 8/5.During an interview on 8/11/25 at 9:57 a.m., the Administrator (ADM) indicated it was not unusual for family members to bring food into the residents, and residents could keep food in their rooms with or without a refrigerator. The ADM indicated, the facility had not attempted interventions for food storage in the resident rooms such as plastic baggies or bowls with lids. On 8/11/25 at 12:37 p.m., the Administrator (ADM) provided a Pest Control policy, dated 9/15/21, and indicated the policy was the one currently being used by the facility. The policy indicated, A. All areas in the center will be sprayed monthly by a duly licensed agent. B. If a problem should develop, the Environmental Services Director will contact [pest control company] personnel to review before starting so special attention can be given to this area.On 8/11/25 at 2:10 p.m., the Administrator (ADM) provided a Storage of Resident Food policy, undated, and indicated the policy was the currently being used by the facility. The policy indicated, .1. Foods will be stored in a closed container with sealable lids. C. Staff will provide plastic or other closed containers with sealable lids, if needed.E. Staff will date the container when food or beverages are brought into the facility and discard food when non-safe.III. A. Dry storage foods may be stored at resident's bedside in amounts that maintain a safe environment.This citation relates to Intakes 1835271, 1835279, and 2581409.3.1-19(f)(4)

Based on observation and interview, the facility failed to ensure resident food was stored in a safe and sanitary manner when resident and staff food were co-mingled and not labeled in 3 of 4 nurse's station refrigerators observed for resident food storage, and failed to ensure resident food was stored in a safe and sanitary manner when food was left open in residents' rooms (Residents C, L, and Q) with visible gnats. Findings include: 1. During the initial tour, on 8/6/25 at 10:45 a.m., a refrigerator with a combination lock was observed in each nurse's stations. A sign printed on bright pink paper, taped to the front of each refrigerator indicated, This is for the storage of resident's food and drinks only [with name and date]. Any personal items will be thrown away.During an interview on 8/7/25 at 12:19 p.m., Certified Nursing Assistant (CNA) 7 indicated, the nurse's stations refrigerators were for the storage of the residents' food and drinks, but sometimes staff working off hour shifts would put their food and drinks in the resident refrigerators.On 8/8/25 at 11:15 a.m., observation of the [NAME] 2 hallway nurse's station refrigerator included:a. Nine (9) cartons of TwoCal HN vanilla supplement with expiration dates of October 10, 2024.b. One (1) carton of diabetisource AC formula with expiration dates of December 18, 2024.c. One (1) carton of thickened cranberry cocktail juice, opened on 3/21/25.d. A paper plate of scrambled eggs, bacon and toast, inside a retails store bag, with no name or date.On 8/8/25 at 11:51 a.m., observation of the Health hallway nurse's station refrigerator, included:a. Five (5) cartons of Glucerna supplement with expiration dates of June 1, 2025.b. Two (2) bottles of white milk for prior resident KK with expiration dates of July 13.c. Two (2) slices of cheese rubber banned to an open package of ham, inside a retail store bag, with no name or date.d. Two (2) cans of soda inside a blue insulated lunch bag, with no name or date.e. Two (2) plastic bowls of food, with no name or date.On 8/8/25 at 12:00 p.m., observation of the Heritage hallway nurse's station refrigerator included:a. An open package of lunch meat, dated 7/28.b. An open package of sharp cheddar cheese with no name or date.c. A store bought Caesar salad with no name or date.d. A package of cheddar brats with no name or date.e. Three (3) separate sandwiches wrapped in wet napkins, dated 7/28, with no name.f. A box of chicken wings from a fast-food restaurant, with no name or date. 2. On 8/6/25 at 12:50 p.m., gnats were observed flying around Resident C's room as she sat in a geriatric chair at bedside, indicating she had gnats everywhere. An open bottle of hot sauce was observed sitting next to the resident on the top of a bedside dresser.On 8/6/25 at 11:37 a.m., gnats were observed flying in Resident L's room as she was wheeling herself into her room in a manual WC (wheelchair). A protein shake with an expiration date of 6/26/25 and an opened container of coffee with tissue paper stuffed in the top, were sitting next to an opened bottle of wound spray that had a dried dark food substance down the side, all sitting among additional food and personal items on her dresser. There were open containers of powdered vanilla creamer, sugar, and frosted cereal on the shelves near the bathroom door.On 8/6/25 at 12:20 p.m., gnats were observed flying around Resident Q's room, with an open box of snack crackers sitting on a bedside dresser. During an interview on 8/8/25 at 12:12 p.m., the Director of Nursing (DON) indicated refrigerators in the nurse's stations were for resident use, and a refrigerator for staff use in the staff breakroom. Dietary staff were responsible for ordering, stocking, and making sure supplement drinks were not outdated in the resident refrigerators. Nurse unit managers were responsible for monitoring that resident food brought in from outside the facility was labeled with the resident's name and dated when it was put into the refrigerator.During an interview on 8/8/25 at 12:54 p.m., the Dietary Manager (DM) indicated nursing staff were responsible for monitoring the expiration dates on resident supplements, and monitoring food brought from outside the facility and stored in the resident refrigerators. The UM was responsible for monitoring that staff were not storing personal food in the resident refrigerators.On 8/11/25 at 2:10 p.m., the Administrator (ADM) provided a Storage of Resident Food policy, undated, and indicated the policy was the currently being used by the facility.A. The facility maintains a pantry for resident food, dry storage, and a dedicated resident refrigerator for cold storage for those residents who have food brought in from visitors.1. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained. 2. Daily monitoring for refrigerator storage duration and discard of any food items that have been stored for [more than] 7 days.3. Cleaned weekly.D2. Food not for immediate consumption, will be properly contained and labeled for storage to be consumed at a later time.II. Food and liquid consumables may be brought into the facility for the resident's using the following guidelines.B. Foods will be stored in a closed container with sealable lids. C. Staff will provide plastic or other closed containers with sealable lids, if needed.E. Staff will date the container when food or beverages are brought into the facility and discard food when non-safe.III. The dietary staff will monitor refrigerator contents for food safety and reserve the right to dispose of expired, unsafe foods. A. Dry storage foods may be stored at resident's bedside in amounts that maintain a safe environment.D. The dietary staff will monitor refrigerator storage areas for resident's food monitoring for outdated, unsafe or otherwise food unfit for consumption.3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a comprehensive and individualized care plan was developed for a resident with behaviors related to wandering, adjustment to new living conditions and personal hobbies for 1 of 1 residents reviewed for elopement, (Resident 88) and failed to implement a comprehensive care plan for a resident who admitted to the facility with a trans metatarsal amputation (TMA) ( a surgical procedure that involves the removal of the distal portion of the metatarsal bones in the foot) for 1 of 5 residents reviewed (Resident 196). Findings include: 1. On 2/24/25 at 11:36 a.m., Resident 88 was observed through his open door. He refused to allow entrance and instead of answering questions, he became agitated and demanded that he get his bicycle back. He adamantly declared he was a cyclist, his bicycle had been confiscated from him, that he was being kept against his will, and institutionalized. Resident 88 was observed to wear slick-styled nylon sports pants and wore cleats. A wanderguard bracelet was observed around his left ankle. During an interview on 2/24/25 at 11:40 a.m., Licensed Practical Nurse (LPN) 13 indicated sometimes Resident 88 got upset and demanded to get his bike. It was best to just let him blow off steam because he was very hard to redirect, and the staff were not sure what other approaches to take with him since they could not offer him his bike. On 2/26/25 at 10:18 a.m., Resident 88 was observed as he held his arms out wide and jogged up and down the hallway making swishing sounds as if he was an airplane. During an interview on 2/26/25 at 11:09 a.m., the Social Service Director (SSD) indicated when Resident 88 first got to the facility he had a hard time adjusting to the new environment and would become very upset that he was not allowed to ride his bicycle. He made statements about wanting to leave to go get the bike, so the decision was made to place a wandergard on him. After a couple weeks, he seemed to adjust and she did not consider him at risk for elopement any longer. She did not know if he still had a wanderguard in place, and had not heard form nursing staff if he continued to have any behaviors. On 2/26/25 at 1:04 p.m., Resident 88 was observed as he continued to jog and weave up and down the halls with his arms out and made airplane sounds. During an interview on 2/27/25 at 9:08 a.m., the [NAME] President of Risk, provided an elopement assessment, dated 1/29/25, which indicated Resident 88 was at risk for elopement. He was assessed after his first several days when he began to make statements about getting out to catch the bus and go to his apartment to get his bike. He was adamant about being a cyclist and wanting to ride, and talked constantly about how much he rode his bike. Resident 88 was very fit, and liked to stay moving. On 2/25/25 at 1:46 p.m., Resident 88's medical record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, cerebral amyloid angiopathy (CAA, a condition in which proteins called amyloid build up on the walls of the arteries in the brain causing bleeding into the brain), alcohol abuse, and unspecified dementia. His admission Minimum Data Set (MDS) assessment, dated 1/31/25, did not indicate any wandering behaviors noted in the 7-day look back window. His behavior monitoring was reviewed from the time of his admission through 2/25/25 and lacked documentation of behaviors of wandering. A care plan, dated 1/30/25, indicated he wandered aimlessly from place to place and interventions included but were not limited to,offering structured activities, but lacked revision to include person-centered preferences for his hobbies. Overall, his comprehensive care plan and lacked implementation of an individualized, person-centered plan of care to address his hobby of being a cyclist, fitness enthusiasm, and/or interventions to help address his irritation about not being able to ride his bike. 46414 2. On 2/26/25 at 11:27 a.m., a record review was completed for Resident 196. He had the following diagnoses which included but were not limited to end stage renal disease, trans metatarsal amputation (TMA), hypertension, left above the knee amputation, and major depressive disorder. Resident 196's care plan lacked a care plan problem of TMA. During an interview with the [NAME] President of Risk Management, she indicated she could not find a care plan for TMA for Resident 196. On 2/27/25 at 10:35 a.m., a policy titled, Plan of Care overview was provided by the [NAME] President of Risk Management on 2/27/25 at 10:35 a.m. It indicated, .The facility will provide an Registered Nurse (RN) assessment of the resident as an on-going, periodic review that provide the foundation for the resident focused care and the care planning process. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to reassess the effectiveness of interventions and review and revise a resident's care plan (Resident 28 and Resident 241) for 2 of 23 residents reviewed for care plan revision. Findings include: 1. Resident 28's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, hemiplegia (paralysis of one side of the body), and dysphagia (difficulty swallowing.). A social service note that was a summary of a care plan meeting, dated 8/2/24, indicated they reviewed dietary concerns and Resident 28 indicated she cannot chew the food. Resident 28 had a care plan with a revision date of 9/16/24 that indicated the Resident was at nutritional risk due to poorly fitting dentures and a mechanically altered diet. The care plan lacked documentation of interventions related to the resident's complaints of chewing or swallowing noted. Resident 28 had an order, dated 9/18/24, that indicated she was on a regular texture diet. Resident 28 had a care plan with a revision date of 9/28/23 that indicated the resident had poor fitting dentures. The care plan lacked documentation of interventions related to the resident's complaints of chewing or swallowing noted. On 2/26/25 at 1:01 p.m., Resident 28 indicated it took her so long to chew up bacon and other tough meats. She indicated she cannot eat a lot of the food they brought because it is too hard and hurt her gums when she chewed. 2. Resident 241's medical record was reviewed. He was a long-term care resident whose diagnoses included but were not limited to, sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage) and open wounds. A skin and wound note, dated 11/12/24, indicated it was recommended Resident 241 wear pressure relieving boots while in bed. A skin and wound note, dated 12/17/24, indicated Resident 241 refused to wear his heel boot. A skin and wound note, dated 1/17/25, indicated Resident 241 would not allow the Nurse Practitioner (NP) to put heel boots on him. A nursing note from 2/20/25 indicated Resident 241 refused to wear his pressure-relieving boots for both heels. Resident 241 had a care plan with a revision date of 2/19/25 that indicated he has episodes of refusing medications, refusing care, wound care and interventions. All interventions related to this care plan were dated 2/7/24. Upon review it was found that there was no care plan interventions related to the resident's regular refusal of pressure relieving boots and no interventions outlining what staff should do when the resident refuses to wear pressure relieving boots. On 2/28/25 at 11:57 a.m., a policy related to care plan revision was requested. Registered Nurse (RN) 11 indicated they could not find a policy specifically related to care plan revision at this time. 3.1-35(c)(1)

Based on interview and record review, the facility failed to ensure a resident who was at high risk for falls had a timely treatment after a fall which resulted in actual harm when staff continued to transfer him in and out of bed, he was taken to participate in therapy, and his mobile x-ray was canceled after no physician's order could be provided to the x-ray technician for 1 of 3 residents reviewed for falls (Resident D). Findings include: During a phone interview on 1/27/23 at 11:05 a.m., Resident D's family member indicated an e-mail grievance had been sent to the facility Administrator on 1/10/23 regarding a delay in treatment for Resident D after a fall. According to the family member, they called to check in on Resident D on 12/31/22 and he complained of pain at that time. It wasn't until 1/3/23 when x-ray results were received and revealed a broken hip that the family member was notified of the fall and a new order had been given to send him to the hospital. The family member indicated Resident D had complained of pain for several days and wondered why he had not been sent out earlier. The staff just said, Resident D had refused to go to the hospital, which was odd, because when the family member spoke to him, Resident D indicated he was in pain and waiting for treatment. If the facility had called sooner, the family member indicated they would have been able to convince him to go to the hospital. When the family member was notified of the fall, they were told he fell from his bed after reaching for his urinal which he was accustomed to using, so the family member wondered why it was out of reach. Further, the family member complained that the bed controls had not worked, so there was no way to know if his bed was lowered. Often when the family member visited, his bed was at regular height. The family member indicated one of Resident D's friends came to visit him and noted he was in pain and complained that it was taking too long to get help. The family member also wondered if his several room moves contributed to his confusion and fall. He was originally put in a room upstairs, then he was told he needed to move rooms for new residents, but he would be put in a bigger room. He was moved a third time to a room at the end of the hall, where the service lights weren't working so he had to call out for help a lot. During a phone interview on 1/31/23 at 2:00 p.m., a former co-worker and close friend indicated she visited Resident D on afternoon of New Year's Eve, 12/32/23. When she arrived, he was sitting up in a chair and complained of pain, so she did not visit for long. She asked what happened, and he indicated he fell . She asked if he was still getting physical therapy and he said, yes- they took him down earlier. A nurse came in the room, and she told her that Resident D was complaining of pain because he fell he and wanted to get back in bed. When asked about Resident D's bed position, the friend indicated it was a regular bed, not too high and not too low. Resident D's friend indicated the resident was not one to complain much, but he was uncomfortable enough that he asked for pain medicine. On 1/31/23 at 2:32 p.m., a phone interview was conducted with Resident D, who no longer resided in the facility. Resident D indicated he did remember being at Evergreen and that he fell out of bed. He indicated, I fell out of bed, I just rolled over and fell out, it didn't feel good at all, and it hurt for days. I think I was sleeping and just rolled over. He did not remember how he got off the floor or back in bed. He indicated he was at another facility still rehabilitating from the fall. On 1/27/23 at 8:30 a.m., Resident D's medical record was reviewed. Resident D had been admitted to the facility on [DATE] after an acute hospital stay. A hospital discharge report, dated 10/28/22, indicated Resident D had been treated for breakthrough seizures which resulted in a fall with a hematoma (A pool of mostly clotted blood that forms in an organ, tissue, or body space) to his forehead. A physical therapy note on the discharge report indicated, some confusion, but pleasant .Sat [on the] edge of bed with assist of 1 today but [unable] to tolerate transfer to stand, stating his right leg felt too weak and 'I will fall.' He is considered a high fall risk currently due to his dependent mobility level and poor safety awareness Upon admission to Evergreen, Resident D had diagnoses which included, but were not limited to hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) which affected his right/dominant side, epilepsy, unsteadiness on his feet and anxiety. An admission nursing evaluation, which also included the 48-hour baseline care plan, was dated 10/28/23. The baseline care plan indicated Resident D had experienced a fall within the previous 30 days but did not make a note of his head injury. Interventions from the baseline care plan were as follows; Ensure resident was wearing appropriate non-skid footwear, refer to therapy, place call bell within reach, room to be well let and free of clutter, assist with ADLs (activities of daily living), bed in lowest position, remind resident to call for assistance. Further, the baseline care plan indicated bed assist bars were in place. An admission fall risk assessment, dated 10/28/22, indicated Resident D was at risk for falls and gave instructions to proceed to the care plan. Resident D's care plans lacked documentation that he had a vagal nerve stimulator placed as preventative equipment to treat his epilepsy and seizure disorder, which also placed him at a greater risk for falls. Resident D's care plan lacked documentation of his bowel/bladder status, level or frequency of incontinence, and/or his use of and preference for a urinal at his bedside. A Nurse Practitioner (NP) progress note, dated 11/8/22 at 9:59 a.m., indicated, Resident D was being seen for an initial psychiatric consult. Resident D had increased anxiety and yelled out frequently, often for something he could reach, other times for assistance that he was unable to do alone. Resident D indicated he did not remember yelling out loudly. His medications were reviewed, and a new order was given to start Buspar (an anti-anxiety medication that can cause some people to become dizzy, lightheaded, drowsy, or less alert than they are normally). A nursing progress note, dated 12/23/22 at 3:37 p.m., indicated, Resident D was noted to have loud outbursts every 15-30 minutes and put his call light on. Staff would enter the room, and he would not remember putting the light on. He was checked for incontinence as he wore briefs. Resident D's therapy progress notes were reviewed and indicated the following: A Speech Therapy (ST) noted, dated 12/31/22 at 11:28 a.m., indicated, Patient stated he had a fall reaching for his urinal earlier this morning and was requesting something for pain. Nursing was immediately notified and stated not being aware of his fall. A Physical Therapy (PT) note, dated 12/31/22 at 2:26 p.m., indicated, transferred with maximum assistance from bed to wheelchair (wc) and wc to bed. Patient needed moderate assistance for supine to sit and moderate assistance for sit to supine getting lower extremities into bed as well. Patient needing visual cues for sequencing/safety and patient yelling out wincing due to pain throughout each transfer. Patient completed 15' (feet) on sci-fit (a specialized piece of therapy equipment similar to a seated bike and row machine) on level 2, with his left lower extremity and both upper extremities to improve strength, range of motion and endurance. Patient reported severe pain in right hip/thigh area due to fall. Per nursing nothing was reported. Patient was unable to extend right knee past 40 degrees today without pain increasing and patient resisting. Patient completed bilateral lower extremity exercises in sitting to improve strength and range of motion. Patient did what he could tolerate. Patient nurse notified of change in transfers and range of motion. A ST progress note, dated 1/2/23 at 1:54 p.m., indicated Resident D had increased confusion. A ST progress note, dated 1/3/23 at 4:03 p.m., indicated Resident D was seen in bed that day due to increased pain in his leg. During an interview on 1/27/23 at 12:21 p.m., PT 50 indicated she had worked with Resident D on 12/31/22 and put the above progress note in. She indicated, she saw him earlier in the day, before lunch time. She went down to get him that day and remembered his bed was at a normal height, not lowered, and not left very high. Ne needed maximum assistance to transfer into his wheelchair. He went to therapy and participated but with decreased ability, they only worked his left side since his right leg hurt. She took him back to the nurses' station and reported his pain, and the nurse was unaware of any new pain. A late entry nursing progress note was dated effective as of 12/31/22 at 2:50 p.m. but had been created 1/6/2023 at 3:03 p.m. The note indicated Resident D had no pain, even though ST and PT both reported pain in his right hip on 12/31/22 before lunch. A late entry nursing progress note was dated effective as of 12/31/22 at 3:03 p.m. but had been created 1/2/2023 at 10:46 a.m. The note indicated Resident D had no pain, even though ST and PT both reported pain in his right hip on 12/31/22 before lunch. A late entry nursing progress note was dated effective as of 12/31/22 at 4:35 p.m. but had been created 1/1/2023 at 4:55 p.m. The note was a post fall evaluation which indicated the physician had been notified of the fall on 12/31/22 at 1:30 a.m., and Resident D complained of pain in his right hip. A late entry nursing progress note was dated effective as of 12/31/22 at 8:32 p.m. but had been created 1/2/2023 at 9:00 a.m. The note indicated, update to note: resident did fall. Upon further investigation, resident did admit to falling. Resident states he was in bed, reaching for his urinal and slid out of bed. When sliding out of bed resident states he hit his hip on the bed. Mild pain of 2, [as needed] given and effective. In house NP notified and ordered x-ray due to pain A late entry nursing progress note was dated effective as of 12/31/22 at 8:35 p.m. but had been created 1/4/2023 at 3:11 p.m., family aware. A late entry nursing progress note was dated effective as of 12/31/22 at 8:40 p.m. but had been created 1/3/2023 at 3:30 p.m the note indicated .spoke with NP and advised [a contracted mobile x-ray company] could not come out prior to 1/1/244 resident denies going to ER to be evaluated NP resident and family aware Resident D's completed and discontinued physician orders were reviewed. An order for Resident D's right hip/pelvis was not placed until 1/3/23 at 10:45 a.m. The x-ray was ordered due to fall, pain and decreased mobility. He had an order for Acetaminophen (Tylenol) 325 mg (milligrams) with instructions to give 2 tablets every 6 hours as needed for pain, which was only administered once in the month of December on the 31st at 7:34 p.m. On 11/28/22, Resident D had a procedure to pace Vagal Nerve Stimulator, (VNS- an implanted medical device placed by a surgeon near the collarbone to help control seizure activity via electrical stimulation) and had been given a 6 tablet prescription for Oxycodone (a narcotic pain medication) 5 mg every 6 hours as needed for pain. Although a pharmacy prescription summary was provided, no physician's ordered was placed in his record for the Oxycodone, therefore, no corresponding Medication Administration Record, (MAR) was available to verify the administration. The 6th and final tablet was signed out on 1/2/23 at 1:00 p.m., even though no pain was indicated on his MAR. On 2/1/23 at 2:50 p.m., the [NAME] President of Compliance and Internal Operations for mobile x-ray company provided recorded phone messages and internal notes related to Resident D's x-ray orders. A phone recording, timestamped 12/31/22 at 8:46 p.m., (approximately 9 hours after ST initially reported acute pain to nursing), Registered Nurse (RN) 50 called and ordered a regularly scheduled x-ray. At 8:52 p.m., six minutes later, she called back to verify the right hip had been requested. A phone recording, timestamped 1/1/23 at 3:24 p.m., Licensed Practical Nurse (LPN) 52 called to inquire when they would be coming to complete Resident D's x-ray. His appointment was located in the system as a routine x-ray scheduled for Tuesday 1/3/23, to which LPN 52 indicated, oh no, no. He's complaining of pain, his family is here. We need that called in STAT, they are going to take him to the hospital, but he has dementia .so he needs to be going to the hospital right now Representative 53 checked to see if there was an x-ray technician in the area and re-ordered the x-ray from routine to STAT (immediately). LPN 52 asked for an estimated time of arrival and Representative 53 indicated, the technologist is going to reach out to your facility to give you guys an ETA on when they are on the way to the facility, I can't guarantee a time frame they are going to be the ones to give the ETA, I do need to let you guys know there is only one tech and its extremely busy in the area so it could be a later than usual ETA. LPN 52 entered a late corresponding nursing progress note, dated effective 1/1/23 at 7:21 p.m., but created 1/3/23 at 4:08 p.m., which indicated, several attempts to call the mobile x-ray company were made and there were two patients before Resident D. A phone recording on 1/1/23 at 5:11 p.m., was the assigned x-ray technician, Tech 54 who called internally to see if Resident D's x-ray could be rescheduled due to care trouble. Representative 55 indicated she would tell the facility it would be tomorrow. Representative 55 called Evergreen on 1/1/23 at 5:16 p.m. but the call went unanswered. A mobile x-ray company GPS transmitter indicated X-Ray Tech 56 arrived to Evergreen on 1/2/23 at 5:47 p.m., and left at 6:17 p.m. The X-ray order was cancelled at that time due to no physician order for the exam was on the resident's file. A phone recording on 1/3/23 at 9:32 a.m., was Nurse Practitioner 56 who called to inquire about Resident D's x-ray. Representative 58 explained a technician had been out the day before but was unable to complete the x-ray because there was not a doctor's order so the exam was cancelled. NP 56 re-ordered the exam STAT and indicated, can we please order that STAT because we are going to end up taking our patient to the ER. On 1/3/23 at 10:28 a.m., the x-ray was performed and the results were received at 10:41 a.m., which revealed, an acute subcapital fracture proximal right femur with angulation and superior displacement of distal fragment. A nursing progress note, dated 1/2/23 at 8:49 a.m., indicated Resident D complained of mild pain, and his PRN medication was administered. However, there was no documentation on his Medication Administration Record (MAR) that the medication was administered. On 1/3/23 at 11:44 a.m., .patient alert and oriented has pain but continues to refuse any pain medication . New orders were given to send Resident D to the ER where he was admitted to the hospital for evaluation and treatment, approximately 72 hours after Resident D initially complained of pain. During an interview on 2/1/23 at 2:22 p.m., NP 57 indicated she had been notified of Resident D's complaints on pain on the evening of 12/31/22. By that time, he had self-reported a fall, so NP 57 ordered an x-ray. Initially he did not want to go to the hospital, and when she came in to see him on 1/3/23 a STAT x-ray was reordered because there was some mix up with the x-ray company, but throughout those day he never complained of pain. During an interview on 2/2/23 at 10:15 a.m., Certified Nursing Assistant (CNA) 14 indicated she worked with Resident D on New Year's Eve and her ADL charting activity was reviewed with her. She indicated Resident D called out for help a lot and often forgot that he had. He was used to using the urinal by himself. CNA 14 indicated she had finished working with another resident and was taking some trash out when she heard Resident D call out, Help! Nurse nurse! She indicated when she entered his room, she found him on the floor and asked, oh my god, what happened? and he only said, I fell . She went to get help and it took three staff member to get him off the floor. During an interview on 2/2/23 at 10:39 a.m., Qualified Medication Aid, (QMA) 26 indicated she did not know Resident D had a fall until therapy reported it to her and she went to tell her nurse. QMA 26 indicated PT came down to get him and took him to therapy like usual, but when they returned the therapist indicated Resident D had complained of pain and could not continue. During a follow up interview on 2/2/23 at 2:23 p.m., CNA 14 indicated she may have remembered wrong and wanted to clarify that she did not find Resident D on the floor, but instead it appeared that he was slipping out of his chair and was almost on the ground, when she went in and was able to assist him back into his chair. On 2/2/23 at 2:33 p.m., the RN Divisional Risk Strategist provided a copy of the post fall investigation which included the following phone statements: a. RN 50 who indicated, [Resident D] did not fall on my shift, he said he was in pain after therapy, I went to assess him, I called [NP 57] she ordered an x-ray, I asked him did he want to go to the hospital and he said no. [Refer above: ST progress note reported pain to nursing on 12/32/22 at 11:28 a.m., and RN 50 did not call mobile x-ray to place the x-ray request until 12/31/22 at 8:46 p.m.] b. QMA 26 who indicated, He did not fall on my shift, I helped him in his chair, and he did complain of pain and we told the nurse. c. NP 57 who indicated, A nurse called me and stated he was in pain, I don't remember what nurse, but I gave an order for an x-ray, I did not order STAT because his pain was mild, at that time they did not know he had called. They also called to tell me that the x-ray had not been done and I told them to send him to the ER they called and told me he refused. I came in and saw him and encouraged him to go to ER and he refused, I put in an order for a STAT x-ray. d. Electronic Health Record Coordinator, (EHR) 7 who indicated, I came in Saturday 12/31/22 afternoon/evening. When I first came in, I did my rounds on the unit, I was not working the cart- I was helping on call person [nurse]. RN 50 stated patient was getting x-ray on patient due to pain states had fall. I asked her to come with me to patient's room, patient self-reported fall and instructed RN 50 to complete charting for fall- resident state he did not have pain at that time and refused to go to hospital. On 2/2/23 at 2:45 p.m., The RN Divisional Risk Strategist provided copies of an in-service sign in sheet, dated 11/28/22, and in-service material. At this time, she indicated, nursing staff had been in-serviced on the provided material upon Resident D's return from a procedure where he had a vagal nerve stimulator (VNS) placed for his epilepsy and seizure activity. She highlighted a portion of the training which stated, .all nursing staff must be aware that his seizures and VNS cause him to be at a higher risk for falls. Ensure that side effect monitor is in place, call light remains in reach, frequently used items (magnet, remote, cell phone, water, urinal wheelchair) are within reach, nonskid footwear as tolerated, environment clutter free, bed is locked, reminders to call for assistance as needed On 1/31/23 at 2:00 p.m., the Administrator, (ADM) provided a copy of current facility policy titled, Fall Prevention and Management, revised 6/1/22. The policy indicated, Is it the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage a resident's care if a call occurs . If the resident is identified to be at risk for fall, a care plan should be initiated that includes a plan to potentially diminish the risk of falls. The care plan can include interventions that address environmental factors, ADL factors, risk factors that result from dementia and other mental diagnosis, medical diagnosis that put the resident at higher risk. Issues such as toileting, eating, transferring, and impulsiveness should be considered. The care plan can address furniture arrangements, footwear, medications that can cause dizziness, drowsiness and instability. The care plan should also address how the resident can be transferred in and out of bed as well as how the resident can ambulate and move around the facility. The care plan should be reviewed and updated as needed with each change of condition On 1/31/23 at 2:00 p.m., the Administrator, (ADM) provided a copy of current, but undated facility policy titled, Urinal: Placement of. The policy indicated, If is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors . Self-Care: resident may be able to remove urinal himself and/or advise when he is finished, provide standby assist as needed, remain with resident if unable to advise when he is finished and provide privacy if you stay with resident, remove urinal On 2/1/23 at 3:50 p.m., the RN Divisional Risk Strategist provided a copy of current facility policy titled, Laboratory and Radiological Services and Results Reporting, revised 6/13/22. The policy indicated, .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents . the facility will have an on-going written agreement with a qualified laboratory(ies) and radiology units to provide services to meet the needs of the resident population . the facility will collaborate with the lab and/or radiology unit to provide reports to the facility in a timely manner On 2/1/23 at 3:50 p.m., the RN Divisional Risk Strategist provided a copy of the current Radiology Service Agreement, dated 2/25/21. The Agreement indicated, . all orders must include the exams to be performed, the number of views to be taken, the medical necessity of the exam, and if x-ray, why is was ordered to be done portably. As the legal custodian of the patient's medical records Facility will obtain and store within each patient's chart the signature of the practitioner who ordered that exam. Facility agrees to provide all required information and documentation for proper billing and/or related audits in a timely manner This Federal tag related to Complaint IN00399180. 3.1-37(a) 3.1-37(b)

Based on observation, interview and record review, the facility failed to ensure thorough assessments of residents with urinary catheters to identify a change in condition, to send residents with a change of condition out to the hospital including upon the residents' request for 2 of 2 residents reviewed for urinary catheters/urinary tract infections (Resident B and D) and failed to ensure catheter care for a resident with a indwelling foley catheter to prevent the development of wounds to the penis and scrotum for 1 of 8 residents reviewed for urinary catheters/urinary tract infections (Resident B). The immediate jeopardy began on 6/14/22 when Resident B called 911 to go the hospital emergency room (ER) for nausea, vomiting, and not feeling well. Upon arrival to the hospital ER, on 6/22/22, the resident was covered in stool and urine. Resident B had green urine in the indwelling urinary catheter, and wounds to the base of the penis and scrotum measuring 0.5 centimeters (cm) by (x) 0.5 cm x 2 cm with minimal serosanguineous drainage, and significant urethral injury. Resident B was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident remained in the hospital as of 7/8/22 and indicated he was afraid to return to the facility. Resident D had an indwelling urinary catheter and a suprapubic catheter. Resident D was sent to the hospital on 6/18/22 for bloody urine and being lethargic. Resident D went to the hospital on 6/21/22 and returned with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . From 7/5/22 through 7/7/22, Resident D was observed with bloody urine in the urinary catheter bag, and there were multiple observations of the resident's urinary tubing and catheter bag on the floor. On 7/7/22, the Nurse Practitioner (NP) indicated she was unaware of increased hematuria (bloody urine), assessed the resident as lethargic, and sent the resident to the ER. On 7/7/22, at the hospital the resident was diagnosed with a urinary tract infection ([CONDITION(S)]) and the hospital removed the indwelling urinary catheter since the suprapubic catheter was functioning. The Administrator (ADM), Director of Nursing (DON), Regional Clinical Risk Manager (RCRM), and the Regional Director of Clinical Operations (RDCO) were notified of the immediate jeopardy on 7/8/22 at 5:20 p.m. The immediate jeopardy was removed on 7/9/22, 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: 1. On 7/7/22 at 8:45 a.m., Resident B's medical record was reviewed after his emergent discharge on 6/14/22. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B's annual Minimum Data Set (MDS) assessment, dated 3/9/22, indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. No behaviors were coded for the 7-day look back and he was at risk for the development of pressure ulcers with 3 open areas at the time of the assessment. Resident B was followed by the wound care team and copies of his wound notes were provided on 7/8/22 at 10:00 a.m., by the Director of Risk Management (DRM). The wound notes indicated he had moisture associated skin damage (MASD) on his scrotum, which was healed out on 3/8/22. Resident B had comprehensive care plan which included, but were not limited to: a. A care plan, most recently revised on 1/1/22, indicated he required assistance with his ADLs (activities of daily living). Interventions for this plan of care included, but were not limited to, staff assistance for bed mobility, toileting, bathing, and eating. b. A care plan, most recently revised on 4/13/22, indicated he was at risk for skin break down and had an arterial ulcer on his right ankle, and right lateral foot. Interventions for the plan of care included, but were not limited to, evaluation of the existing wound daily to monitor for signs/symptoms of the wounds worsening and to provide peri-care as needed to avoid skin breakdown due to incontinence. c. A care plan, most recently revised on 9/15/21, indicated he had a foley catheter due to [CONDITION(S)]. Interventions for this plan of care included, but were not limited to, change catheter per medical doctor (MD) orders, observe/document for pain/discomfort related to the catheter, observe /record/report to MD for signs and symptoms of [CONDITION(S)] (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns and to provide catheter care every shift and as needed. Notify medical provider if urine was of abnormal color, consistency, or odor. d. A care plan, most recently revised on 3/16/22, indicated he required the use of a g-tube, (gastrostomy tube, a surgically placed device used to give direct access to the stomach for supplemental feeding) and that he sometimes refused his g-tube feedings. Interventions for this plan of care included, but were not limited to, administer flushes per medical provider's order, administer medications via tube, per orders and Nutritional consults. There was no care plan for Resident B's refusal of care or treatments. The record lacked documentation of Resident B's refusal of care or treatments. The record lacked documentation of any additional open wounds at the time of his discharge on 6/14/22. Resident B had the following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Change foley drainage bag monthly every night shift every 4 weeks on Tuesdays. b. Foley catheter care every shift and as needed with soap and water. Secure straps if applicable Empty foley output and document output every shift. c. Treat Scrotum MASD by cleaning with soap and water, apply triad paste every shift and as needed. d. Weekly skin assessment to be completed. Documentation to be completed on Weekly Skin Assessment during evening shift every Thursday for Skin Assessment. Resident B's MAR/TAR (medication/treatment administration records) from May and June were reviewed. Catheter care was checked off as completed on every shift with no abnormalities noted and Resident B's foley drainage bag was checked off as changed on 6/14/22. Resident B's foley drainage bag was checked off as changed on 5/17/22. The record lacked documentation that a weekly skin assessment had been completed as scheduled for 6/9/22. A nursing progress note, dated 6/14/22 at 12:33 p.m., indicated Resident B called 911 without notifying nurse. An ambulance arrived to the facility by 11:00 a.m., and Resident B stated he was vomiting. No one was aware of that change in condition. The resident left facility by ambulance to the hospital and the DON was present. A hospital record was scanned into Resident B's electronic charting system, dated 6/14/22 at 2:43 p.m. The hospital Emergency Department (ED) report indicated .Chief complaint: nausea, vomiting, and dark green urine .the patient is a pleasant 61-year male who presented to the ED from a nursing home via ambulance. Patient has not been very well cared for at the facility .per report, the nursing home is sending him in because he had made a mess of himself and they did not feel like cleaning him up. On arrival the ED, the patient was very disheveled and has an indwelling Foley catheter which is causing significant urethral injury. He has an unstageable sacral ulcer and is complaining of back pain. He reports that he has been having nausea and vomiting and dark green urine for the past 2 days and nobody was willing to get him cleaned, hence why he decided to call 911 himself .Review of present symptoms, positive for: [CONDITION(S)], nausea, back pain Upon a physical exam the following was noted: .skin: gangrenous lower extremity toes, clear wound also noted to the heel .[CONDITION(S)]: swollen penis and testicles. Urethral meatus slightly visible, white discharge noted at the creases between the penis and scrotum .Psychiatric: cooperative and pleasant. Judgement and insight, memory, mood and affect within normal limits A comprehensive metabolic blood panel was completed on 6/14/22 at 12:10 p.m., and returned with significantly elevated BUN [blood urea nitrogen-high levels in your blood sample can mean kidneys are not working normally and can also indicate dehydration] level of 59 (normal range 9-20). A urinalysis, completed 6/14/22 at 12:27 p.m., indicated his urine was cloudy with trace amounts of blood. A hospital record scanned into Resident B's electronic charting system, dated 6/14/22 at 2:43 p.m., indicated .Assessment and Plan: Problem 1: [CONDITION(S)] secondary to [CONDITION(S)]. Patient presenting [CONDITION(S)] [rapid heart rate], tachypnea [rapid breathing] and notable leukocytosis, chief complaint of nausea, vomiting and dark green urine, started on [MEDICATION(S)] and [MEDICATION(S)] [antibiotic medications] Problem 2: penile trauma. Patient on chronic foley, at presentation the foley had extended to the posterior of his penis, meatus visible. Swollen scrotum .he has consistently complained of back pain .Attending physician addendum: presenting to the ED today for nausea, vomiting, and dark urine. He is found to have indwelling foley and evidence of [CONDITION(S)] and [CONDITION(S)]. He also has acute kidney injury and [CONDITION(S)]. Further, he has evidence of penile injury/inflammation from his foley. We are concerned about his level of hygiene at time of presentation and consequently concerned about the quality of care he has received at facility .patient admitted to the hospital A hospital record scanned into Resident B's electronic charting system, dated 6/15/22 at 11:23 a.m., indicated a wound skin assessment was completed and revealed the following: Wound #1: base of penis/scrotum which measured 0.5 cm (centimeters) long by 0.5 cm wide, and 2 cm deep with serosanguineous drainage.patient seen today for penis and sacrum .Patient has a split urethra from his chronic catheter and patient also found to have a wound at the base of his penis/scrotum A hospital record scanned into Resident B's electronic charting system, dated 6/17/22 at 6:42 a.m., indicated .spoke to patient about disposition and his current facility. He stated that he would like to be in a different facility if other options were available .Problem #12: Social: patient brought in from facility, disheveled, covered in stool and urine. Foley extending deep into his penis. Also, with notable penile, sacral, and foot wound. Strong concern of neglect at facility .Social Worker referral was made due to abuse/neglect concerns, patient did tell medical team that he does not feel safe returning to Evergreen Crossing at discharge During an interview, on 7/7/22 at 10:43 a.m., Resident B indicated he was still at the hospital. He was going up and down but overall was feeling better. Resident B indicated he had not been feeling well for a couple of days and no one would help him. He called 911 because he knew something wasn't right, and no one would help him. During a confidential interview conducted during the survey indicated Resident B's condition upon arrival to the ED was very alarmingly, he arrived covered in stool and urine with several wounds and was septic with a [CONDITION(S)]. Resident B indicated he had made a mess of himself, and no one would help him get cleaned up, so he called 911. During an interview, on 7/8/22 at 11:54 a.m., CNA (certified nursing assistant) 23 indicated she had worked with Resident B. He was usually pleasant and cooperative. She had not noticed any sign of a change in his condition before his discharged . As a CNA, she did complete catheter care for him as needed but had never noticed anything concerning. He was particular about how the catheter bag was repositioned because he did not want it pulled and tugged on, as it caused him pain. During an interview, on 7/8/22 at 12:04 p.m., Wound Nurse 25 indicated he saw Resident B on 6/14/22. At the time of the evaluation, the only open wound being treated at that time was the arterial wound on his ankle. On 7/11/22 at 9:20 a.m., the Pike Township Fire Chief provided a copy of the ambulance Run Report for the day of Resident B's discharge. The Run Report, dated 6/14/22 at 11:25 a.m., indicated .dispatched to a sick person. Arrived to find [Resident B] alert oriented x4 [oriented to person, place, time and situation]. He complained of nausea, vomiting and weakness .states he was not getting any help from nursing home staff and patient had vomit on self and bed. Patient stated staff did not give him any medication for nausea and vomiting seen after attempts to get staff help .Patient had catheter, tubing and urinary drainage bag were green. Patient states nursing home staff have not changed his tubing or bag in 'a couple of months,' last date on bag was April 2022. Patient states he has not been able to eat for 2 days 2. On 7/05/22 at 9:37 a.m., Resident D's door was observed open, his Foley bag and tubing were visible from the hallway. No dignity bag was in place. His Foley bag and tubing were observed with deep, red urine. The Foley tubing was on the floor. On 7/5/22 at 10:11 a.m., Resident D's door was observed open, his Foley bag and tubing were visible from the hallway. No dignity bag was in place. His Foley bag and tubing were observed with deep, red urine. The Foley tubing was on the floor. On 7/5/22 at 11:09 a.m., Resident D's door was observed open, his Foley bag and tubing were visible from the hallway. No dignity bag was in place. His Foley bag and tubing were observed with deep, red urine. On 7/5/22 at 12:08 p.m., Resident D's door was observed open, his Foley bag and tubing were observed in a pillowcase. The pillowcase was touching the floor. On 7/6/22 at 9:24 a.m., Resident D's door was observed open, his Foley bag was observed in a pillowcase. The tubing was observed laying on the floor with deep, red urine. On 7/7/22 at 10:07 a.m., Resident D's door was observed open. No dignity bag was in place. His Foley bag and tubing were observed with deep, red urine. On 7/7/22 at 11:05 a.m., Resident D's record was reviewed. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 5/23/22, indicated Resident D was in renal failure and to observe for complications and notify the medical provider of abnormal findings. A care plan, dated 5/23/22, indicated Resident D had a suprapubic catheter with a history of UTIs. Interventions indicated to notify the medical provider if the urine was of an abnormal color and to provide a privacy bag. A progress note, dated 6/8/22 at 4:55 p.m., indicated Resident D had a new order to schedule an intervention radiology (IR) appointment related to his suprapubic catheter (a urinary catheter inserted above the pubic bone). A nurse practitioner (NP) note, dated 6/9/2022 at 1:34 p.m., indicated Resident D was seen by her recently due to cloudy urine observed by staff. Over the weekend, staff reported the suprapubic catheter was irrigated due to oliguria (excessive small amounts of urine produced). Staff noted the urine was milky and his white blood cell (WBC) count was elevated yesterday. Last week, the suprapubic catheter insertion site was red. It was evaluated by the wound team and Resident D was started on [MEDICATION(S)] (antibiotic) for [CONDITION(S)]. status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the hospital records, he presented to the Emergency Department (ED) with [CONDITION(S)] (low blood pressure), poor intake by mouth and diarrhea from an extended care facility. He had a chronic (long time) Foley need and his Foley had become displaced. He was given intravenous (inside a vein) fluids. He had a weight loss of 27 pounds in one month. His WBC was up to 28,000 (normal male levels: 5,000-10,000) with creatinine (measure of kidney function) (normal levels: 0.7-1.3 mg/dL) of 3.18. Review of systems from nursing staff indicated no hematuria (blood in the urine) or pain. Resident had frequent urinary tract infections (UTIs). NP 15 indicated the plan of care was to reorder a urinary analysis (urine test) and continue the [MEDICATION(S)]. A nursing progress note, on 6/16/2022 at 2:36 p.m., indicated Resident D's catheter was leaking and draining. An appointment was scheduled for replacement on 6/21/22. A physician's note, on 6/18/2022 at 6:03 p.m., indicated Resident D had a suprapubic catheter. It was reported to have a large amount of hematuria, it cleared up, but was recurring. Resident was lying in bed, slow to respond, more lethargic than usual, and hypotensive (low blood pressure). He was due for IR replacement of catheter on 6/21/22. The resident needed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further evaluation needed. A nursing progress note, dated 6/18/2022 at 9:59 p.m., indicated Resident D was sent to the hospital for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident D's hospital notes, dated 6/18 to 6/21/22 were reviewed. They indicated Resident D's primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital orders were to start taking [MEDICATION(S)]-[MEDICATION(S)] ([MEDICATION(S)]) (antibiotic). To take one tablet by mouth, 2 times a day, for 5 days. A nursing progress note, dated 6/24/2022 at 9:47 p.m., indicated Resident D's suprapubic catheter fell out, it was sutured in place, and he needed to be sent to the hospital for evaluation and treatment. A nursing progress note to the NP on-call, dated 6/29/2022 at 2:33 a.m., indicated Resident D had a suprapubic catheter and a Foley catheter. There was blood-tinged urine in both bags from both sites. Resident complained of chills and pain from the suprapubic site. The urine was dark amber with a minimal amount of blood in tubing. A nursing progress note, on 6/29/2022 at 8:32 a.m., indicated nursing staff spoke to Licensed Practical Nurse (LPN) 16. The nurse referred to her as the NP. Resident D had a suprapubic and Foley catheter draining blood-tinged urine during the night shift. An order was obtained to start IV fluids of normal saline (NS). This morning the suprapubic and Foley were still draining tinged urine. NP (LPN 16) would assess and possible send resident back to the ED. A nursing progress note, on 6/29/2022 at 6:40 p.m., indicated Resident D returned to the facility. No medicine changes but indicated to return to the ER (emergency room ) with new or worsening symptoms. Resident D's 6/24/22 hospital notes were reviewed. They indicated Resident D presented to the ED after his suprapubic catheter came out. The catheter was placed on 5/6/22 after sustaining any [sic] urethral injury from a Foley. He was recently inpatient for [CONDITION(S)] related to a [CONDITION(S)] with hematuria, fever of 102 Fahrenheit (F), fatigue, and chills. The UA sample grew proteus (bacteria) and [CONDITION(S)] (bacteria) on urine culture. He was treated with [MEDICATION(S)] (antibiotic) for 3 days and then discharged on [MEDICATION(S)] to complete 7 days total. Physical exam on discharge indicated the penile indwelling Foley catheter was in place with a clear, yellow urine output. A nursing progress note, on 6/30/2022 at 8:17 a.m., indicated Resident D's suprapubic catheter was draining dark-tinged (brown) urine, and the Foley was draining light, pink-tinged urine. A nursing progress note, dated 7/5/22 at 10:36 p.m., indicated Resident D's vital signs (VS) were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated 7/6/22 at 10:43 p.m., indicated Resident D's VS were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 7/7/22 at 11:30 a.m., NP 15 indicated she saw Resident D last week after his trip to the ED. She thought the ED issues of blood in the urine were resolved. No one on the nursing staff had indicated to her the issue was back and worse. During an interview, on 7/7/22 at 11:34 a.m., LPN 16 (scribe for NP 15) indicated we (NP 15 and LPN 16) thought the hematuria was resolved and they had not heard about it all week. We need to order UAs several times, then double check that they are completed. During an interview, on 7/7/22 at 11:40 a.m., LPN 22 indicated she noticed Resident D's Foley bag had deep, red urine in it this morning. On 7/7/22 at 11:45 a.m., NP 15 was in Resident D's room. She indicated there was [MEDICATION(S)] in the Foley tubing and the resident was difficult to arouse. She tried a sternal rub and yelled in his face. He opened his eyes. She indicated with the increased blood in the Foley bag, he should return to the ED. On 7/7/22 at 2:05 p.m., the Director of Nursing (DON) provided the most recent UAs. One, dated 6/17/22, indicated Resident D had proteus mirabilis (bacteria) in his urine. The second one, indicated the resident had mixed skin flora (skin bacteria) in his urine. Resident D's 7/7/22 hospital notes were reviewed. They indicated the patient presented with hematuria for three days. He had a suprapubic and Foley catheter in place. He was positive for mild suprapubic tenderness and abdominal pain. Irritation noted around suprapubic catheter insertion site. The UA was abnormal with increased red blood cells and increased white blood cells. The ED physician indicated .Patient presents thing [sic] with concerns of hematuria. No gross blood in his suprapubic catheter bag her [sic] Foley bag. Suprapubic flashes and drains adequately. UA with a [CONDITION(S)]. Patient given [MEDICATION(S)] (antibiotic). The Foley was removed ED ordered [MEDICATION(S)] (antibiotic) 500 mg capsule, to take 1 capsule by mouth 4 times a day for 10 days. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 7/8/22 at 11:19 a.m., the Director of Risk Management (DRM) indicated it was her expectation the nursing staff should have let the NP know about the increased blood in the Foley bag. During an interview, on 7/8/22 at 11:40 a.m., the DON indicated it was her expectation for the nurse to have notified the NP when the urine went from light pink to deeper red. The Foley bag, tubing and dignity bag should not have been on the floor. The expectation was for the nurses to keep them off the floor. A current policy, titled Catheter Care, dated 6/2/21, was provided by the DRM at 3:15 p.m., indicated .CAUTI (Catheter Associated Urinary Tract Infections) is the most common adverse event associated with indwelling urinary catheters, including those that are asymptomatic. The risk of bacteremia (bacteria in the blood) in residents with indwelling catheters is 3-36 more likely than residents without an indwelling catheter .prevent symptomatic infections and incorporate antibiotic stewardship recommendations to reduce unnecessary drugs and antibiotics .as well as maintain the dignity and hygiene to the resident .Check that collection bag is not on the floor and is draining properly .Document and report any adverse findings to nurse The immediate jeopardy that began on 6/14/22 was removed on 7/9/22 when the facility assessed all residents with urinary catheters for signs and symptoms of infection, wounds at catheter insertion site, and proper placement of drainage bag. Nursing staff were in-serviced on catheter care, prevention of wounds from catheters, placement of drainage bags, and urinary tract infections. Staff were educated that all residents that request to go to the hospital will be immediately assessed, and the physician will be notified. The noncompliance remained at the lower scope and severity level of 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 related to Complaints IN 623 and IN 312. 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to ensure thorough assessments of residents to identify change in conditions, send residents with change of conditions out the hospital upon residents' request and failed to identify necrotic toes on a resident's foot prior to admission to the hospital emergency room for 2 of 3 residents reviewed for hospitalization (Resident B and C). The immediate jeopardy began on 6/14/22, when Resident B called 911 and requested to be sent to the hospital due to nausea, vomiting, and not feeling right. Resident B arrived at the hospital emergency room (ER) covered in stool and urine, had gangrenous toes, and had open wounds to his heel. On 6/20/22, Resident C was seen by the psychiatrist and was confused. Laboratory tests were obtained and indicated the resident had a high ammonia level of 194 (normal range 11-74). On 6/21/22, Resident C requested to go to the ER multiple times starting at 10 a.m., the Nurse Practitioner ordered for the resident to go to the ER at 5:04 p.m., and the resident was sent to the ER by EMS at 7:07 p.m., after falling on the floor. Upon arrival at the ER, the resident's ammonia level was 137 and his creatinine was 2.03 (normal range 0.7 to 1.3) and was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. On 7/7/22 at 8:45 a.m., Resident B's medical record was reviewed after his emergent discharge on 6/14/22. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B's annual Minimum Data Set (MDS) assessment, dated 3/9/22, indicated he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. No behaviors were coded for the 7-day look back and he was at risk for the development of pressure ulcers with 3 open areas at the time of the assessment. Resident B was followed by the wound care team and copies of his wound notes were provided on 7/8/22 at 10:00 a.m., by the Director of Risk Management (DRM). The wound notes were reviewed at that time and revealed: a. An arterial wound on his right lateral ankle which was still being treated. b. A stage III (Full thickness tissue loss where subcutaneous fat may be visible, but bone, tendon or muscle are not exposed and slough may be present but does not obscure the depth of tissue loss) pressure ulcer on his right heel, which was healed out on 3/22/22. c. A stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling) pressure ulcer on his right lateral foot, which was healed out on 4/19/22. Resident B had comprehensive care plan which included, but were not limited to: a. A care plan, most recently revised on 1/1/22, which indicated he required assistance with his activities of daily living (ADLs). Interventions for this plan of care included but were not limited to staff assistance for bed mobility, toileting, bathing, and eating. b. A care plan, most recently revised on 4/13/22, which indicated he was at risk for skin break down and had an arterial ulcer on his right ankle and right lateral foot. Interventions for the plan of care included, but were not limited to, evaluation of the existing wound daily to monitor for signs/symptoms of the wounds worsening and to provide peri-care as needed to avoid skin breakdown due to incontinence. c. A care plan, most recently revised on 3/16/22, which indicated he required the use of a gastrostomy tube (g-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding) and that he sometimes refused his g-tube feedings. Interventions for this plan of care included, but were not limited to, administer flushes per medical provider's order, administer medications via tube per orders and Nutritional consults. There was no care plan for Resident B's refusal of care or treatments. The record lacked documentation of Resident B's refusal of care or treatments. The record lacked documentation of any concerns related to Resident B's toes at the time of his discharge on 6/14/22. The record lacked documentation of any additional open wounds at the time of his discharge on 6/14/22. The record lacked documentation of a change in Resident B's condition due to nausea and vomiting. Resident B had the following physician orders: a. Treatment to the right lateral ankle: Cleanse with normal saline, and pat dry. Apply Collagen to wound bed & cover by a border gauze three days and week and as needed for soilage & dislodgement every day shift every Tuesday, Thursday, Saturday for arterial wound. b. Weekly skin assessment to be completed. Documentation to be completed on Weekly Skin Assessment during evening shift every Thursday for Skin Assessment. The record lacked documentation that a weekly skin assessment had been completed as scheduled for 6/9/22. A hospital transfer assessment was dated 6/14/22 at 11:22 a.m., but did not indicate any change in the resident's skin condition. Resident B was sent to the hospital for nausea and vomiting. A nursing progress note, dated 6/14/22 at 12:33 p.m., indicated Resident B called 911 without notifying the nurse. An ambulance arrived to facility by 11:00 a.m., and Resident B stated he was vomiting. No one was aware of that change. The resident left the facility by ambulance to the hospital and the DON was present. A hospital record scanned into Resident B's electronic charting system was dated 6/14/22 at 2:43 p.m. The ED (Emergency Department) summary indicated, Chief complaint: nausea, vomiting, and dark green urine .the patient is a pleasant 61-year male who presented to the ED from a nursing home via ambulance. Patient has not been very well cared for at the facility .per report, the nursing home is sending him in because he had made a mess of himself and they did not feel like cleaning him up. On arrival the ED [Emergency Department], the patient was very disheveled .He has an unstageable sacral ulcer and is complaining of back pain. He reports that he has been having nausea and vomiting and dark green urine for the past 2 days and nobody was willing to get him cleaned, hence why he decided to call 911 himself .Review of present symptoms, positive for: [CONDITION(S)], nauseas, back pain Upon a physical exam the following was noted .skin: gangrenous lower extremity toes, clear wound also noted to the heel .Psychiatric: cooperative and pleasant. Judgement and insight, memory, mood and affect within normal limits A hospital record scanned into Resident B's electronic charting system, dated 6/14/22 at 2:43 p.m., indicated .Assessment and Plan .Problem 11: sacral wound and lower extremity wound. patient with notable sacral wound, no discharge of bleeding, however he has consistently complained of back pain. Similarly, he has a wound on his heel. All lower extremity are gangrenous .wound evaluation pending .Attending physician addendum: presenting to the ED today for nausea, vomiting, and dark urine .We are concerned about his level of hygiene at time of presentation and consequently concerned about the quality of care he has received at facility .patient admitted to the hospital A hospital record scanned into Resident B's electronic charting system, dated 6/15/22 at 11:23 a.m., indicated a wound skin assessment was completed and revealed the following .Wound #2: stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcer to the sacrum which measured 0.5 cm long by 0.5 cm wide and 0.1 cm deep. Wound #3: stage II pressure ulcer on the right ankle which measured 3 cm long by 2 cm wide and 0.1 cm deep with serosanguineous drainage .Patient also has a right ankle wound that his nurse pointed out to me prior to seeing the patient A hospital record scanned into Resident B's electronic charting system, dated 6/17/22 at 6:42 a.m., indicated, .spoke to patient about disposition and his current facility. He stated that he would like to be in a different facility if other options were available .Problem #12: Social: patient brought in from facility, disheveled, covered in stool and urine .Also, with notable .sacral, and foot wound. Strong concern of neglect at facility .Social Worker referral was made due to abuse/neglect concerns, patient did tell medical team that he does not feel safe returning to Evergreen Crossing at discharge During an interview, on 7/7/22 at 10:43 a.m., Resident B indicated he was still at the hospital. He was going up and down but overall was feeling better. Resident B indicated he had not been feeling well for a couple of days and no one would help him. He called 911 because he knew something wasn't right. During a confidential interview during the survey indicated Resident B's condition upon arrival to the ED was very alarmingly, he arrived covered in stool and urine with several wounds and was septic with a [CONDITION(S)]. Resident B indicated he had made a mess of himself, and no one would help him get cleaned up, so he called 911. During an interview, on 7/8/22 at 11:54 a.m., Certified Nursing Assistant (CNA) 23 indicated she had worked with Resident B. He was usually pleasant and cooperative. She had not noticed any sign of a change in his condition before his discharged . During an interview, on 7/8/22 at 12:04 p.m., Wound Nurse 25 indicated he saw Resident B on 6/14/22. At the time of that evaluation, the only open wound being treated at that time was the arterial wound on his ankle. He would have thoroughly evaluated Resident B's whole foot at the time of the assessment and did not notice any concerns related to his toes other than they were extremely dried and had cracked skin. On 7/11/22 at 9:20 a.m., the Pike Township Fire Chief provided a copy of the ambulance Run Report for the day of Resident B's discharge. The Run Report was dated 6/14/22 at 11:25 a.m., and indicated .dispatched to a sick person. Arrived to find [Resident B] alert oriented x4 [oriented to person, place, time and situation]. He complained of nausea, vomiting and weakness .states he was not getting any help from nursing home staff and patient had vomit on self and bed. Patient stated staff did not give him any medication for nausea and vomiting seen after attempts to get staff help .Patient states he has not been able to eat for 2 days On 7/8/22 at 3:15 p.m., the Director of Risk Management (DRM) provided a current policy, dated effective 7/1/16 and reviewed on 10/5/21, titled, Skin Care & Wound Management Overview. This policy indicated .the facility strives to prevent resident/patient skin impairment and to promote the healing of existing wounds. The interdisciplinary team [IDT] works with the resident/patient and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The IDT evaluated and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying conditions contributing to it and descriptions of impartment to determine appropriate treatment .each resident is evaluated upon admission and weekly thereafter for changes in skin condition. Resident/patient skin condition is also re-evaluated with change in clinical condition, prior to transfer to the hospital and upon return from hospital On 7/8/22 at 3:15 p.m., the DRM provided a current policy, dated effective 10/31/13 and reviewed on 4/6/16, titled, Routine Resident Care. This policy indicated .It is the policy of this facility to promote resident centered care by attending to the physical emotion, social, and spiritual needs and honor resident lifestyle preferences while in the care of this facility .provide routine daily care by a certified nursing assistant with specialized training in rehabilitation/restorative care under the supervision of a licensed nurse including but not limited to .implementing and maintaining program for skin care .assisting and teaching activities of daily living .toileting, providing care for incontinence with dignity and maintaining skin integrity 2. On 7/5/22 at 10:10 a.m., during an interview and observation, Resident C was observed sitting in a wheelchair in his room playing a video game on a computer. He appeared to be greater than 400 pounds in size/weight and appeared to be middle aged. He was alert and oriented. He spoke clearly and carried a conversation without any difficulty. When asked if he had a recent hospitalization , the resident indicated he had. Resident C indicated his ammonia level was too high and he was feeling bad. He had asked the staff several times to send him out to the hospital, but they would not send him. About 4 hours passed. He was weak and could not reach his phone. He had tried to get up, but his legs were weak and would not support him and he fell on the floor. He had been kept in the hospital for about a week. On 7/6/22 at 3:57 p.m., the medical record was reviewed for Resident C. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse progress note, dated 6/16/22 at 11:25 a.m., indicated Resident C was assessed and had plus 2 to 3 pitting [CONDITION(S)] (large amount of swelling) from bilateral lower extremities (both feet and legs) to the knees. The Nurse Practitioner (NP) had been notified and he was sent to the emergency room due to a change in condition. On 6/16/22 at 10:56 p.m., a nursing note indicated the resident returned to the facility with no medication changes. The hospital records were not scanned into the electronic record and were not in the hard (paper) chart. There were no additional progress notes in the medical record until 6/21/22. A review of Resident C's hospital records, dated 6/16/22, indicated he was sent to the emergency room for reported lab abnormalities. Reported bilirubin in the 150's (tests liver function, a normal range according to A Manual of Laboratory and Diagnostic Tests is 0.3 to 1.0). Emergency Medical Services (EMS) reported when they arrived a low blood pressure was reported to EMS, but it appeared the cuff was slipping when the facility staff tried to obtain the blood pressure. For EMS, the blood pressure was 122/70. Hemoglobin (red blood cell count) was low at 9.8 (normal range according to A Manual of Laboratory and Diagnostic Tests is 14 to 17.4) and his ammonia level was 88 (normal range according to A Manual of Laboratory and Diagnostic Tests is 15 to 60). diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/21/22 at 10:10 a.m., a nursing note indicated Resident kept stating his ammonia level was too high and he needed sent to the emergency room (ER). The nurse informed the NP's scribe and indicated she was aware of his high levels and would see him on that day, 6/21/22. On 6/21/22 at 5:04 p.m., a psychiatry provider progress note indicated, reason for visit psych medication management. The note indicated Resident C was seated in his wheelchair and was nude. He was lethargic (sluggish, weak, lack of energy) and had a poor intake. Resident C stated his ammonia levels were high. The auto populated history (baseline) showed Resident C's most recent, Brief Interview for Mental Status (BIMS) score was 14 (mentally intact). The provider note contained Laboratory reports, a prior blood draw from the day before, dated 6/20/22, indicated Resident C's ammonia level was 194 (normal range according to A Manual of Laboratory and Diagnostic Tests is 15 to 60), blood glucose was 180 (normal range is 65-99), BUN 30 (blood urea nitrogen indicates kidney health, normal range according to A Manual of Laboratory and Diagnostic Tests is 6 to 20), creatinine 1.5 (waste product indicates kidney health, normal male range according to A Manual of Laboratory and Diagnostic Tests is to 0.9 to 1.3mg/dl). There were no NP or physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/21/22 at 7:07 p.m., a post transport note indicated, Resident has been sent to ER per his demands. He was unable to provide a reason to be transferred. He is alert and oriented x3. Signed by the Clinical Nurse Practitioner. On 6/21/22 at 7:42 p.m., a nursing note indicated, Resident kept on asking nurse to go to ER, Nurse informed MD [medical doctor] on the floor and assessed him but did not send him out. Resident kept on asking to out to hospital then slid himself to the floor. Nurse then had no choice but to call 911. Resident went out to hospital. On 6/22/22 at 4:05 a.m., a nursing note indicated admitted to hospital for [CONDITION(S)] (kidneys) and weakness. On 6/30/22 at 9:53 a.m., an Interdisciplinary team (IDT) note indicated, Resident C alleged lack of care. The root cause of incident was identified as .self neglect . false allegation negative comments regarding care Interventions put in place included educate staff on patients care needs. The care plan was updated to include to have CNA bring supplies and encourage resident to care and offer assistance.Per therapy resident able to complete ADLs [activity of daily living] A review of Resident C's hospital records, dated 6/21/22 through 7/1/22, indicated Resident C came to the ER from his nursing facility with complaint of increased weakness, unable to sit upright. He indicated he felt sluggish, his ammonia level was high at the facility. The resident indicated it was always high. Labs in ER showed ammonia level at 137. Record indicated previously 88 on 6/16/22 (last ER visit). [MEDICATION(S)] was 2.03 (previous ER visit on 6/16/22 was 1.2, normal male range according to A Manual of Laboratory and Diagnostic Tests is to 0.9 to 1.3mg/dl ). Resident was given IV (intravenous) fluids in ER and admitted to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Weakness, right facial droop. The record indicated the hospital was unable to complete an MRI (imaging) test due to the resident's size. He had been referred (in the past) for possible bariatric surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician notes indicated he suspected the resident's elevated renal (kidney function) numbers were related to him being over diuresis (dehydration related to medication and fluid excretion). The hospital treatment included holding diuretics and [MEDICATION(S)] (diabetic oral medication). His ammonia levels were treated with [MEDICATION(S)] (a medication to increase excretion of toxins through the bowel). The resident's medical record did not contain a code status order. The face sheet was blank, had nothing documented in the code status section. Upon request, on 7/6/22, the Director of Risk Management provided a POST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C signed the form on 7/5/22 and the NP signed on 7/6/22. A new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/8/22 at 3:12 p.m., during an interview, the Infection Preventionist (IP) indicated on 6/21/22 she was at the facility, working. She had been assisting the nurse who was working the floor. She went to Resident C's room to help and then went to office and told the NP's nurse (scribe) Resident C was requesting to go to the hospital because his ammonia level was high. She was told (by the Nurse Scribe) the NP would see him. When a resident requested to go to the hospital they let the doctor or NP know. On 7/8/22 at 3:15 p.m., during an interview, the Director of Risk Management indicated Resident C's ammonia level was always high, he had a chronic condition with his liver. They were aware of his labs from 6/20/22 and he was being treated with his scheduled medication. He often refused to take his [MEDICATION(S)] (medication to reduce ammonia level), and then wanted to go to the hospital. A copy of Resident C's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The record reflected all ordered doses were documented as given. On 6/16/22, the record indicated the resident was away from home with meds. The record did not show any missed or refused [MEDICATION(S)] doses. On 7/8/22 at 3:15 p.m., the Director of Risk Management provided a current policy, dated effective 10/30/13 and reviewed on 1/19/22, titled Physician Notification for Change in Condition Reporting. This policy indicated .It is the policy of this facility to promote resident centered care by using evidence based practice for notification of providers for changes in conditions and when to report signs and symptoms to the MD/NP/PA. This facility will make notifications for changes in condition (CIC) based on the AMDA guidelines and the INTERACT protocol On 7/8/22 at 3:15 p.m., the DRM provided a current policy, dated effective 5/19/16 and reviewed on 4/20/17, titled Resident Rights. This policy indicated .It is the policy of this facility to promote resident centered care by protecting and promoting the rights of each resident that falls within the 483.10 standard of care The immediate jeopardy that began on 6/14/22 was removed on 7/9/22 when the facility assessed all residents for a change in condition and skin impairments. Any resident found with a change in condition and/or skin impairments had the physician and responsible party notified. Any new skin impairments identified were immediately assessed, treated, care planned, and a skin grid was completed. All residents with laboratory results in the last 7 days had their labs reviewed to ensure notification to the physician and appropriate orders were obtained. All licensed nurses were educated on follow up assessments and documentation when a resident experiences a change in condition, educated on ensuring that any resident requesting to go to the hospital are assessed, educated all licensed nurses on laboratory services and reporting laboratory results to the physician, and educated all licensed nurses on skin assessments, treatment orders and completing a skin grid. The noncompliance remained at the lower scope and severity level of 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 related to Complaints IN 623 and IN 312. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure an effective pain management program was in place for a resident on hospice and at risk for pain. (Resident 87) This resulted in actual harm when Resident 87 experienced a change of condition related to pain during her transition into the active dying process, when her pain went un-controlled for over 18 hours for 1 of 1 resident reviewed for pain. Finding includes: On 7/5/22 at 11:07 a.m., Resident 87 was initially observed. She wore a hospital gown, which hung lose off her shoulder. Her hair was ruffled and tangled, and there was crusty discharge around her mouth and nose. She opened and closed her eyes intermittently and rocked her head from side to side slowly. She moaned and cried out. She reached her right arm up as if she reached for something. Her brows were tightly furrowed, and tears were observed in the corners of her eyes. Although she was alert to verbal stimuli, and calling her name, she could not answer questions, she only cried out. Resident 87's family member, who was in the room for a visit, paced back and forth, and indicated Resident 87 had been like this since yesterday evening and had not eaten in three days. He complained to the facility nurse and hospice staff, were not doing anything to help with the pain and just kept telling him to wait, wait, wait which was why he called 911 to take her to the hospital. The nurse kept telling him, to wait for pain medicine which was supposed to be on the way. He wanted her to be sent to the hospital since it was taking too long for the facility to do anything about it. During an interview, on 7/5/22 at 11:13 a.m., Hospice RN (Registered Nurse) 36 indicated, STAT (immediate) pain medication had been ordered yesterday (7/4/22) but had not arrived yet. RN 36 indicated she would call the pharmacy at 12:00 p.m., if they had not arrived by then because she believed Resident 87 was transitioning into the active-dying process. RN 36 indicated there was a cultural and language barrier between the family and facility, so it had been difficult to help them understand the death/dying process and Hospice role in facilitating end of life. The family wanted her sent to the hospital, but the facility did not see a reason to do so since she was on hospice. When asked if there were available medications in the EDK (emergency drug kit), RN 36 indicated she had to come into to give written orders, and the orders provided were not in the doses available from the EDK. On 7/5/22 at 11:20 a.m., Resident 87 was observed. She continued to call out, her face was grimaced, and her brows were tightly furrowed. She lifted her arm up and laid it down repeatedly. She was unable to answer any questions. On 7/5/22 at 11:31 a.m., RN 36 indicated to the Regional Risk Manager (RM) can we get something for this poor lady now? RN 36 explained to RM and the Assistant Director of Nursing (ADON) the pain medication which had been STAT ordered yesterday still had not arrived and the resident was very uncomfortable. RN 36 requested [MEDICATION(S)] (an anti-anxiety medication) for restlessness and agitation. During an interview, on 7/5/22 at 11:57 a.m., Licensed Practical Nurse (LPN) 29 indicated, she received report from the night nurse that Resident 87 had a change of condition over the weekend and had started calling out in pain yesterday around 7-8 p.m., and had continued to call out all morning. LPN 29 was waiting for the Unit Manager or ADON to get an order in for [MEDICATION(S)]. She believed Resident 87 had transitioned into the active-dying phase and did not know why there were not comfort/pain medication orders already in place, which was typical for residents who go onto Hospice. On 7/5/22 at 12:00 p.m., Resident 87's family member was overheard from her room. His voice was raised in anger, they just keep saying wait, wait, wait! You want her to die, ok! But no pain! Tell me where the medication is, Texas? Fine, I'll go to Texas and get it! F*** this, F*** Hospice! During an interview, on 7/5/22 at 12:16 p.m., LPN 29 indicated they did not have the correct dosage of the ordered pain medication in the EDK, so part of the delay was waiting to get new orders for the correct dosages put in. In the meantime, she had a one-time dose for [MEDICATION(S)] which LPN 29 was going to pull from the EDK at that time. On 7/5/22 at 12:35 p.m., Resident 87 continued to roll her head. Intermittently opened her eyes, moaned and cried out. Her voice was weaker, and she continued to cry. On 7/5/22 at 12:45 p.m., LPN 29 exited Resident 87's room with an empty pill cup and indicated she had just administered the [MEDICATION(S)]. On 7/5/22 at 2:39 p.m., Registered Nurse (RN) 28 indicated, the pharmacy had finally delivered the pain medication and Resident 87 had just received the following, [MEDICATION(S)] (a prescription medication used to reduce salivation) 2 drop sublingual (under the tongue). [MEDICATION(S)] (a narcotic pain medication) 0.5 ml (milliliters) sublingual (with instructions to give every 2 hours as needed for discomfort). From the previous interview with LPN 29, who received report from the night nurse that Resident 87's pain started around 8-9 p.m., on July 4th. From the previous interview with Resident 87's family member, her pain continued uncontrolled to the point they called 911 around 10:00 p.m. Resident 87 was observed multiple times on July 5th, from 11:07 a.m., until 2:39 p.m., as she appeared to be in pain as previously described. On 7/5/22 at 3:01 p.m., Resident 87 was observed. She appeared to rest more comfortably. Her eyes remained closed, she took short shallow breaths, but she did not moan, cry or reach out. On 7/6/22 at 9:14 a.m., Resident 87 was observed. She rested peacefully. Certified Nursing Assistant (CNA) 37 was at her bedside. CNA 37 indicated she was happy to see Resident 87 calmed down. She had been in a lot of pain yesterday. CNA 37 did not know all the details, but there was something about waiting for medicine. When asked about non-pharmacological interventions while they were waiting for pan meds, CNA 37 indicated she did not know what else to try. During an interview, on 7/6/22 at 9:37 a.m., Hospice RN 36 indicated there had definitely been a break down in the system which failed to get pain medication to Resident 87 in a timely manner. A text-blast went out from the facility to the Hospice provider on 7/3/22 which indicated Resident 87 had a change of condition related to not eating/drinking. There was a second note on 7/4/22 which indicated the Resident's family member was adamant that she be sent to the hospital, he even called 911. When the EMT's arrived, they explained the DNR (do not resuscitate) order and hospice end of life expectations. Another note, dated 7/4/22, indicated STAT pain medication had been ordered but did not give any descriptions of Resident 87 being in pain. STAT orders were placed. RN 36 called the pharmacy and had an at length conversation about why the medications were never delivered, and as best as she understood the pharmacies response was it got lost over the 4th of July Holiday. There was a disconnect with the pharmacy, the holiday threw them off, they communicated they provided STAT deliveries even over the holidays, so this should not have happened. It is a big deal, I totally agree that the ball was dropped, and she was not sure why it took so long to get additional pain medications ordered, pull from the EDK, or why it took so long to get her the [MEDICATION(S)]. On 7/7/22 at 9:12 a.m., Resident 87 was observed. She appeared to rest peacefully. Her eyes were closed. She took short, shallow, rapid breaths with the sound of a death rattle (terminal respiratory secretions, commonly known as a death rattle, occur when mucous and saliva build up in the patient's throat. As the patient becomes weaker and/or loses consciousness, they can lose the ability to clear their throat or swallow.) She was unresponsive to verbal stimuli. On 7/6/11 at 3:25 p.m., Resident 87's medical record was reviewed. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was admitted to Hospice care on 6/3/22. She had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no previous completed or discontinued orders for comfort pain management. She had a current comprehensive care plan, initiated on 6/8/22, which indicated she was admitted to Hospice services. Interventions for the plan of care included, but were not limited to, administering medication and treatments per physician orders, and coordinate with the Hospice company. The record lacked documentation of a comprehensive care plan for pain management. A nursing progress note, dated 7/4/22 at 10:40 p.m., indicated Resident 87 continued to have an overall decline. A family member was in for a visit and wanted her to be sent to the hospital because she was unresponsive. The nurse assessed the resident. She was alert to self and name, with no respiratory distress. The nurse called the Hospice team because the family member had called 911. Hospice spoke to the family member and indicated they would order STAT comfort medication. 911 showed up and tried to explain to the family member Resident 87 was on Hospice, EMT's convinced family member Resident 87 should stay at the facility and follow up with Hospice. The Hospice Triage nurse indicated the comfort meds would be delivered that evening. A nursing progress note, dated 7/5/22 at 3:44 p.m., indicated .writer received report this [morning] [Resident 87 was in pain] noted with decline, not eating or drinking and at times combative when meds offered. Patient's family member was at bedside this morning and afternoon while writer administrating [MEDICATION(S)] and [MEDICATION(S)], pain/anxiety. Patient now relaxed no loud outburst/moans with receiving narcotics. A Hospice Progress note, dated 7/5/22 (no time), indicated .patient was restless and moaning, notified facility nurse, possible need for pain medication On 7/8/22 at 3:15 p.m., the RM provided a copy of current facility policy titled, Pain Management and Assessment, dated 7/25/18 and revised 1/18/22. The policy indicated, .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents .to the extent possible and in consideration of cognitive abilities, the nurse will provide a thorough assessment by observation of activities and treatment/relief for detection of pan an to attempt to identify location and any limitation imposed by the pain. i. Clues may include not participating in favorite activities or outings. ii. Facial grimaces during care. iii. Guarding or protecting a body limb or part. iv. Unexplained behaviors when the resident is unable to verbalize On 7/8/22 at 3:15 p.m., the RM provided a copy of current facility policy titled, Coordination of Care for Hospice Services, dated 11/1/13, revised 2/15/22. The policy indicated, .Quality of life is a fundamental principle that applies to all care and services provided to the residents at this facility. End of life care of hospice care is a valuable resource to families and residents and will be provided while the resident is in the facility at the request of the resident, responsible party/family and physician .Staff communication and coordinated services, the facility clinical [NAME] will coordinate services and care with the hospice team for comfort, care, and therapeutic measures as appropriate .pain management including breakthrough pain assessment and treatment 3.1-37(a)

Based on record review and interviews, the facility failed to ensure a resident's foley urinary catheter orders for check, change, and monitor were reactivated upon his re-admission to the facility and a urinalysis was obtained after signs/symptoms of a urinary tract infection were noted which resulted in actual harm when the resident experienced lower abdomen pain and tenderness, decreased catheter output with foul smelling urine and puss discharge from his catheter resulting in a transfer to the hospital for care for 1 of 1 resident reviewed for Bowel and Bladder (Resident 78). Findings include: On 1/24/22 at 10:10 a.m., Resident 78's room was observed to be empty with only a few personal items left on top of a bedside table. At this time, a passing nursing staff member indicated, Resident 78 had been sent to the hospital and would not be returning. On 1/28/22 at 2:00 p.m., Resident 78's medical record was reviewed. Resident 78 was a long-term care resident who initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a [CONDITION(S)] bag (a plastic bag that collects fecal matter from the digestive tract through an opening in the abdominal wall) and a chronic indwelling foley urinary catheter (a flexible tube inserted through the urethra and into the bladder to drain urine). A nursing progress note, dated 10/31/21 at 8:20 a.m., indicated Resident 78 had a change of condition and reported multiple episodes of bilious vomiting for the prior 24 hours and was not eating. He had severe abdominal pain and his ostomy bag had 300 ml (milliliters) overnight which was less than his usual 500 ml. He was sent out to the emergency room for further evaluation and treatment. A nursing progress note, dated 11/6/21 at 5:20 p.m. (a late entry), indicated Resident 78 readmitted back to the facility. His foley catheter was still in place at that time and drained yellow urine. A hospital History and Physical, dated 11/1/21, indicated Resident 78 admitted to the hospital on 10/31/21 with acute pancreatitis and likely had a urinary tract infection. A Physician's Progress note, dated 11/9/21 at 12:37 p.m., indicated the chief complaint for follow up was foley was plugged up. Resident 78 presented to the hospital on October 31st with nausea/vomiting (N/V) and had abdominal pain. He was in the hospital for 1 day. He was found to have a lipase (an enzyme the body uses to break down fats in food so they can be absorbed in the intestines) of 1824 and CT scan revealed [CONDITION(S)] changes around the head of the pancreas. He had a chronic Foley and was diagnosed with a [CONDITION(S)], no discharge summary or culture results were sent when patient returned but he had an appointment to see Infectious Disease (ID) back later in the month. His Foley was changed. He felt well without complaint. Assessment Plan Summary included but not limited to, .1. Acute pancreatitis: continue regular diabetic diet, repeat lipase if again has abdominal pain and N/V. 2. [CONDITION(S)]: completed medication, follow up with ID. 3. Retention of urine: continue Foley, change monthly or prn Before his discharge to the hospital, on 10/31/21, Resident 78 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Foley catheter size 16 with 10 ml to continuous drain. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] b. Foley catheter care every shift as needed with soap and water, and document output every shift. c. Change Foley catheter as needed per Medical Director (MD) order. The medical record lacked documentation that the above orders were reactivated upon Resident 78's readmission to the facility. Resident 78's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A comprehensive care plan, dated 4/27/21, indicated Resident 78 had an indwelling foley catheter related to his pressure ulcers. Interventions for this plan of care included but were not limited to, .change the catheter per MD order and as needed, observe/record/report to MD for s/sx [signs/symptoms] [CONDITION(S)]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change behavior, change in eating patterns. Provide catheter care every shift and PRN [as needed]. Notify medical provider if urine is of abnormal color, consistency, or odor A nursing progress note, dated 12/13/21 at 1:14 p.m., indicated Resident 78's catheter bag was changed. A Physician's progress note, dated 12/30/21 at 3:36 p.m., indicated Resident 78 was seen for complaints of foul-smelling urine with mucous, lower abdominal pain, and N/V. A urinalysis (UA) was obtained 2 days ago [12/28/21], but results showed pending in lab portal . will ask staff to call results this weekend to on call Resident 78's medical record lacked documentation of any UA results for the month of December. A nursing progress note, dated 1/19/22 at 9:09 a.m., indicated there had been no urine in Resident 78's drainage bag from the evening shift yesterday. His lower abdomen was noted tender and painful to touch. His catheter was changed and about 700 milliliters (mls) of foul-smelling urine filled with pus was drained from his bladder. A sample was shown to the MD and collected to be sent the following day alongside a previously scheduled blood work test. Staff were to continue to observe for signs of retention. A nursing progress note, dated 1/20/22 at 2:00 p.m., indicated Resident 78 vomited 4 times overnight and complained of lower abdomen pain. He had not eaten all morning, and the lab had not been in yet to collect bloodwork. His catheter still drained creamy colored urine and he had decreased output. [CONDITION(S)] suggested and Resident 78 was transferred to the emergency room . During an interview on 1/31/22 at 2:11 p.m., the Clinical Manager (CM) reviewed Resident 78's medical record and indicated there were no UA labs for the month of December. At this time, she indicated she had worked with Resident 78 and recalled he did have a foley catheter. Any resident with a catheter should have orders to monitor, check and change as needed and monitor for output, this helped catch early signs or symptoms of possible UTIs (urinary tract infections). The CM indicated upon her review, there was no documentation of catheter care in his record after the orders had been discontinued. During an interview on 1/31/22 at 3:36 p.m., the Interim Director of Nursing (DON) and CM indicated Resident 78's catheter orders should have been reactivated when he returned to the facility. The orders would have triggered daily monitoring on the MAR/TAR so sign/symptoms of complications would be seen as early as possible to prevent infections. The Interim DON indicated he reviewed the lab portal and did not find any UA from the month of December as noted in the Physician's progress note. The only UA he had was dated 1/20/22. Results from the UA, dated 1/20/22, indicated the presence of greater (>)1000,000 CFU/ml (colony forming unit, a type of measurement of the amount of growth) [CONDITION(S)] Pneumoniae (a type bacteria) and 70-99,000 CFU/ml Proteus Mirabilis (a type of bacteria). On 1/31/22 at 4:00 p.m., the Administrator provided a copy of current facility policy titled, Catheter Care, dated 5/1/17. The policy indicated, .It is the policy of this facility to provide resident care that meets the psychosocial, physical and emotional needs and concerns of the residents. Catheter care is performed at least twice daily on resident that have indwelling catheters, for as long as the catheter is in place. CAUTI (Catheter Associated Urinary Tract Infections) is the most common adverse even associated with indwelling urinary catheters . the risk of bacteremia in resident with indwelling catheters is 3-36 times more likely than residents without an indwelling catheter 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a resident received [CONDITION(S)] transportation which resulted in harm when a resident requiring antibiotics for endocarditis (a serious potentially life threatening infection of the inner lining of the heart's chambers and valves) to be given during [CONDITION(S)] sessions missed multiple [CONDITION(S)] sessions and had to go to the hospital for [CONDITION(S)] treatment, antibiotics for the endocarditis, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 1/27/22 at 9:15 a.m., Resident 90's record was reviewed. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment indicated Resident 90 discharged from the facility to an acute care hospital on 10/16/21 and returned 10/21/21 and discharged again on 10/29/21 and returned to the facility on [DATE]. A nurse practitioner (NP) note, on 10/5/21 at 1:18 p.m. by NP 19, indicated Resident 90's cognitive level of functioning was sufficient to permit the patient to participate meaningfully in his treatment. A nursing progress note, on 10/16/21 at 6:37 p.m. by Licensed Practical Nurse (LPN) 32, indicated Resident 90 felt nauseous at 5:00 p.m. She provided [MEDICATION(S)] (antinausea) 25 milligrams (mg) by mouth, and he immediately started vomiting yellow fluid. The resident indicated he would like to go to the hospital. His 6:00 p.m. blood sugar was 67. A call was placed to the on-call Medical Doctor (MD). The resident held Sprite down for 20 minutes. Then the resident indicated he was uncomfortable with abdominal pain. She placed another call to the on-call MD, then placed a call for the ambulance. Resident indicated he felt weak. His family was called at 6:51 p.m. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He had been sent to the hospital to receive intravenous (IV) antibiotics as well as hemodialysis (HD) as he missed several appointments due to transportation issues. According to his previous records he was on IV antibiotics after HD for at least one month. He was hospitalized for nausea and vomiting, found to be hypoglycemic (low blood sugar) and had [CONDITION(S)]-susceptible staphylococcus aureus (MSSA) endocarditis. [MEDICATION(S)] (antibiotic) was ordered until at least 11/20/21. A nursing progress note, on 10/21/22 at 7:23 p.m. by LPN 33, indicated Resident 90 returned from the hospital with orders for IV antibiotics (ATB) to be administered at [CONDITION(S)]. A nursing progress note, on 10/29/21 at 2:05 p.m. by LPN 32, indicated she called the [CONDITION(S)] center. Resident 90 was not picked up for transport. Orders given were to monitor for complaints of shortness of breath, chest pain, and [CONDITION(S)] (swelling). A nursing progress note, on 10/29/21 at 2:48 p.m. e-signed by the Director of Nursing (DON), indicated the [CONDITION(S)] center called and stated the nephrologist wanted the resident sent to the hospital for [CONDITION(S)] and antibiotics due to the resident needing antibiotics and missing a couple of his treatments related to transportation issues. A nursing progress note, on 10/29/21 at 3:27 p.m., LPN 32 indicated the resident was not picked up for [CONDITION(S)] and Resident 90 was to be sent to the emergency room (ER) for [CONDITION(S)] and antibiotics. A nursing progress note, on 10/29/21 at 7:30 p.m. e-signed by the DON, indicated the resident was transferred to an acute care hospital for [CONDITION(S)] and antibiotic treatment. A nursing progress note, on 10/30/21 at 5:00 p.m. by LPN 32, indicated Resident 90 returned from the hospital. On 1/31/22 at 10:27 a.m., the Regional Consultant Nurse provided the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/29/21, a new order was added, it indicated, .Per nephrologist send to ER for eval (evaluation) and treat (treatment). A hospital physician summary report, dated 10/30/21 at 4:03 p.m. by MD 38, indicated Resident 90 was here for missing [CONDITION(S)] sessions and due transportation issues. He was found to have tricuspid (heart valve) endocarditis secondary to chronic [CONDITION(S)]. A nursing progress note, on 11/1/21 at 9:45 a.m. by Registered Nurse (RN) 4, indicated Resident 90 missed his [CONDITION(S)] appointment due to transportation being canceled while he was in the hospital. A nursing progress note, on 11/10/21 at 11:53 a.m. by LPN 8, indicated transportation did not show up for Resident 90's routine [CONDITION(S)] and usual chair time. Resident 90 indicated he did not want a later [CONDITION(S)] time but did go to [CONDITION(S)] later. A nursing progress note, on 11/15/21 at 6:09 a.m., LPN 36 indicated Resident 90's [CONDITION(S)] transportation did not show up. The transportation company indicated to LPN 36 that the facility was notified on 11/13/21 at noon of their inability to provide transport this day. A nursing progress note, on 11/18/21 at 1:53 p.m., LPN 32 indicated Resident 90 was noted to have, bilateral [CONDITION(S)]. His physician was notified. A nursing progress note, on 11/28/21 at 3:38 p.m., LPN 32 indicated Resident 90 was noted with whole body swelling. His physician was notified. A physician's progress narrative, on 12/2/21 at 1:32 p.m. by MD 20, indicated Resident 90 was seen due to, whole body swelling due to missed [CONDITION(S)] sessions .the issue is due to transportation. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .This resident has anasarca [generalized body swelling], this is due to transportation issues and him not being able to get to [CONDITION(S)]. He is very compliant and very concerned about missing [CONDITION(S)] sessions A nursing progress note, on 12/2/21 at 4:13 p.m. by LPN 32, indicated Resident 90 had an appointment this an afternoon with infectious disease physician 37 and transportation did not show up. She was not able to secure other transportation. A nursing progress note, on 12/8/21 at 3:26 p.m., LPN 32 indicated Resident 90 went to [CONDITION(S)] today, the [CONDITION(S)] company had arranged for the resident to receive [CONDITION(S)] for this day only. Resident 90's care plan, dated 2/28/21, indicated he was currently on [CONDITION(S)] therapy related to end stage renal failure. The goal was for him to be free of signs and symptoms of complications from hemodialysis. There was no intervention added to be sure he would be picked up and taken to [CONDITION(S)] on Monday, Wednesday, and Friday. A spreadsheet, dated 10/1/21 to 1/27/22, titled, Hemodialysis Treatment, for Resident 90, was emailed by Charge Nurse 23 at Fresenius Kidney Care, on 1/28/22 at 12:28 p.m. A review of this document indicated Resident 90 missed [CONDITION(S)] on the following days: 10/4/21, 10/27/21, 10/29/21, 11/1/21, 11/8/21, 11/10/21, 11/17/21, 11/22/21, 11/24/21, and 1/3/22. On 2/4/22 at 9:30 a.m., the DON indicated his expectation for [CONDITION(S)] residents was to go to [CONDITION(S)]. Sometimes residents refused or there was a transportation issue. For a resident who required a stretcher, the facility scheduled state transportation and sometimes transportation canceled. For residents in wheelchairs, the facility's backup plan was to take them in the facility van. If a resident missed [CONDITION(S)], the facility notified the doctor, and the doctor may cancel it or reschedule. Resident 90 used a stretcher for [CONDITION(S)] in October and November 2021. He was using a wheelchair in December and January. A current policy titled, Hemodialysis Care and Monitoring, with no date was provided by email on 2/4/22 at 11:05 a.m. A review of this policy indicated, .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents .Residents will be transported to a specialized center for hemodialysis .The facility remains responsible for the overall quality of care the resident receives 3.1-37(a) 3.1-37(b)

Based on interview and record review, the facility failed to monitor, assess and had a delay in providing Cardio-Pulmonary Resuscitation (CPR) according to the resident's code status preference, and failed to follow the CPR procedure for unresponsive residents for 1 of 3 residents reviewed for death (Resident J). The Immediate Jeopardy began [DATE], when the facility failed to initiate CPR on a resident found unresponsive. The Executive Director (ED), Administrator in Training (AIT) and Regional Director of Operations (RDCO) were notified of the Immediate Jeopardy on [DATE] at 4:25 p.m. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Findings include: Resident J's record was reviewed on [DATE] at 9:13 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On [DATE] CBC and CMP weekly x 4 b. On [DATE] Attempt Resuscitation/CPR c. On [DATE] CBC, and CMP d. On [DATE] STAT chest x-ray related to pain and bruises on the left chest wall. e. On [DATE] STAT (urgent, rush, immediately) laboratory orders for a complete blood count (CBC), comprehensive metabolic panel (CMP), prothrombin (PT), partial thromboplastin time (PTT) related to jaundice. An Indiana Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatment Goal: Full interventions including life support measures in the intensive care unit. In addition to care described in Comfort Measures and Limited Additional Interventions above, use intubation, advanced airway interventions, and mechanical ventilation as needed. Transfer to hospital and/or intensive care unit if indicated to meet medical needs. Physician Order: full code. An Admission Initial Evaluation assessment for Resident J, dated [DATE] at 5:52 p.m., indicated 48 Hour Baseline Care Plan, Code Status: full code . Vital Sign documentation for Resident J indicated, a. On [DATE] at 5:53 a.m., temperature 96.9 Fahrenheit (°F), (normal 97 F - 99 F), respirations 22 breaths per minute (normal 12 - 16, and oxygen saturations 96% on room air per LPN 19. b. On [DATE] at 9:40 a.m., blood pressure 105 / 66 (normal per American Heart Association,d+[DATE]) per LPN 19. c. On [DATE] at 11:16 a.m., temperature 97.2 °F, respirations 18 breaths per minute, and oxygen saturations 94% on room air per LPN 19. A Progress Note for Resident J, dated [DATE] at 9:06 a.m., indicated the resident was observed to have yellow eyes, with bruises on the left side of his chest area extending a little to his back with associated pain when touched. The resident was seen by the physician with STAT labs ordered with a chest x-ray. The resident's Tylenol and [MEDICATION(S)] (used to treat high cholesterol) was discontinued. Staff to continue observing. A Late Physicians Progress Note for Resident J, dated [DATE] at 1:33 p.m., created by the physician's scribe on [DATE] at 1:34 p.m., indicated the patient was seen for admission history and physical. Per hospital records the patient presented to the hospital prior to admit to the facility with progressive weakness and shortness of breath. He was found to have segmental and subsegmental PE. New orders were given for stat labs and a chest x-ray related to new onset jaundice and chest wall bruising with pain. A late Progress Note for Resident J, dated [DATE] at 6:00 p.m., created by Licensed Practical Nurse (LPN) 10 on [DATE] at 5:24 p.m., indicated the writer was summoned to the resident's room by the unit staff. The resident was noted to be unresponsive. LPN 10 and other staff initiated CPR at that time. An automated external defibrillator (AED) was applied. 911, resident representative and the physician were called. Emergency medical technicians (EMT's) attempted resuscitation without success. Code Event Minutes for Resident J, dated [DATE], created by LPN 10, indicated first response CNA 20, time resident found approximately between 5:35 p.m. - 5:40 p.m. Resident found in bed non-responsive, no pulse, and not breathing. Time code called/initiated between 5:50 p.m. - 6:00 p.m., unable to obtain vital signs. Attempted CPR, AED utilized, no shock advised, CPR provided for 8 cycles. Oxygen was administered per mask. EMS called at 6:00 p.m. and arrived at 6:10 p.m. The resident record for Resident J, dated [DATE], lacked documentation Activity of Daily Living (ADL) services were provided after 1:15 p.m. when the entirety of the morning care was input into the system. A handwritten Witness Statement by CNA 20, dated [DATE], indicated, When I got here at 3:45 p.m. got upstairs and did a round check seen/thought he was sleep 3:48 p.m. is when I last seen him sleep then I went to check on my next resident didn't go back in his room till dinner then I realize he was gone and got the qualified medication aide [QMA] around 5:30ish then got [LPN 22] the nurse. A handwritten Witness Statement by QMA 21, dated [DATE], indicated, At 5:32 p.m the aide came and got me she said the resident was not waking up I looked at him he was unresponsive and I told her to get the nurse and she was notified at 5:30ish. A handwritten Witness Statement by LPN 22, dated [DATE], indicated, CNA alerted nurse that resident had passed away in [room number] around 5:45 p.m. Nurse then alerted unit manager [LPN 10] at 5:46 p.m. When nurse entered room resident right arm in air very stiff nurse layed arm down. Then QMA and [LPN 10] to unit stating that resident was a full code so CPR initiated at 6:00 p.m. A Witness Statement typed by the Divisional Risk Coordinator, signed by LPN 22, undated, indicated, At 5:42 p.m. the CNA came I was giving insulin and she said we need you the patient in [room number] is dead. I gave the insulin and went right over to the room and his arm was in the air and I moved his arm down. Then I went out to the nurse's station and looked for the chart but could not locate it, so then I went to the computer and looked up his code status and it said [attempt resuscitation] and at the same time [QMA 23] found the chart and said he is a full code. [LPN 10] was coming with the crash cart and said call 911 and he immediately started CPR and I called 911. 911 put me on hold twice and I called back a third time and they finally answered. They arrived shortly after and they continued CPR. I was at the desk getting the paperwork and they came out and said he had passed. I called the son and let him know the situation. A handwritten Witness Statement by QMA 23, dated [DATE], indicated, Around 5:50 p.m. I was notified by [LPN 10] that resident in [room number] was found unconscious. I checked [the electronic documentation system] to verify his code status he was a full code. [LPN 10] and I started CPR on resident. A handwritten Witness Statement by LPN 10, dated [DATE], indicated, On [DATE] about 5:46 p.m. I received call from [LPN 22] the nurse on [NAME]. I returned call at this time she stated resident in [room number] had passed away and needed 2nd nurse for verification. I told her I was on my way. Unsure of time got to unit but QMA had informed me he was attempt CPR/Full Code. I grabbed crash cart and proceeded to unit. At that time nurse was at desk and stated he's a attempted resuscitation I educated nurse and all staff that means full code and proceeded to room and .started CPR. I instructed nurse to call 911. [QMA 23] and I continued several rounds of CPR with other floor staff present and [LPN 22] the nurse in room. [LPN 22] stated unable to get hold 911 at this time CNA called and was able and gave address as writer and [QMA 23] continued CPR. Then EMT arrived began CPR for ,d+[DATE] rounds and stated has gone and stopped. I then instructed [LPN 22] to get paperwork and inform NP/MD on call. I then left the unit. During an interview on [DATE] at 11:07 a.m., LPN 10 indicated, on [DATE] LPN 22 had called him and indicated someone had passed away and wanted him to verify. He went upstairs and brought the crash cart with him and stopped at the nurse's station as LPN 22 was sitting at the desk. LPN 10 went to Resident J's room and started CPR and instructed LPN 22 to call 911. LPN 10 indicated, he knew resident J was a full code as he had been told by QMA 23. LPN 22 told him Resident J was an attempt CPR and he told her that meant he was a full code. LPN 10 indicated, when he entered the room, Resident J was still warm, and was not blue or cold. As the nurse he would know if the resident was a code or no code as the code status automatically popped up on the banner in the electronic medical record every time the resident record was accessed. A resident code status could also be found in the hard chart in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 10 indicated Resident J had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 10 indicated, he could not answer as to why LPN 22 had not started CPR or called 911 prior to his arrival on the unit. During an interview on [DATE] at 12:06 p.m., the Divisional Risk Coordinator indicated, on the evening of [DATE], CNA 20 went to check on Resident J at 3:45 p.m. and thought he was sleeping. When she went to deliver his dinner somewhere between 5:30 p.m. - 5:40 p.m., she noticed he wasn't responding and went to get QMA 21. QMA 21 went to Resident J's room while the aide went and got LPN 22 from [NAME] 1. LPN 22 was administering insulin and when she finished, she went to [NAME] 2 and checked on the resident who wasn't responsive. LPN 22 indicated the resident was stiff and she went to the desk to validate his code status. LPN 22 indicated she could not find the resident's chart although it was at the desk. LPN 22 called LPN 10, then LPN 10 and QMA 23 came upstairs with the crash cart. LPN 10 and QMA 23 passed LPN 22 at the nurse's desk who said she was in the electronic medical record and his orders said, attempt CPR. LPN 10 and QMA 23 went to Resident J's room and started CPR while LPN 22 called 911. Resident J had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 3:08 p.m., LPN 22 indicated, on [DATE] at approximately 5:40 p.m., QMA 21 came to unit [NAME] 1 where she was giving insulin, and stated she was needed on the other side as Resident J was dead. QMA 21 told her Resident J was cold and hard. LPN 22 indicated she got a call from QMA 21 but did not answer because she was already in route to the unit. At 5:46 p.m. while in route to [NAME] 2 LPN 22 call the unit manager LPN 10 and reported Resident J was dead. LPN 22 entered Resident J's room and to her he looked clinically dead. His right arm was in the air, his feet were cold, and he had no pulses in either carotid artery. In her opinion the resident was already clinically dead, and CPR should not have been performed at that point. LPN 22 put the resident's arm down by his side and went to the nurse's station. At that time, she could not locate the resident's hard chart to find family information, so she logged into the electronic medical record. Once inside the chart she observed attempt CPR. LPN found the family contact information and called the son at approximately 5:52 p.m. to notify him the resident was deceased . At approximately 5:55 p.m. LPN 10 and QMA 23 were observed getting off the elevator and he yelled, Resident J was a full code, start CPR and call 911. LPN 10 and QMA 23 had the crash cart and went to Resident J's room and started CPR. The ambulance arrived at 6:05 p.m., and the EMT's did 1 round of CPR before calling the resident dead. It was her opinion that if [NAME] 2 staff to include QMA 21, CNA 20, and CNA 24 had checked on the resident he would have been found before he was cold. The resident was newer to the facility and his code status was not signed which made him an automatically a full code. LPN 22 indicated, she had never received education related to code status or when to initiate CPR during her employment at the facility. On [DATE] at 10:40 a.m., the AIT indicated there was no nursing documentation in Resident J's chart to indicate the resident was being monitored throughout the day for his decline in mental status, yellow eyes, bruises on his chest and back, or if STAT labs had been completed, beween 9:06 a.m. and when he was found unresponsive at 5:30 p.m. The AIT indicated, she could not answer as to why there was a delay more than 20 minutes for staff to initiate CPR after the resident was found, or why 911 was not called immediately after the resident was found unresponsive. On [DATE] at 10:50 a.m., the RDCO proved a basic life support (BLS) Provider CPR card for LPN 22 card issue date [DATE] and expiration date ,d+[DATE]. The RDCO indicated, as LPN 22 was no longer certified to perform CPR as her certification had expired, that was the reason she called LPN 10 to come perform CPR. Indicated, code status and CPR protocol education was presented to staff via electronic education, she did not provide a copy of the training per request. The facility lacked documentation to indicate LPN 22 had been CPR training or education regrading code status. During an interview on [DATE] at 11:00 a.m., LPN 10 indicated, Resident J's medical record lacked documentation on [DATE] to indicate the resident's vital signs or change in condition were monitored after the NP visit. LPN 10 indicated, he could not answer as to why there was a delay more than 20 minutes for staff to initiate CPR after the resident was found, why 911 was not called immediately after the resident was found unresponsive, or why there was no documentation to indicate the resident was being monitored after stat labs orders were obtained in the morning for a change in condition. On [DATE] at 3:10 p.m., the AIT indicated, there was no documentation in the electronic training to indicate nursing staff had received training regarding CPR and code status, or when to initiate CPR. It was the standard of the facility to have at least 1 CPR certified person in the facility every shift. On [DATE] at 4:10 p.m., the AIT provided a General Code Status policy, dated [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, The purpose of this policy is to guide clinical staff to quickly and accurately identify residents in the facility that do and do not request CPR as a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .The use of an electronic health record [EHR] provides for fast retrieval to identify and how to appropriately respond to respiratory and [CONDITION(S)] based upon the resident/representative wishes .Code Status is found in the electronic health record and will be used by the nurse to validate Code Status before initiating CPR .Two basic code status categories will be entered into the electronic medical record to guide staff for appropriate emergency treatment/actions should respirations cease and/or pulselessness occur are: i. CPR Code Status, ii. Do Not Resuscitate/DNR Status . On [DATE] at 4:10 p.m., the AIT provided an Initiate CPR policy, dated [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, It is the policy of this facility to promote resident centered care by respecting resident's right to formulate an advanced directive including to initiate CPR by training staff .1. Upon admission, discuss code status with the resident and/or family/guardian and document .2. The facility will maintain and train staff on a communication method that will quickly alert staff as to the code status of a resident in the event heart or respirations cease. 3. Residents found unresponsive, not breathing or without a pulse, will have staff immediately locate the Code Status and communicate this to the team. 4. If CPR is initiated, staff will begin CPR and call 911 with these expectations: a. There is a valid DNR order in place. b. There is obvious signs of clinical death [e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition] are present . The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility conducted an audit on all residents that required CPR in the building for the prior 90 days, with no further findings. Charts were reviewed to ensure code status was correct on the charts, physicians' orders were in place, and care plans in the charts were accurate. All licensed nurses and QMA's were educated on the facilities policy identified as, General Code Status and Initiate CPR with emphasis on initiating CPR as soon as a code status is identified as Full Code, CPR, and Attempt Resuscitation. The DON/designee documented interviews with licensed nurses and QMA's on the facility policy regarding initiating CPR when a Full Code, CPR or Attempt Resuscitation. The noncompliance remained at the lower scope and severity level of 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 Complaints IN 436 and IN 028.

Based on interview and record review, the facility failed to have a system in place for ordering, obtaining, and tracking of STAT (urgent, rush, immediate) laboratory orders, and failed to ensure assessments and documentation were completed after a change in condition for 1 of 3 residents reviewed for death (Resident J). The Immediate Jeopardy began October 8, 2021, when the facility failed to ensure STAT laboratory orders were obtained and failed to document follow up assessments after the physician noted a change in condition to include a further decline in mental status, and new onset jaundice and bruising. The Executive Director (ED), Administrator in Training (AIT), Regional Director of Operations (RDCO), and Mobile Director of Nursing (Mobile DON) were notified of the Immediate Jeopardy on 10/21/21 at 5:15 p.m. The Immediate Jeopardy was removed on 10/22/21, but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Findings include: Resident J's record was reviewed on 10/19/21 at 9:13 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 10/1/21 complete blood count (CBC) and comprehensive metabolic panel (CMP) weekly times (x) 4 b On 10/7/21 CBC, and CMP c. On 10/8/21 STAT (urgent, rush, immediately) chest x-ray related to pain and bruises on the left chest wall. d. On 10/8/21 STAT laboratory orders for a CBC, CMP, prothrombin (PT), partial thromboplastin time (PTT) related to jaundice. Vital Sign documentation for Resident J indicated, a. On 10/8/21 at 5:53 a.m., temperature 96.9 Fahrenheit (°F), (normal 97 F - 99 F), respirations 22 breaths per minute (normal 12 - 16), and oxygen saturations 96% on room air per Licensed Practical Nurse (LPN) 19. b. On 10/8/21 at 9:40 a.m., blood pressure 105/66 per LPN 19. c. On 10/8/21 at 11:16 a.m., temperature 97.2 °F, respirations 18 breaths per minute, and oxygen saturations 94% on room air per LPN 19. d. The resident record lacked documentation vital signs were monitored after 11:16 a.m. on 10/8/21. American Health Associates Laboratory report, dated 10/7/21, indicated unable to obtain specimens. On the first attempt the phlebotomist was unable to obtain and adequate sample for testing. A second phlebotomist will be sent. The resident record lacked documentation on 10/7/21 that a 2nd attempt was made to obtain a sample related to the orders. The resident record lacked documentation on 10/8/21 that STAT lab orders were drawn. A late Skilled Documentation Assessment, dated 10/7/21 at 11:09 a.m. and created on 10/8/21 at 6:16 a.m. by Licensed Practical Nurse (LPN) 25, indicated no documentation of vital signs, resident denied pain, alert and within normal limits for mental status, mood and affect. Speech was clear. Lung sound was clear to auscultation bilateral. Abdomen was soft and non-tender with positive bowel sounds. Skin color and condition was within normal limits (WNL). The option for jaundice was not checked. Functional status was maintaining base line. No labs were obtained in the past or diagnostic tests in the past 24 hours. Resident wound, and [CONDITION(S)] were not selected when given an option. No abnormal findings. Skilled services provided included education for discharge planning. A late entry Skilled Documentation Assessment, dated 10/8/21 at 10:30 a.m. and created on 10/14/21 at 10:41 a.m. by LPN 26, indicated no documentation of vital signs, resident denied pain, was alert and within normal limits for mental status, mood and affect. Speech was clear. Lung sound was clear to auscultation bilateral. Abdomen was soft and non-tender with positive bowel sounds. Skin color and condition WNL. The option for jaundice was not checked. Functional status was maintaining base line. No labs obtained in the past or diagnostic tests in the past 24 hours. Resident wound, and [CONDITION(S)] were not selected when an option. There were no abnormal findings. Skilled services provided included management and evaluation of care plan. A Progress Note for Resident J, dated 10/8/2021 at 9:06 a.m., indicated the resident was observed to have yellow eyes, with bruises on the left side of his chest area extending a little to his back with associated pain when touched. The resident was seen by the physician with STAT labs ordered with a chest x-ray. The resident's Tylenol and [MEDICATION(S)] (used to treat high cholesterol) was discontinued. Staff were to continue observing. A Late Physicians Progress Note for Resident J, dated 10/8/21 at 1:33 p.m., created by the physician's scribe on 10/12/21 at 1:34 p.m., indicated the patient was seen for admission history and physical. Per hospital records the patient presented to the hospital prior to admission to the facility with progressive weakness and shortness of breath. He was found to have segmental and subsegmental pulmonary embolism. New orders were given for STAT labs and a chest x-ray. The physician indicated, new onset jaundice, added LFT's [liver function tests] and [MEDICATION(S)] level. He has a history of [CONDITION(S)] but previous liver enzymes unknown. The resident record for Resident J, dated 10/8/21, lacked documentation Activity of Daily Living (ADL) services were provided after 1:15 p.m. when the entirety of the morning care was input into the system. On 10/19/21 at 10:40 a.m., the AIT indicated there was no nursing documentation in Resident J's chart to indicate the resident was being monitored throughout the day for his decline in mental status, yellow eyes, bruises on his chest and back, or if STAT labs had been completed, between 9:06 a.m. and when he was found unresponsive at 5:30 p.m. On 10/21/21 at 11:05 a.m., the laboratory manager indicated, upon review of the laboratory services submitted through the electronic lab ordering system, Resident J had no orders submitted 10/1/21 to 10/7/21. The lab manager indicated: a. On 10/4/21 on a routine laboratory (lab) day the phlebotomist was in the facility and was given orders for the resident to have a CBC and CMP weekly x 4 weeks. The blood draw was attempted one time without success, and the phlebotomist indicated she would send out another phlebotomist to get the sample. The laboratory manager indicated, after a discussion between the nurse and phlebotomist, a decision was made to reschedule the blood draw for the next routine lab day. b. On 10/7/21 on a routine lab day the phlebotomist was in the facility and was given orders for the resident to have a CBC and CMP. The blood draw was attempted one time without success, and the nurse requested another phlebotomist come the same day and get the sample. The 2nd phlebotomist did not come to the facility. c. On 10/8/21 at 8:45 a.m., an order from the facility for STAT labs was put into the electronic lab ordering system. The dispatcher saw the STAT order, in addition to the routine orders on 10/1/21 and 10/7/21 and thought they were duplicate orders. The STAT orders were then canceled in error by the dispatcher, and the routine orders not completed as it was not a routine service day. The laboratory manager indicated, the dispatcher should have canceled the routine orders, not the STAT orders. During an interview on 10/19/21 at 11:00 a.m., LPN 10 indicated Resident J's medical record lacked documentation on 10/8/21 to indicate the resident's vital signs or change in condition were monitored after the Nurse Practitioner (NP) visit. LPN 10 indicated he could not answer as to why there was no documentation to indicate the resident was being monitored after STAT labs orders were obtained in the morning for a change in condition. On 10/20/21 at 2:16 p.m., the Mobile DON indicated lab personnel told the facility they were unable to get a specimen on 10/7/21. The Mobile DON indicated she was unsure why. There was a call out to see if staff could get reasoning why the blood was not drawn on 10/7/21. She had no comment regarding completion of STAT lab orders for 10/8/21. On 10/21/21 at 9:49 a.m., the NP indicated she had seen Resident J on 3 separate occasions the week he was admitted before his death. On 10/1/21 the NP saw the resident for an initial admission assessment as he was newly admitted from the hospital on 9/30/21. The resident was alert and oriented, sitting up in bed, and talkative. The visit addressed the resident having [CONDITION(S)] in the lower extremities, a sacral wound, and generalized pain. Labs ordered were given to do a CMP and CBC weekly x 4. The NP indicated she never received the results. On 10/5/21 the NP saw resident for continued follow up of his chronic pain and opioid medication management. On 10/6/21 the NP was asked by the Occupational Therapist (OT) to see the resident related to altered mental status (AMS). The resident was laying down in bed, alert, and verbalized he was aware he was confused, and did not feel like himself. The NP indicated she again gave lab orders for a CBC, and CMP. She documented in her note on the resident's chart she would get a urinary analysis with culture and sensitivity (US C&S) but did not specify that in her orders. The NP indicated she never received the results for those lab orders. On 10/8/21 the physician saw Resident J in the morning between 8:00 a.m. and 9 a.m. to complete a History and Physical (H&P). The physician ordered STAT labs to include a CBC, CMP, [MEDICATION(S)] level and chest x-ray related to a worsening AMS, new onset of jaundice and bruising, the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/8/21 the NP arrived at the facility after 9:00 a.m., was told the resident had already been seen that morning by the MD between 8:00 and 9:00 a.m., and given STAT orders, so she did not go see him. On 10/21/21 at 10:00 a.m., the NP indicated Resident J was admitted to the facility post hospitalization after being on blood thinners for PE's but had not presented with the bruising on the initial visits per the NP. Hospital documentation prior to facility admission indicated Resident J had a procedure in the hospital and had been on intravenous (IV) blood thinners. The procedure was called inferior vena cava (IVC) filter placement (looks like a wire umbrella with netting meant to catch blood clots) where a catheter was run up the femoral artery from the groin to the top of the heart and a little rounded plug with mesh net meant to catch blood clot and prevent them from entering the heart was placed in the vessel. Concerns post procedure would be bleeding in the groin, monitoring of back and abdomen for rigidity, and bruising and tenderness that would indicate internal bleeding. The resident denied falling, and without further information she would assume the bruising on Resident J's side and back were internal bleeding. If the labs had been completed as ordered, the physician and NP could have determined if the resident was critical and could have sent him to the hospital as needed. AMS did not determine that a resident needed hospitalization . But abnormal critical lab values with AMS would have been a reason to hospitalize the resident for closer monitoring on a critical unit, where continued labs could have been drawn. In her medical opinion if she could have had those labs results, and if those labs were critical, she would have sent him to the hospital for critical care, and possibly prevented his death. On 10/21/21 at 10:15 a.m., the NP indicated after rounding and seeing residents, she would discuss her visit with the nurse if available and the nurse would write the orders and contact the labs. If the nurse was not at the desk, the NP would leave written orders on the nurse computer keyboard for her viewing. Physician or NP notes were dictated, and a scribe would input the notes into the residents in 1 to 2 weeks depending on when the scribe had time to process them. The scribe had documented in the NP notes that the resident had refused the labs, but that was a mistake. The lab phlebotomist came on 10/4 and 10/7 and had documented she was unable to get enough blood for a sample and would send another phlebotomist to obtain. When reviewing the laboratory electronic records, she could not see 10/8/21 STAT labs. On 10/21/21 at 11:05 a.m., the laboratory manager indicated the lab was scheduled to come into the facility routinely two days a week. When the phlebotomist shows up, he/she would draw any labs needed or requested by the facility staff. Staff in the facility could add labs to the electronic system at any time. If a lab was documented as a routine order, the lab personnel could not see the orders and would get a list when they arrive at the facility. If the nurse input the order as a STAT lab, then the order would show up at the lab on the electronic system. STAT draws were generally completed in a 4-5 hour turnaround time. It was preferred the phlebotomist get the blood within 2 hours to allow for processing. On routine labs i.e., PT/INR the facility could expect results before 3:00 p.m., basic chemistry and hematology results on the same day, and any other lab results could be expected within 24 hrs. The laboratory manager indicated when a blood draw was unsuccessful, a discussion was had with the nurse and a decision was made to either reschedule or plan to try on the next routine lab day. On 10/21/21 at 11:14 a.m., the RDCO indicated labs from 10/8/21 were put into the facility electronic documentation system. On 10/21/21 at 12:25 p.m., the RDCO indicated the facility had no policy for completion of STAT labs. On 10/21/21 at 2:57 p.m., Registered Nurse (RN) 8 indicated if she received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It the lab was written as STAT the lab could see the order. The night shift nurse would print out a list for the phlebotomist on the routine lab days. RN 8 indicated if she had ordered a STAT lab, and the draw was not done on her shift, she would pass on the information to the next shift. She indicated she had no idea on the expected turn around time for a STAT lab. The contracted laboratory was ultimately responsible for assuring resident lab orders were completed. On 10/21/21 at 3:13 p.m., RN 19 indicated when getting a lab order from the physician, she would ask if the blood draw was a routine or STAT order. If routine the order was put into the electronic lab system for the next lab day. If a STAT order put into the system, the phlebotomist was expected to come that same day. STAT orders should be done within 2 hours, but in that facility, sometimes the lab did not come until the end of the shift. If STAT lab were done within a few hours or on her shift, she would call the lab to see why not. On 10/21/21 at 3:23 p.m., Licensed Practical Nurse (LPN) 25 indicated, if a resident received orders for new labs, she would put the orders into the resident's electronic medical record, the labs electronic medical system, and notify the family. When the phlebotomist came to the facility, he/she was given a lab requisition. After the blood draw was completed, the staff waited for the results then notified the physician, resident, and family. STAT lab orders were called to the lab, the nurse would be given a confirmation number, and the lab determines when they were coming. If the phlebotomist did not come within 2-4 hours she would call and ask where they were. If STAT labs were not drawn on her shift, she would pass along the information to the next shift. LPN 25 indicated nurses should document in the progress notes when the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was the responsibility of the nurse to assure labs orders were completed, but she could not control the lab or when they arrived to draw. On 10/21/21 at 3:32 p.m., LPN 32 indicated if she receives new lab order from the physician, she would enter the orders into the resident's electronic medical record, and the labs electronic system. The order was filed in the resident's hard chart, and she would notify the resident and family of the new orders. If the lab draw was a STAT order, it was supposed to be done within 4 hours, if not she would call the lab to see why it hadn't been done. If not completed on her shift, she would pass along the information to the next shift. If the phlebotomist was not coming for some reason, she would notify the physician and document the information in the resident's progress notes. On 10/22/21 at 3:50 p.m., the Mobile DON indicated there was no policy for monitoring of documentation related to a resident change in condition. Nurses were trained upon hire orientation on how to enter new laboratory orders into the laboratory provider electronic data base, then there was no further training related to processing or tracking of laboratory orders during the time of employment. A Quality Concern/Performance Improvement Report from the contracted laboratory, dated 10/22/21, indicated, orders for CMP and CBC were submitted to the laboratory on 10/4, 10/7, and 10/8 for Resident J. The phlebotomist was unsuccessful in her attempts to obtain blood from the resident on 10/4 and 10/7. On 10/8 the routine a.m. orders for Resident J, and the STAT orders specifying the same resident were interpreted by the phlebotomist team lead as duplicates. The STAT venipuncture was deferred to the phlebotomist in the faciilty performing the morning blood draws; that phlebotomist however did not attempt to obtain a blood specimen due to her unsuccessful attempts on 10/4 and 10/7. Lab tests for Resident J on 10/4, 10//7, and 10/8 were not completed as ordered. On 10/20/21 at 3:59 p.m., the AIT provided a Laboratory and Radiology Services and Results Reporting policy, dated 3/22/19, and indicated the policy was the one currently being used by the facility. The policy indicated, The facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside source. There are clinical and physiological risks when laboratory, radiology, or other diagnostic services are performed in a timely manner, or the results of these services are not reported or acted upon quickly. Delays may adversely affect a resident's diagnosis, treatment, assessment, and interventions . b. The facility assumes responsibility for the timeliness and quality of the laboratory and radiological services chosen and will make changes as needed to secure services On 10/21/21 at 4:35 p.m., the Mobile DON proved a Clinical Documentation Standards policy, dated 8/31/18, and indicated the policy was the one currently being used by the facility. The policy indicated, .A complete record contains an accurate and functional representation of actual experience of the resident and must contain enough information to show that the status of the individual is known, and a plan of care has been identified to meet the care needs identified in the medical record .The primary purpose of the medical record[s] is to provide continuity of care. i. Other reasons also include: 1. Clinical evidence of care and treatment records as evidence of care .iii. Document entries during the work shift and complete all entries before leaving the facility for that tour/shift. iv. Document the status of the resident including changes The immediate jeopardy that began on 10/8/21 was removed on 10/22/21 when the facility completed audits of laboratory orders for all resident with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The laboratory provider electronic data base was reconciled with the facility electronic resident medical records, discrepancies identified, and the medical director notified. An audit was completed of all residents identified as having a change in condition in the prior 30 days to validate follow up assessments and documentation was completed. Staff education was provided to licensed nursing staff regarding ordering of resident laboratory orders, tracking of laboratory results, follow up when laboratory orders were not completed, and documentation required. Staff education provided to all direct care staff on how to identify resident change in condition, notification regarding change in condition, and documentation requirements. The noncompliance remained at the lower scope and severity level of 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 028. 3.1-37(a)

Based on interview and record review, the facility failed to have a system in place for ordering, obtaining, and tracking of routine and STAT (urgent, rush, immediate) laboratory orders for 1 of 3 residents reviewed for completion of laboratory orders (Resident J). The Immediate Jeopardy began October 1, 2021, when the facility failed to ensure routine laboratory orders were completed on 10/1/21 and 10/6/21, and STAT laboratory orders were completed on 10/8/21 after a physician noted a change in condition to include a further decline in mental status, and new onset jaundice and bruising. The Executive Director (ED), Administrator in Training (AIT), Regional Director of Operations (RDCO), and Mobile Director of Nursing (Mobile DON) were notified of the Immediate Jeopardy on 10/21/21 at 5:11 p.m. The Immediate Jeopardy was removed on 10/22/21, but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Findings include: Resident J's record was reviewed on 10/19/21 at 9:13 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 10/1/21 complete blood count (CBC) and comprehensive metabolic panel (CMP) weekly times (x) 4 b On 10/7/21 CBC, and CMP c. On 10/8/21 STAT (urgent, rush, immediately) chest x-ray related to pain and bruises on the left chest wall. d. On 10/8/21 STAT laboratory orders for a CBC, CMP, prothrombin (PT), partial thromboplastin time (PTT) related to jaundice. American Health Associates Laboratory report, dated 10/7/21, indicated unable to obtain specimens. On the first attempt the phlebotomist was unable to obtain and adequate sample for testing. A second phlebotomist will be sent. The resident record lacked documentation on 10/7/21 that a 2nd attempt was made to obtain a sample related to the orders. The resident record lacked documentation on 10/8/21 that STAT lab orders were drawn. A Progress Note for Resident J, dated 10/8/2021 at 9:06 a.m., indicated the resident was observed to have yellow eyes, with bruises on the left side of his chest area extending a little to his back with associated pain when touched. The resident was seen by the physician with STAT labs ordered with a chest x-ray. The resident's Tylenol and [MEDICATION(S)] (used to treat high cholesterol) was discontinued. Staff to continue observing. A Late Physicians Progress Note for Resident J, dated 10/8/21 at 1:33 p.m., created by the physician's scribe on 10/12/21 at 1:34 p.m., indicated the patient was seen for admission history and physical. Per hospital records the patient presented to the hospital prior to admission to the facility with progressive weakness and shortness of breath. He was found to have segmental and subsegmental pulmonary embolism. New orders were given for STAT labs and a chest x-ray. The physician indicated, new onset jaundice, added LFT's [liver function tests] and [MEDICATION(S)] level. He has a history of [CONDITION(S)] but previous liver enzymes unknown. On 10/21/21 at 11:05 a.m., the laboratory manager indicated, upon review of the laboratory services submitted through the electronic lab ordering system, Resident J had no orders submitted 10/1/21 to 10/7/21. The lab manager indicated: a. On 10/4/21 on a routine laboratory (lab) day the phlebotomist was in the facility and was given orders for the resident to have a CBC and CMP weekly x 4 weeks. The blood draw was attempted one time without success, and the phlebotomist indicated she would send out another phlebotomist to get the sample. The laboratory manager indicated, after a discussion between the nurse and phlebotomist, a decision was made to reschedule the blood draw for the next routine lab day. b. On 10/7/21 on a routine lab day the phlebotomist was in the facility and was given orders for the resident to have a CBC and CMP. The blood draw was attempted one time without success, and the nurse requested another phlebotomist come the same day and get the sample. The 2nd phlebotomist did not come to the facility. c. On 10/8/21 at 8:45 a.m., an order from the facility for STAT labs was put into the electronic lab ordering system. The dispatcher saw the STAT order, in addition to the routine orders on 10/1/21 and 10/7/21 and thought they were duplicate orders. The STAT orders were then canceled in error by the dispatcher, and the routine orders not completed as it was not a routine service day. The laboratory manager indicated, the dispatcher should have canceled the routine orders, not the STAT orders. On 10/20/21 at 2:16 p.m., the Mobile DON indicated lab personnel told the facility they were unable to get a specimen on 10/7/21. The Mobile DON indicated she was unsure why. There was a call out to see if staff could get reasoning why the blood was not drawn on 10/7/21. She had no comment regarding completion of STAT lab orders for 10/8/21. On 10/21/21 at 9:49 a.m., the NP indicated she had seen Resident J on 3 separate occasions the week he was admitted before his death. On 10/1/21 the NP saw the resident for an initial admission assessment as he was newly admitted from the hospital on 9/30/21. The resident was alert and oriented, sitting up in bed, and talkative. The visit addressed the resident having [CONDITION(S)] in the lower extremities, a sacral wound, and generalized pain. Labs ordered were given to do a CMP and CBC weekly x 4. The NP indicated she never received the results. On 10/5/21 the NP saw resident for continued follow up of his chronic pain and opioid medication management. On 10/6/21 the NP was asked by the Occupational Therapist (OT) to see the resident related to altered mental status (AMS). The resident was laying down in bed, alert, and verbalized he was aware he was confused, and did not feel like himself. The NP indicated she again gave lab orders for a CBC, and CMP. She documented in her note on the resident's chart she would get a urinary analysis with culture and sensitivity (US C&S) but did not specify that in her orders. The NP indicated she never received the results for those lab orders. On 10/8/21 the physician saw Resident J in the morning between 8:00 a.m. and 9 a.m. to complete a History and Physical (H&P). The physician ordered STAT labs to include a CBC, CMP, [MEDICATION(S)] level and chest x-ray related to a worsening AMS, new onset of jaundice and bruising, the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/8/21 the NP arrived at the facility after 9:00 a.m., was told the resident had already been seen that morning by the MD between 8:00 and 9:00 a.m., and given STAT orders, so she did not go see him. On 10/21/21 at 10:00 a.m., the NP indicated Resident J was admitted to the facility post hospitalization after being on blood thinners for PE's but had not presented with the bruising on the initial visits per the NP. Hospital documentation prior to facility admission indicated Resident J had a procedure in the hospital and had been on intravenous (IV) blood thinners. The procedure was called inferior vena cava (IVC) filter placement (looks like a wire umbrella with netting meant to catch blood clots) where a catheter was run up the femoral artery from the groin to the top of the heart and a little rounded plug with mesh net meant to catch blood clot and prevent them from entering the heart was placed in the vessel. Concerns post procedure would be bleeding in the groin, monitoring of back and abdomen for rigidity, and bruising and tenderness that would indicate internal bleeding. The resident denied falling, and without further information she would assume the bruising on Resident J's side and back were internal bleeding. If the labs had been completed as ordered, the physician and NP could have determined if the resident was critical and could have sent him to the hospital as needed. AMS did not determine that a resident needed hospitalization . But abnormal critical lab values with AMS would have been a reason to hospitalize the resident for closer monitoring on a critical unit, where continued labs could have been drawn. In her medical opinion if she could have had those labs results, and if those labs were critical, she would have sent him to the hospital for critical care, and possibly prevented his death. On 10/21/21 at 10:15 a.m., the NP indicated after rounding and seeing residents, she would discuss her visit with the nurse if available and the nurse would write the orders and contact the labs. If the nurse was not at the desk, the NP would leave written orders on the nurse computer keyboard for her viewing. Physician or NP notes were dictated, and a scribe would input the notes into the residents in 1 to 2 weeks depending on when the scribe had time to process them. The scribe had documented in the NP notes that the resident had refused the labs, but that was a mistake. The lab phlebotomist came on 10/4 and 10/7 and had documented she was unable to get enough blood for a sample and would send another phlebotomist to obtain. When reviewing the laboratory electronic records, she could not see 10/8/21 STAT labs. On 10/21/21 at 11:05 a.m., the laboratory manager indicated the lab was scheduled to come into the facility routinely two days a week. When the phlebotomist shows up, he/she would draw any labs needed or requested by the facility staff. Staff in the facility could add labs to the electronic system at any time. If a lab was documented as a routine order, the lab personnel could not see the orders and would get a list when they arrive at the facility. If the nurse input the order as a STAT lab, then the order would show up at the lab on the electronic system. STAT draws were generally completed in a 4-5 hour turnaround time. It was preferred the phlebotomist get the blood within 2 hours to allow for processing. On routine labs i.e., PT/INR the facility could expect results before 3:00 p.m., basic chemistry and hematology results on the same day, and any other lab results could be expected within 24 hrs. The laboratory manager indicated when a blood draw was unsuccessful, a discussion was had with the nurse and a decision was made to either reschedule or plan to try on the next routine lab day. On 10/21/21 at 11:14 a.m., the RDCO indicated labs from 10/8/21 were put into the facility electronic documentation system. On 10/21/21 at 12:25 p.m., the RDCO indicated the facility had no policy for completion of STAT labs. On 10/21/21 at 2:57 p.m., Registered Nurse (RN) 8 indicated if she received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the lab was written as STAT, the lab could see the order. The night shift nurse would print out a list for the phlebotomist on the routine lab days. RN 8 indicated if she had ordered a STAT lab, and the draw was not done on her shift, she would pass on the information to the next shift. She had no idea on the expected turnaround time for a STAT lab. The contracted laboratory was ultimately responsible for assuring resident lab orders were completed. On 10/21/21 at 3:13 p.m., RN 19 indicated when getting a lab order from the physician, she would ask if the blood draw was a routine or STAT order. If routine the order was put into the electronic lab system for the next lab day. If a STAT order put into the system, the phlebotomist was expected to come that same day. STAT orders should be done within 2 hours, but in that facility sometimes the lab did not come until the end of the shift. If STAT lab were done within a few hours or on her shift, she would call the lab to see why not. On 10/21/21 at 3:23 p.m., Licensed Practical Nurse (LPN) 25 indicated if a resident received orders for new labs, she would put the orders into the resident's electronic medical record, the labs electronic medical system, and notify the family. When the phlebotomist came to the facility, he/she was given a lab requisition. After the blood draw was completed, the staff waited for the results then notified the physician, resident, and family. STAT lab orders were called to the lab, the nurse would be given a confirmation number, and the lab determines when they were coming. If the phlebotomist did not come within 2-4 hours she would call and ask where they were. If STAT labs were not drawn on her shift, she would pass along the information to the next shift. LPN 25 indicated nurses should document in the progress notes when the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It was the responsibility of the nurse to assure labs orders were completed, but she could not control the lab or when they arrived to draw. On 10/21/21 at 3:32 p.m., LPN 32 indicated if she receives new lab order from the physician, she would enter the orders into the resident's electronic medical record, and the labs electronic system. The order was filed in the resident's hard chart, and she would notify the resident and family of the new orders. If the lab draw was a STAT order, it was supposed to be done within 4 hours, if not she would call the lab to see why it hadn't been done. If not completed on her shift, she would pass along the information to the next shift. If the phlebotomist was not coming for some reason, she would notify the physician and document the information in the resident's progress notes. On 10/22/21 at 3:50 p.m., the Mobile DON indicated there was no policy for monitoring of documentation related to a resident change in condition. Nurses were trained upon hire orientation on how to enter new laboratory orders into the laboratory provider electronic data base, then there was no further training related to processing or tracking of laboratory orders during the time of employment. A Quality Concern/Performance Improvement Report from the contracted laboratory, dated 10/22/21, indicated orders for CMP and CBC were submitted to the laboratory on 10/4, 10/7, and 10/8 for Resident J. The phlebotomist was unsuccessful in her attempts to obtain blood from the resident on 10/4 and 10/7. On 10/8 the routine a.m. orders for Resident J, and the STAT orders specifying the same resident were interpreted by the phlebotomist team lead as duplicates. The STAT venipuncture was deferred to the phlebotomist in the facility performing the morning blood draws; that phlebotomist however did not attempt to obtain a blood specimen due to her unsuccessful attempts on 10/4 and 10/7. Lab tests for Resident J on 10/4, 10//7, and 10/8 were not completed as ordered. On 10/20/21 at 3:59 p.m., the AIT provided a Laboratory and Radiology Services and Results Reporting policy, dated 3/22/19, and indicated the policy was the one currently being used by the facility. The policy indicated, The facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside source. There are clinical and physiological risks when laboratory, radiology, or other diagnostic services are performed in a timely manner, or the results of these services are not reported or acted upon quickly. Delays may adversely affect a resident's diagnosis, treatment, assessment, and interventions . b. The facility assumes responsibility for the timeliness and quality of the laboratory and radiological services chosen and will make changes as needed to secure services The immediate jeopardy that began on 10/1/21 was removed on 10/22/21 when the facility completed audits of laboratory orders for all resident received in the prior 30 days. The laboratory provider electronic data base was reconciled with the facility electronic resident medical records, discrepancies identified, and the medical director notified. Staff education was provided to licensed nursing staff regarding ordering of resident laboratory orders, tracking of laboratory results, follow up when laboratory orders were not completed, and documentation required. The noncompliance remained at the lower scope and severity level of 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 028. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure pain management was provided to 8 residents, (Residents, BC, CX, BG, BD, BF, AH, CR and CT) consistent with professional standards of practice to relieve their pain and honor their residents' preferences for 8 of 8 residents reviewed for pain management. The immediate jeopardy began on 8/31/21 when the Nurse Practitioner (NP) changed the 8 alert and oriented residents' narcotic pain medications. Residents BC, CX, BG, BD, BF, CR and CT were not notified prior to the change in their medication and therefore, did not have the opportunity to participate in making decisions about their medical care. Resident CR requested to go to the emergency room (ER) for increased pain, Resident CT left AMA (against medical advice) and all 6 remaining residents complained of increased pain and side effects due to the medication change. Residents BC, CX, BG and BD indicated the medication change created side effects which interrupted their daily routines and decreased their ability to participate in their activities of daily living (ADLs). The Executive Director (ED), the Administrator in Training (AIT) and the Director of Nursing (DON) were notified of the immediate jeopardy on 9/9/21 at 4:54 p.m. The immediate jeopardy was removed on 9/10/20, 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. On 9/7/21 at 3:02 p.m., Resident BC was observed during an interview. He sat in a wheelchair between his bed and the window, huddled up next to the window's PTAC (Packaged Terminal Air Conditioner, appliance used for heating and cooling indoors) unit with his arms tucked into his shirt. His head dropped and his eyes were closed. He woke to the sound of his name. Resident BC indicated his pain medication had recently been changed from a pill to a liquid and he was upset about it. He was not notified of the change, one day it was a pill, then the next day they brought a cup of liquid. He tried the liquid form of the medication, but it did not last as long, or help manage his pain level as well as the pill had. He complained about the change to his nurse. The nurse told him to talk to the NP, but the NP said she would not change it back. At this time, Resident BC's family member entered the room and indicated they were also upset about Resident BC's care because his pain was not controlled. They had both complained about his wounds and pain management, but nothing seemed to help. Resident BC indicated the liquid medication tasted horrible, did not touch his pain like the pills had and because it did not last as long, he could not do as much as he wanted to and stayed in his room more than he liked because he hurt too bad and was too cold to get out. On 9/8/21 at 9:10 a.m., Resident BC was observed during an interview. He laid in bed and indicated he was in excruciating pain. He pressed on his forehead and temples, his face was grimaced, and he winced in pain. Resident BC indicated, and the Certified Nursing Assistant (CNA) had just finished helping him get cleaned up and positioned which caused an increase in his pain because of the wound on his bottom. Please, I need pain medication, it's all I ask! At this time, the nurse was notified of his pain. Registered Nurse (RN) 18 entered Resident BC's room with his morning medications in a small plastic medication cup. He indicated he was in pain and asked if his pain pill was in the cup. RN 18 indicated no because the order had been changed to a liquid. Resident BC indicated it was nasty and did not work, he wanted his pain pill back, but he would try the liquid again. When RN 18 returned, she indicated Resident BC was out of his liquid narcotic pain medication and when Resident BC asked how that could be if he never took it? RN 18 did not know why his liquid pain medication was out, but she would go ask the NP if she could pull the medication from the EDK (Emergency Drug Kit). RN 18 asked what his pain level was on a scale of 1-10, 10 being the worst. Resident BC indicated, 1000! I don't know, it's just really bad. During an interview on 9/8/21 at 9:45 a.m., the NP indicated she found Resident BC as a challenging patient due to his many refusals of wound treatments and other various medication/supplement refusals, for instance he did not want to take a stool softener, because he preferred to manage his own bowels and ostomy care. Recently the biggest issue with Resident BC and several others, had been over the NP's decision to switch the narcotic pain medication from a pill to a liquid. She suspected Resident BC and several other residents, of misusing their narcotic medication so she devised a plan to flush out the problem. She suspected several residents of illegal substance abuse because she saw them in the parking lot with vans and had been told that some residents liked to sit outside of the facility late at night. The NP indicated she suspected a couple residents also smoked marijuana but did not have proof and had not ordered drug tests for any of the residents she suspected of illicit drug abuse. The NP came up with the idea of changing their pain medications from pill form to liquid form and brought it to the IDT (Interdisciplinary Team) for approval. The NP indicated, I figured whoever fusses with me the most about it was probably the ones selling it or profiting from it. The NP indicated she individually selected 8 residents because they were mobile enough to go outside on their own, and if it was going to be anybody, it was going to be them. The NP indicated of the 8 residents, Resident CR sent himself to the hospital for uncontrolled pain last week, Resident CT went LOA (Leave of Absence) and never came back. Resident BD had last complained on Friday, but she had not planned to see him again since he was going to discharge soon anyway. Resident BC complained about it the very first day, but she had not seen him out of his room and had not gone to see him either. Resident BC had complained the most about the change. He was considered an incomplete quad (Incomplete [CONDITION(S)] means that the injury has not completely severed your spinal cord and some neural circuits between the brain and body still exist) and did have some sensation in his lower extremities, so he probably did have some discomfort and pain due to his wound, but if he was in that much pain, he should take the liquid medication. During an interview on 9/8/21 at 10:05 a.m., RN 18 indicated she had no suspicions that Resident BC had misused his narcotic medication. He always took it as ordered, never asked for too much, and would swallow his pills with a full cup or two of water. Yes, he was non-complaint with his wound treatments a lot of the time, but he was fully alert, oriented, and aware of the consequences. RN 18 believed his pain was legitimate, and he had complained of more pain, more frequently since the change in his medication. He had been staying in his room more than usual and that was not like him. During an interview on 9/8/21 at 10:10 a.m., Licensed Practical Nurse (LPN) 8 and Assistant Director of Nursing (ADON) both indicated they had never seen Resident BC pocket his pills (a technique where a pill is tucked in an oral cavity, not swallowed, and spit out at a later time) or misuse his pain medications. They did not understand why the narcotic medication had been changed, or why it had not been changed back after he complained. He had been in more pain since the change and had not been out of his room as much. On 9/8/21 at 4:00 p.m. a record review was completed on Resident BC. He was a young male, with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive assessment was a quarterly Minimum Data Set (MDS) assessment dated [DATE]. The MDS indicated Resident BC was cognitively intact with a BIMS (brief interview for mental status) score of 15 of 15. He had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident BC's MAR (Medication Regimen Review) indicated he needed to be monitored for signs/symptoms of pain every shift. The week before his medication was changed, indicated he only complained of pain for 8 of 24 shift: 8/24: day shift= 0, evening shift= 0, night shift= 5 8/25: day shift= 0, evening shift= 0, night shift= not recorded 8/26: day shift= 10, evening shift= 1, night shift= 0 8/27: day shift= 0, evening shift= NA, night shift= 0 8/28: day shift= 0, evening shift= 0, night shift= 7 8/29: day shift= 2, evening shift= 0, night shift= 6 8/30: day shift= 2, evening shift= 0, night shift= 0 8/31: day shift= 9, evening shift= 0, night shift= 0 The week after his medication was changed, indicated he complained of pain for 15 of 27 shifts: 9/1: day shift= 0, evening shift= 0, night shift= 0 9/2: day shift= 10, evening shift= 0, night shift= 5 9/3: day shift= 5, evening shift= not recorded, night shift= 8 9/4: day shift= 8, evening shift= 5, night shift= 0 9/5: day shift= 5, evening shift= not recorded, night shift= 4 9/6: day shift= 5, evening shift= 0, night shift= 0 9/7: day shift= 0, evening shift= 0, night shift= 0 9/8: day shift= 10, evening shift= 6, night shift= 8 Resident BC had a comprehensive care plan, initiated 5/3/21 and revised 9/2/21, which indicated he had complaints of acute and chronic pain related to his pressure ulcer. Interventions for this plan of care included, but were not limited to, notifying the medical provider if interventions were unsuccessful, and to monitor for signs/symptoms of side effects and evaluate effectiveness of medications. A nursing progress note, dated 9/2/21 at 7:34 a.m., indicated Resident BC had been informed that the NP/MD (Medical Director) had the right to change medications/orders as prescribed in accordance with the facilities new POC (Plan of Correction). At any time, the provider was able to DC (discontinue) or change a medication should they saw fit. A nursing progress note dated 9/3/21 at 2:54 p.m., indicated Resident BC took his scheduled medication, but refused his pain medication. On 9/9/21 at 4:25 p.m., Resident BC's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . a. On 9/2/21 at midnight, LPN 19, charted on the narcotic sheet that Resident BC refused his oxycodone 10 mLs of pain medication. On the MAR, on the same date and time, she indicated Resident BC took his oxycodone medication 10 mLs. b. On 9/2/21 at 4:00 a.m., LPN 19, charted on the narcotic sheet that Resident BC refused his oxycodone 10 mLs. On the MAR, on the same date and time, she indicated Resident BC took his oxycodone medication 10 mLs. c. On 9/3/21 at 4:00 p.m., LPN 20 charted on the narcotic sheet that Resident BC took his oxycodone 10 mLs. On the MAR, on the same date and time, she indicated Resident BC refused his oxycodone medication 10 mLs. d. On 9/4/21 at 8:00 p.m., Temp Med Tech (TMT) 21 charted on the narcotic sheet that Resident BC took his oxycodone 10 mLs. On the MAR, on the same date and time, she indicated Resident BC refused his oxycodone 10 mLs. On 9/9/21 at 11:40 a.m., Resident BC was observed. He sat upright in his wheelchair in his bathroom as prepared his ostomy supplies. His eyes were bright, and he indicated he was feeling a lot better. He had received a pain pill the night before and it worked. On 9/9/21 at 1:36 p.m., Resident BC was observed as he returned in from sitting outside, and indicated it was the first time he had been outside in a while. 2. During an interview on 9/8/21 at 2:45 p.m., Resident CX indicated his pain medication had been changed from a pill to a liquid without notification. He indicated the liquid medicine burned his throat and did not work as well or last as long. He indicated he had an increase of pain in his hips and when he tried to talk to the NP about it, she told him everyone's medication had been changed and she would not change it back, no discussion. On 9/8/21 at 4:10 p.m. a record review was completed on Resident CX. He was a middle aged male and had current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive assessment was a quarterly MDS assessment dated [DATE]. The MDS indicated Resident BC was cognitively intact with a BIMS score of 15 of 15. He had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident CX's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The week before his pain medicine was changed, there were no recorded pain levels. The week after his medication was changed, indicated he complained of pain for 10 of 21 shifts: 9/1: day shift= not recorded, evening shift= not recorded, night shift= not recorded 9/2: day shift= not recorded, evening shift= 0, night shift= 6 9/3: day shift= 0, evening shift= 7, night shift= 6 9/4: day shift= 6, evening shift= 0, night shift= 6 9/5: day shift= 6, evening shift= 3, night shift= 0 9/6: day shift= 0, evening shift= 0, night shift= 0 9/7: day shift= 3, evening shift= 8, night shift= 1 A vital sign report graph for pain level indicated, after 8/31/21 Resident CX reported pain increased to a level 8 out of 10 on 9/5, 9/6, 9/7 and 9/8. Resident CX had a comprehensive care plan, initiated 6/15/21 and revised 9/2/21, which indicated he had complaints of lower back and left femur pain. Interventions for this plan of care included, but were not limited to, notifying the medical provider if interventions were unsuccessful, and to monitor for signs/symptoms of side effects and evaluate effectiveness of medications. A nursing progress note, dated 9/2/21 at 7:00 a.m., indicated Resident CX had been informed that the NP/MD had the right to change medications/orders as prescribed in accordance with the facilities new POC. At any time, the provider was able to DC or change a medication should they saw fit. A nursing progress note, dated 9/4/21 at 3:16 p.m., indicated Resident CX was alert, oriented and able to make his needs known. He complained of pain and discomfort in his back. On 9/8/21 at 3:58 p.m., Resident CX's [MEDICATION(S)] apap (for severe pain relief) 7.5-325 mg bottle was observed with LPN 22 for the quantity inside. It was 53 mL. The order indicated give 15 mL by mouth every 6 hours as needed (PRN) for pain. The narcotic sheet was observed to be inaccurate indicating 38 mL in the bottle. On 9/9/21 at 4:20 p.m., the Director of Nursing (DON) provided updated copy of Resident CX's narcotic sheet. After the quantity was identified as 38 mL on 9/8/21 at 3:58 p.m., the distribution of the remaining medication was as follows: a. On 9/8/21 at 1636 (4:36 p.m.), 15 mL were provided for the resident, with 23 mL remaining in the bottle. b. On 9/8/21 at 2145 (9:46 p.m.), 15 mL were provided for the resident with 8 mL remaining. These doses were not 6 hours apart. c. On 9/9/21 at midnight, an illegible name indicated the correct count remaining in the bottle was 20 mL. d. On 9/9/21 at 0630 (6:30 a.m.), 15 mL were given, leaving 5 mL in the bottle. e. On 9/9/21 at 7:00 a.m., an illegible name indicated the count was correct again with 10 mLs still in the bottle. f. On 9/9/21 at 11:21 a.m., 10 mL were given, leaving 0 mL in the bottle. On 9/10/21 at 11:41 a.m., Resident CX's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 9/1/21 at 6:00 a.m., LPN 23 charted on the narcotic sheet that Resident CX took his PRN oxycodone 15 mL. This dose was not charted on the MAR. b. On 9/2/21 at 12:30 a.m., LPN charted on the narcotic sheet that Resident CX took his PRN oxycodone 15 mL. This dose was not charted on the MAR. c. On 9/2/21 at 12:00 p.m., the Assistant Director of Nursing (ADON) charted on the narcotic sheet that Resident CX took his PRN oxycodone 15 mL. This dose was not charted on the MAR. d. On 9/5/21 at 8:00 p.m., LPN 7 charted on the narcotic sheet that Resident CX took his PRN oxycodone 15 mL. This dose was not charted on the MAR. e. On 9/7/21 at 2:40 a.m., LPN 23 charted on the narcotic sheet that Resident CX took his PRN oxycodone 15 mL. This dose was not charted on the MAR. f. On 9/7/21 at 11:00 p.m., LPN 10 charted on the narcotic sheet that Resident CX took his PRN oxycodone 15 mL. This dose was not charted on the MAR. g. On 9/8/21 at 6:30 a.m., LPN 23 charted on the narcotic sheet that Resident CX took his PRN oxycodone 15 mL. This dose was not charted on the MAR. On 9/9/21 at 4:30 p.m., the AIT indicated the narcotic charting should have been accurate and all narcotic medication should have been accounted for in the charting. 3. During an interview on 9/8/21 at 12:46 p.m., Resident BG indicated her pain medication had been changed from a pill to a liquid without notification. She indicated it did not work and that was why she was still laying in her bed. She indicated she was in pain at that time and did not know if she wanted to get out of bed. The liquid medicine gave her the jerks. The NP never came to tell her the medicine was going to be changed or why, it was just changed. When she complained about it and the NP came to talk to her about and explained she would not change it back to pills, that she switched everyone over to the liquid. She told the NP it did not work as well, but the NP declined to change it back. Resident BG indicated she did not get up as much and did not sit outside like she wanted to. On 9/8/21 at 2:50 p.m., Resident BG was observed in her wheelchair in the hallway. She was stopped and rested her head in her hands with her eyes closed. At this time, she indicated, she left therapy early because her pain broke through and she needed to go ask the nurse for more medicine. On 9/8/21 at 4:15 p.m. a record review was completed on Resident BG. She was a middle aged female and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive assessment was a quarterly MDS assessment dated [DATE]. The MDS indicated Resident BG was cognitively intact with a BIMS score of 15 of 15. She had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident BG's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The week before his pain medicine was changed, there were no recorded pain levels. The week after her medication was changed, indicated she complained of pain for 9 of 21 shifts: 9/1: day shift= not recorded, evening shift= not recorded, night shift= not recorded 9/2: day shift= 6, evening shift= 0, night shift= 5 9/3: day shift= 0, evening shift= 0, night shift= 2 9/4: day shift= 0, evening shift= 0, night shift= 8 9/5: day shift= 8, evening shift= 4, night shift= 0 9/6: day shift= 0, evening shift= 0, night shift= 7 9/7: day shift= 0, evening shift= 0, night shift= 1 Resident BG had a comprehensive care plan, initiated 4/12/21 and revised 9/2/21, which indicated she had acute pain. Interventions for this plan of care included but were not limited to evaluate pain and vital signs. A nursing progress note, dated 9/2/21 at 7:40 a.m., indicated Resident BG had been informed that the NP/MD had the right to change medications/orders as prescribed in accordance with the facilities new POC. At any time, the provider was able to DC or change a medication should they saw fit. A nursing progress note, dated 9/8/21 at 1:40 p.m., indicated Resident BG stated she had pain but refused her narcotic [MEDICATION(S)] (liquid medication). Resident BG requested the pill form. 4. During an interview on 9/8/21 at 11:33 a.m., Resident BD indicated he had a complaint that one of his pain medications had been switched from a pill to a liquid. He was not notified that the medication was going to be changed, and when he tried the new form of medicine it bothered his stomach and messed up his [CONDITION(S)] output, which caused him to be in the bathroom having to clean and adjust it more than usual. He did not know why his medicine was changed, but since it had been changed, he had an increase in his pain and at that time had pain on a scale of 8 out of 10. He indicated he did not want his pills crushed and did not want to be given medicine in a cup like a child. On 9/8/21 at 4:20 p.m. a record review was completed on Resident BD. He was a younger male and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive assessment was an admission MDS assessment dated [DATE]. The MDS indicated Resident BD was cognitively intact with a BIMS score of 15 of 15. He had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a vitals sign report graph indicated Resident BD had an increase of intensity of pain in the week following his medication change. The highest level of pain recorded for the week before the change in his medicine was 8/24/21 on the day shift at a level of 8 out of 10. After the medication was changed his pain increased to a 10 out of 10 on 9/7/21. Resident BD had a comprehensive care plan, initiated 6/17/21 and revised 9/2/21, which indicated he had complaints of acute/chronic pain related to his wound and general discomfort. Interventions for this plan of care included, but were not limited to, notifying the medical provider if interventions were unsuccessful, and to monitor for signs/symptoms of side effects and evaluate effectiveness of medications. A nursing progress note dated 9/2/21 at 7:34 a.m., indicated Resident BD had been informed that the NP/MD had the right to change medications/orders as prescribed in accordance with the facilities new POC. At any time, the provider was able to DC or change a medication should they saw fit. 5. On 9/8/21 at 12:33 p.m., Resident BF was observed during an interview. He laid in his bed with the lights off and indicated he was in pain which was why he did not get up much. He indicated he had not been told that they were going to change his medication from a pill to a liquid, but he had been in too much pain to care so he just accepted it. He had current pain on a scale of 7 out of 10. On 9/8/21 at 4:25 p.m. a record review was completed on Resident BF. He was a young male and had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive assessment was a 5-day MDS assessment dated [DATE]. The MDS indicated Resident BD was cognitively intact with a BIMS score of 15 of 15. He had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident BF had a comprehensive care plan, initiated 9/2/21 and revised 9/2/21 which indicated he had complaints of acute/chronic pain. Interventions for this plan of care included, but were not limited to, notifying the medical provider if interventions were unsuccessful, and to monitor for signs/symptoms of side effects and evaluate effectiveness of medications. A nursing progress note, dated 9/2/21 at 7:05 a.m., indicated Resident BF had been informed that the NP/MD had the right to change medications/orders as prescribed in accordance with the facilities new POC. At any time, the provider was able to DC or change a medication should they saw fit. 6. During an interview on 9/8/21 at 2:55 p.m., CNA 30 indicated she had worked with Resident AH since the medication change. Apart from complaints about food, he complained mostly about the medication switch and so did several other residents. During an interview on 9/8/21 at 2:58 p.m., Resident AH was observed. He laid on his side in his bed and indicated he was in pain. Resident AH's medication had been switched from a pill to a liquid, and the NP had come to talk to him about it before the switch. She assured him it was the same strength and would have the same effect for his pain, so he agreed. After trying the liquid medication however, he found that it did not work as well, and he experienced breakthrough pain. When he complained to the NP about the new medication, she indicated she would not change the order back, but that he could try to take Tylenol with it to help. He indicated his pain was in his back and legs on a scale of 7 out of 10 at that time. During an interview on 9/8/21 at 3:00 p.m., LPN 15 indicated he was aware that Resident AH did not like the new pain medication, but he had agreed to try Tylenol with his next dose to see if that helped more. At this time LPN 15 indicated Resident BD had also complained to him and the wound NP about the medication switch during wound round earlier in the week, but LPN told him, Sorry, wrong NP, and referred him to the prescriber NP. On 9/8/21 at 4:30 p.m. a record review was completed on Resident AH. He was a [AGE] year old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent comprehensive assessment was a quarterly MDS assessment dated [DATE]. The MDS indicated Resident BD was cognitively intact with a BIMS score of 14 of 15. He had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident AH had a comprehensive care plan initiated 2/22/21, revised 9/2/21 which indicated he had chronic lower pain and reported episodes of pain radiating down his legs. Interventions for this plan of care included, but were not limited to, notifying the medical provider if interventions were unsuccessful, and to monitor for signs/symptoms of side effects and evaluate effectiveness of medications. 7. On 8/9/21 at 4:35 p.m., a closed record review was completed for Resident CR. He was a younger male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated 9/2/21 at 10:15 a.m., indicated Resident CR had a change in condition related to uncontrolled pain. He had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note, dated 9/2/21 at 7:02 a.m., indicated Resident BF had been informed that the NP/MD had the right to change medications/orders as prescribed in accordance with the facilities new POC. At any time, the provider was able to DC or change a medication should they saw fit. A nursing progress note dated 9/2/21 at 10:18 a.m., indicated Resident CR complained of stomach pain and pain all over and requested to be sent to the ER. A hospital summary report, dated 9/2/21 at 12:19 p.m. indicated Resident CR presented to the ER with a chief complaint of tailbone pain related to a Stage IV pressure ulcer. The report indicated, Resident CR is a [AGE] year old male who presents to the emergency department for evaluation of tailbone pain. Patient with a history of gunshot wound, has residual chronic [CONDITION(S)] in sacral decubitus ulcers. For the past 2-3 days has had increasing pain, drainage noted from these area. Noticed the drainage is green, intermittent . Patient is also concerned regarding his recent care at his subacute rehab facility. States he does not feel they care caring adequately for his chronic wounds . Patient requesting alternative facility placement. 8. O 8/9/21 at 4:40 p.m., a closed record review, was completed for Resident CT. He was a [AGE] year old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 9/2/21 at 7:05 a.m., indicated Resident CT had been informed that the NP/MD had the right to change medications/orders as prescribed in accordance with the facilities new POC. At any time, the provider was able to DC or change a medication should they saw fit. A nursing progress note dated 9/5/21 at 12:50 a.m., indicated Resident CT was not in his room during midnight checks. He was thought to be LOA (leave of absence) and his listed contact phone number was called. Someone else answered the phone and stated the resident was not with them and would not return to the facility because he had moved out of state. On 9/8/21 at 10:40 a.m., an interview was conducted with the Executive Director (ED), the Administrator in Training (AIT), the Director of Nursing (DON), the Regional Director of Clinical Operations. The AIT indicated she had been made aware of the NP's plan to switch the tablet narcotic medications to liquid. The NP presented the plan to the IDT team as another suggestion for the facilities POC (plan of correction) related to medications that had been left at bedside. The NP assured the IDT team she would order the changes after she spoke with the residents. The ED, AIT, and DON all indicated they had not been made aware of any suspicions the NP may have had about resident's misuse of their medications. The Regional Director of Clinical Operations indicated, she found out about the change in medication a couple of days later and questioned the NP about the adjustment, and offered other options such as mouth checks, or room checks, but the NP declined and indicated she was the provider and could make the changes as she wanted. The Regional Director of Clinical Operations had never witnessed, heard, or seen any suspicious activities from the residents to suggest they misused their medications. The Regional Director of Clinical Operations questioned the NP further, but still she declined to consider other options. The AIT indicated she started hearing complaints from residents the first day after the change. She saw Resident BC and CR outside and when she asked them to move to a smoking area, they began to complain about the medication being switched from a pill to a liquid. She assured the Residents she would talk to the NP about their concerns. When she did, the NP continued to decline the request to consider other options. The Regional Director of Clinical Operations indicated the NP absolutely should have spoken with any alert and oriented resident before making changes to their medications and if she suspected illicit drug use, or misuse of the resident's narcotic medications, she should have reported it to the ED so that an investigation could be conducted, or the police could have been called to do a room search. The Regional Dire

Based on observation, interview, and record review, the facility failed to prevent pressure ulcers on a dependent resident, complete follow-up assessments, track wound progression, implement interventions, or follow interventions recommended by the wound nurse practitioner (NP), resulting in harm when preventive interventions were not implemented and a pressure ulcers on the resident's heel developed into an unstageable ulcer (full thickness tissue loss where the wound bed is covered by slough) and then a stage III (full thickness tissue loss with subcutaneous fat exposed, but bone, tendon, or muscle are not visible) pressure ulcer for 1 of 3 residents reviewed for pressure (Resident C). Findings include: On 7/20/21 at 10:51 a.m., Resident C was observed lying on her back in bed on a regular mattress, head elevated, both feet propped on a pillow, and left foot in a specialty boot. On 7/20/21 at 12:20 p.m., Resident C observed lying on her back in bed on a regular mattress with the head of bed elevated. On 7/21/21 at 6:50 a.m., Resident C was observed lying on her back in bed on a regular mattress with the head of bed elevated. Licensed Practical Nurse (LPN) 23 indicated she was the night nurse and not sure if the resident got out of bed. She was also not sure what nursing measures were being used to prevent skin breakdown for the resident. Resident C was dressed and changed by day shift. Resident C's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a heel treatment, and orders for the NP to see the resident. On 7/21/21 at 8:49 a.m., Resident C was observed lying on her back in bed on a regular mattress, head elevated, and specialty foam boots on both feet. On 7/21/21 at 2:22 p.m., Resident C was observed lying on her back in bed on a regular mattress with the head elevated. Specialty foam boots were on bilateral feet with the left bootie twisted sideways with the straps tight across the lower leg. On 7/22/21 at 9:45 a.m., staff were observed getting Resident C out of bed into a Broda chair (tilt in space positioning chair) at bedside. Once up and staff left room, resident was observed to have her head suspended approximately 3 inches off chair back, no head support, facial grimacing, and resident observed every few minutes with head hyperextended to lay a few minutes on the back of the chair. Left foot with pressure ulcer observed to be braced flat against left foot pedal creating pressure on bottom of foot, toes curled over top of the pedal. Right foot off the foot pedal and turned to the right. Director of Nursing Services (DNS) was summoned to observe resident and placed a pillow behind the head. She indicated she would get a pillow to cushion the bottom of the resident's feet. On 7/22/21 at 2:32 p.m., Resident C was observed still sitting in a Broda chair at bedside. On 7/22/21 at 3:11 p.m., Resident C was observed still sitting in a Broda chair at bedside. The medical record lacked documentation to indicate the resident had her brief changed or weight distribution since gotten up in the am. Resident was observed to be out of bed approximately 6 hours, exceeding therapy recommendations and education to nursing staff of 3-4 hours During a continuous observation on 7/22/21 from 3:25 p.m. to 4:30 p.m., CNA 24, CNA 25 and LPN 26 were observed to bring a mechanical lift into Resident C's room to transfer her back to bed, but after discussion staff indicated they had never transferred the resident with the lift before and did not know how to get her into bed. At 3:40 p.m., CNA 25 and CNA 27 transferred and placed Resident C on a newly placed low air loss mattress on top of 2 folded flat sheets. Resident C's brief observed to be saturated with urine, soiled with bowel movement (bm), and the [MEDICATION(S)] dressing observed with LPN 26 to be displaced off stage 2 (wound extending into the deeper layers of skin, usually tender and painful) sacral wound, with wound and dressing soiled. Stage 2 wound site was circular shaped with small amount bloody drainage. The sacral wound was left open to air, aides were not observed to put protective cream onto bottom with brief change. Heels were lying on the bed. At 4:08 p.m., the left heel wound was observed with nurse LPN 28. The wound dressing was loose around the edges, and the sheet was wet below the heel. Dressing, dated 7/20/21, were heavily soiled with dark blackish drainage. Resident C's record was reviewed on 7/20/21 at 9:15 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (Minimum Data Set) assessment, completed on 6/4/21, assessed Resident C as rarely/never made herself understood, usually understood others. Cognitive skills for daily decision making severely impaired. Resident C required extensive assistance of 2+ persons physical assist for bed mobility, and dressing. Total dependence of 2+ persons physical assistance for transfers. She did not walk in the room or corridor or have locomotion off the unit. Locomotion of the unit only occurred once or twice during the assessment period with 1 person physical assistance. Extensive assistance of 1 person physical assist for eating, toileting, and personal hygiene. Total dependence of 1 person for bathing. Mobility devices included a wheelchair. Always incontinent of bowel and bladder. Resident at risk for developing a pressure ulcer/injury, no current pressure ulcers, or skin problems. A Care Plan for Resident C, dated 5/10/21, indicated the resident had a self-care performance deficit and required assistance with ADLs related to cardiovascular accident and [CONDITION(S)]. The goal was for the resident to demonstrate increased independence with ADL completion. Interventions included the resident required 1 staff assistance with bed mobility, eating, toileting, transfers. Place call light within reach. Remind resident to call for assistance if cognitively intact. PT/OT evaluation and treat per medial provider orders. A Care Plan for Resident C, dated 5/10/21, indicated the resident was at risk for impaired skin integrity. The goal was for the resident's skin to remain intact. Interventions included, keep skin clean and well lubricated, provide skin care per facility guidelines and as needed, and utilize pressure relieving devices on appropriate surfaces. Documentation indicated the focus was revised on 7/7/21 to indicate, risk for impaired skin integrity pressure ulcer unstageable (full thickness tissue loss where the wound bed is covered by slough) to left heel, stage 2 (partial thickness loss of the dermis) on the sacrum. The record lacked documentation the care plan interventions were revised. A physician order, dated 5/10/21, indicated a weekly skin evaluation by licensed nurse on Monday. A physician order, dated 5/10/21, indicated [MEDICATION(S)] (moisture barrier skin protectant) to bilateral buttock every shift for preventative. A physician order, dated 5/25/21, indicated hoyer lift for transfers with assistance of two staff members. Weekly Skin Assessments in the electronic medical record (EMR), dated 5/11/21 - 7/21/21, indicated documentation of weekly assessments were completed only on 6/28/21. A Weekly Skin Assessment for Resident C, dated 6/28/21, indicated resident had a new skin condition since the last review. Left heel mushy dark area measured 4.5 centimeters (cm) by (x) 3.5 cm. Prevalon (cushioned boots used to float heels off the surface of the mattress) on. A Skin/Wound Note by the Wound NP for Resident C, dated 7/7/21 at 9:02 p.m., indicated chief complaint was wounds. A left heel unstageable pressure ulcer due to eschar, and a sacral stage 2 pressure ulcer. Patient had a pressure injury. Pressure reduction and turning precautions discussed with staff at time of visit recommended, including heel protection and pressure reduction to bony prominences. Staff educated on all aspects of care. Factors affecting healing, patient had frequent incontinence which could decrease healing rate of wound. Recommend providing incontinence care as needed. Increased moisture at wound site could promote poor prognosis of wound healing. Please keep wound site covered and avoid contamination with feces at all times. Wound rounds completed and reconciled with wound nurse (LPN 12) today. All questions and concerns answered for staff and patient as applicable. Staff made aware that wound rounds were completed and of any changes in treatment plan. A physician order, dated 7/7/21, indicated [MEDICATION(S)] Solution 5 % ([MEDICATION(S)]-Iodine) apply to left heel topically two times a day for wound management. A physician order, dated 7/7/21, indicated cleanse area to sacrum with normal saline, pat dry and apply [MEDICATION(S)] and secure, change every Tuesday and Friday for wound care. A physician order, dated 7/12/21, indicated wound NP to evaluate and treat open area on left heel and hyper granulation tissue around g-tube. A Tissue Analytics report, dated 7/13/21, indicated unstageable left heel wound measuring 3.67 cm x 4.75 cm x 0.0 cm. Scant serosanguinous drainage. Pressure reduction/offloading: ensure compliance with turning protocol, wedge/foam cushion for offloading, wheelchair cushion, and specialty bed. A Tissue Analytics report, dated 7/13/21, indicated Stage 2 pressure wound on sacrum wound measuring 0.93 cm x 2.39 cm x 0.1 cm. Scant serosanguinous drainage. Pressure reduction/offloading: ensure compliance with turning protocol, wedge/foam cushion for offloading, wheelchair cushion, and specialty bed. A Progress Note for Resident C, dated 7/13/21 at 1:31 p.m., indicated the resident was seen by the wound team today, no new orders given at this time. Nurse left messages for both daughters to call for an update. Will continue to monitor. A Progress Note for Resident C, dated 7/13/21 at 2:51 p.m., indicated chief complaint, comprehensive skin and wound evaluation for sacrum, left heel, and g-tube site. Orders, Aspercreme Lotion 10 % topically 10 % [MEDICATION(S)] [MEDICATION(S)], [MEDICATION(S)] Cream topically skin Protectants, and Lac-Hydrin Lotion 12 % topically 12 % [MEDICATION(S)]. A Progress Note for Resident C, dated 7/13/21 at 1:31 p.m., indicated the resident was seen by the wound team today, no new orders given at this time. Nurse left messages for both daughters to call for an update. Will continue to monitor. A Progress Note for Resident C, dated 7/13/21 at 2:51 p.m., indicated chief complaint, comprehensive skin and wound evaluation for sacrum, left heel, and g-tube site. Orders, Aspercreme Lotion 10 % topically 10 % [MEDICATION(S)] [MEDICATION(S)], [MEDICATION(S)] Cream topically skin Protectants, and Lac-Hydrin Lotion 12 % topically 12 % [MEDICATION(S)]. A Tissue Analytics report, dated 7/20/21, indicated previously unstageable wound improving to Stage III (full thickness tissue loss with subcutaneous fat exposed, but bone, tendon, or muscle are not visible) on left heel wound measuring 1.5 cm x 2.11 cm x 0.2 cm. Scant amount serosanguinous drainage. Pressure reduction/offloading: ensure compliance with turning protocol, wedge/foam cushion for offloading, wheelchair cushion, and specialty bed. A Tissue Analytics report, dated 7/20/21, indicated Stage 2 pressure wound on sacrum wound measuring 1.41 cm x 0.34 cm x 0.1 cm. Scant amount serosanguinous drainage. Pressure reduction/offloading: ensure compliance with turning protocol, wedge/foam cushion for offloading, wheelchair cushion, and specialty bed. A physician order, dated 7/20/21, indicated cleanse area to sacrum with normal saline, pat dry, and apply silver alginate and cover with bordered gauze, change every other day and as needed. Resident C's medical record lacked documentation to indicate the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/21/21 at 3:19 p.m., the DON provided additional Weekly Skin Check sheets had been located and been put into the electronic medical record (EMR). The forms lacked nurse signature and dates of completion. The forms indicated: a. Effective 6/7 21 resident had no skin conditions. b. Effective 6/14/21 resident had not skin conditions. d. Effective 6/21/21 resident had no skin conditions. d. Effective 7/5/21 resident had a change in skin condition. Left heel wound measuring 4.0 cm x 4.5 cm x 0 cm. Sacrum wound measuring 1.0 cm x 2.5 cm x 0.1 cm. Abdomen wound measuring 2.0 cm x 1.0 cm x 0.1 cm. e. Effective 7/12/21 resident had skin conditions that were not new since the last assessment on abdomen, left heel and sacrum. Documentation lacked measurements or description of the wounds. During an interview on 7/19/21 at 12:29 p.m., Resident C's daughter indicated she had filled out 3 blue complaint forms and nobody from management had called her back since she submitted her concerns starting in June 2021. The resident had a heel that was actively bleeding, and the facility did not get the wound NP to see her until 7/13/21. Daughter thought the bandage on her left foot had been changed but did not think nursing staff were using the ordered medications to her heel wound. Aides had been instructed to put cream on the resident's bottom with each brief change, and that was not happening. During an interview on 7/20/21 at 11:38 a.m., LPN 8 indicated she was the nurse treating Resident C. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The sacrum wound order included, normal saline and a [MEDICATION(S)] dressing to be used on Tuesdays and Fridays during dressing changes by the wound team, and staff were responsible for changing the dressing as needed on the other days. During an observation with NP 31, on 7/20/21 at 11:22 a.m., Resident C was laying on her back on a regular mattress, head of bed elevated and left heel in a specialty boot. NP 31 indicated the wound team saw the resident that morning and they may have written new orders. The last time she saw the daughter she had wanted the special boot, but NP 31 was not sure if there had been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff had told her the resident was not compliant with turning and being propped, she was told by staff the resident preferred to be on her back. She had never seen the resident out of bed and was unsure why she did not get out of bed. During an interview on 7/20/21 at 11:48 a.m., the Wound NP and Wound Nurse LPN 12 indicated they had seen Resident C that morning during wound rounds and her heel pressure wound had improved from a Stage IV (Full thickness tissue loss with bone, tendon, or muscle exposed) to a Stage III (full thickness tissue loss with subcutaneous fat exposed, but bone, tendon, or muscle are not visible). Wound Nurse LPN 12 indicated the open area on Resident C's bottom and heel were most likely due to pressure, but he was not sure as she was not his resident and he only saw after being informed she had a wound. He could not answer as to preventative measures or why the resident was not gotten out of bed. On 7/21/21 at 6:50 a.m., LPN 17 indicated, she was the night nurse and usually worked another unit. She was not sure if Resident C was gotten out of bed, and she was not sure what preventative skin measures were used for the resident. LPN 17 indicated the resident was changed by the day shift. There were orders for a dressing change every other day to the sacrum, silver [MEDICATION(S)], and cover with gauze. Heel treatment order only includes NP to see. On 7/21/21 at 6:56 a.m., LPN 20 indicated, the facility had a wound team that came in the mornings, she herself was not sure what preventative nursing measures were being used to treat the resident's skin breakdown. Certified Nursing Assistant's (CNA's) would mark on the bathing sheet if there were skin concerns, they informed the nurse, and then the information went into the Medical Binder and the NP or physician would see when they come into the building. On 7/21/21 at 7:00 a.m., CNA 19 indicated, she had worked in the facility approximately 2 years. She was not sure if Resident C was ever gotten out of bed, possibly the day shift would get her up. The resident usually laid on her back, when pillows were placed under her to prop, she would just move back. [MEDICATION(S)] ointment (protectant) was used on the resident's buttocks with brief changes, and they would prop her heels on a pillow except when specialty foam boots were put on her. On 7/21/21 at 7:00 a.m., CNA 20 indicated, she had worked in the facility approximately 2 years, but she worked night shift. She was not sure if the resident was ever gotten out of bed, possibly the day shift wound got her up. Most times she observed Resident C she was laying on her back, when pillows were placed, she would just try to move back. [MEDICATION(S)] ointment was used on buttocks with brief change, float heels on pillow except when provolone boots on. During an interview on 7/21/21 at 9:10 a.m., Resident C's daughter indicated she was the one who found the open area on the resident's heel on Friday 7/9/21. She was not aware the resident had an open area on her bottom. She had asked the aides to put cream on the resident's bottom to help prevent open areas. The daughter indicated Resident C was not gotten out of bed and she was not sure why. During a care plan meeting in June the daughter had asked therapy to get the resident an appropriate chair and a Broda chair was obtained. The resident had been seen up in her chair per family one time and she was positioned wrong causing her to cry. The resident had not been up since to her knowledge. To her knowledge the resident had only booties to use on her feet, although she had to take them home to wash them due finding them soiled with blood. The resident was not propped on her side, she was always positioned on her back in the bed. Resident C had been seen with booties on her right foot frequently twisted to the side and positioned wrong, and she knew this as there would be an imprint on the leg from the straps. On 7/21/21 at 7:24 a.m., CNA 18 indicated she worked the assignment to include Resident C. Indicated the resident was washed up daily, shower days were Wednesday and Saturday evenings. The resident would occasionally get out of bed with staff using the hoyer lift. [MEDICATION(S)] ointment was used on her bottom with brief changes. As aides they made sure Resident C was dry all the time to help prevent skin breakdown. They had tried in the past to prop the resident onto her side, but she did not stay. CNA 18 indicated, she supposed the staff should have asked therapy to get a special wedge or some kind of cushion to keep her off her back. On 7/21/21 at 11:57 a.m., the DNS indicated, the facility had just started using a new wound company on 7/6/21. The wound company had done a wound sweep of the entire resident population to identify skin concerns and provided documentation. The wound company came every Tuesday and Friday and saw residents along with LPN 12 who was the facility wound nurse. The DNS looked at residents upon admission for special needs, and to make sure the room was set up for the resident. A care plan was initiated by the admitting nurse to open it, then the MDS nurse finished the care plan and kept it updated as needed. The DNS indicated, she would have to look for documentation on how Resident C acquired her wounds and preventative measures that were being used before On 7/22/21 at 10:18 a.m., the Occupational Therapist (OT) indicated, Resident C had been assessed by Physical Therapy (PT) on 5/11/21 and OT on 5/13/21. Resident C had remained on case load and received treatment for 3 weeks. PT assessed Resident C for positioning in a Broda chair and provided range of motion (ROM) to the upper body. Education was provided to staff on proper positioning techniques and having the resident up in a Broda chair to build tolerance at least 3 times weekly. OT indicated she had not observed the resident up in her Broda chair 3 times weekly as recommended. On 7/22/21 at 11:19 a.m., Resident C was observed with the daughter. The resident was sleeping in her Broda chair at bedside, the daughter indicated this was only the 2nd time she had seen the resident out of bed since admission in May. On 7/22/21 at 2:39 p.m., Wound Nurse LPN 12 indicated, Resident C had multiple comorbidities that would put her at risk for skin breakdown, the root cause of her sacrum and heel wounds were documented by the Wound NP as pressure, and thought the wounds were documented as unavoidable but would need to check. The wound team rounded weekly and made recommendations for nursing interventions, then he would put the orders into the computer and the orders should show on the resident orders for nursing to follow and document. The MDS nurse updated most of resident care plans, but he tried to update wound care plans. Turning and repositioning every 2 hours should be standard for all dependent residents. After it had been established Resident C had wounds, she should have had a specialty low air loss mattress placed on her bed. The wound NP gave orders and he put them into the resident chart. In the past 3 weeks they had a new wound company and rounding program. Residents with wounds were seen on Tuesday with the wound NP. Then she would return and the team saw all new resident admissions on Thursday or Friday, or newly identified residents with wounds. On 7/22/21 at 3:30 p.m., the MDS Coordinator indicated, any one of the administrative nurses could update care plans with a change in condition. The MDS nurse might find out about a new wound when reviewing the chart, or in the morning meeting. A new wound group came weekly and put in progress notes, then the clinical team provided a list of residents with wounds or issues to the MDS nurses. The MDS Coordinator indicated, she was not aware Resident C had wounds. If she had known she would have updated her care plan. On 7/22/21 at 5:01 p.m., the DNS indicated Resident C's bathing/shower sheet were not kept on the unit, she kept them in her office. Upon review the resident had only 1 shower documented since admission. Staff had indicated, the resident was too hard to transfer. The resident possibly needed a bigger bed. DNS indicated the wound sheets had not been observed in Resident C's EMR as they were kept in a different section under documents. Some of the wound assessments had measurements and some did not. The resident's skin/wound care plan had not been updated to include preventative measures specific to the resident. Nurses should have read and followed the care plans physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound care team recommendations and therapy recommendations for compliance with turning protocol, wedge/foam cushion for offloading, wheelchair cushion, or specialty bed, were just recommendations. That did not mean the recommendations were orders or staff had to follow them. She thought the Wound NP had documented Resident C's wounds as unavoidable, but if staff had not been following care plan interventions, or using any preventative measures, the wounds could not be considered unavoidable. On 7/21 21 at 3:45 p.m., the DNS provided a Skin Care & Wound Management policy, dated 5/30/19, and indicated the policy was the one currently being used by the facility. The policy indicated, .The staff strives to prevent resident/patient skin impairment and to promote healing of existing wounds .Each resident/patient is evaluated upon admission and weekly thereafter for changes in skin condition .4. Develop a care plan with individualized interventions to address risk factors .6. Evaluate for consistent implementation of interventions and effectiveness at clinical meeting. 7. Modify and document goals and interventions as needed On 7/21/21 at 3:45 p.m., the DON provided a Wound Care policy, dated 5/30/19, and indicated the policy was the one currently being used by the facility. The policy indicated, Residents/patients admitted with or develop skin integrity issues will receive treatment as indicated based on location, stage, and drainage This Federal tag relates to Complaint IN 478. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure adequate supervision to prevent a newly admitted , deaf, cognitively impaired resident, who was assessed with [REDACTED]. After being found by a bystander on a curb next to the road and transported to an emergency room by emergency medical services, the resident was found to have a fractured left knee and high blood pressure. (Resident B) The immediate jeopardy began on 8/03/2020 when the resident exited through a fire exit door at 5:30 a.m. Registered Nurse (RN) 11 turned off the alarm to the fire exit door, failed to investigate the cause of the alarm sounding, failed to report the alarm sounding, and failed to initiate the elopement protocol. The facility failed to identify Resident B as missing from the facility for 4 hours until notified by a local hospital emergency department at 9:30 a.m. The Executive Director (ED), Director of Nursing (DON), and Regional Director of Clinical Services were notified of the immediate jeopardy at 1:40 p.m. on 8/14/2020. The Immediate Jeopardy was removed, and the deficient practice corrected, on 8/7/2020, prior to the start of the survey and was therefore Past Noncompliance. Findings include: An Indiana State Reportable Incident form, dated 8/3/2020 at 4:53 p.m., indicated Resident B eloped from the facility without notifying staff at approximately 5:30 a.m. The resident was located and taken to the hospital for evaluation. An emergency room (ER) Medical Doctor Exam and Disposition report, dated 8/3/2020, indicated it was discovered Resident B had walked out of his nursing facility where he was an inpatient. The patient presented with left knee pain and scrapes on his palms. Patient was deaf and had dementia which made communicating with the interpreter difficult. Resident B indicated he started walking and felt very dizzy. His troponin level (measured heart injury) was slightly elevated, a troponin was to be repeated and a magnetic resonance imaging (MRI) scheduled. Emergency [DIAGNOSES REDACTED]. An emergency room report, dated 8/3/2020, titled, DC Summary, indicated, Patient had MRI of left lower extremity performed due to complaints of knee pain and abrasions. He had acute/subacute stress fracture . Patient was hypertensive on admission with blood pressure 190s/80s Patient's EKG showed left bundle branch block that was reportedly new but I have no prior EKGs to compare to A left knee MRI result for Resident B, dated 8/3/2020, indicated an acute or subacute stress fracture involving the anterior lateral tibial plateau (a break of the larger lower leg bone below the knee that breaks into the knee joint itself), and complex tear of the body and posterior horn of the medial meniscus (back of the knee). A Discharge Planning Assessment from a local hospital, dated 8/3/2020, indicated Resident B required assistance with decision making, and had a primary [DIAGNOSES REDACTED]. The hospital Social Worker indicated Resident B was found down in the community by emergency medical services (EMS). The ER nurse reported he had on clothing labeled with his name and was wearing a nursing home style brief. Resident B was hearing and speech impaired but did answer basic questions for the nurse and interpreter. The resident had a wallet with a name and phone number of his family member. Case management called facilities in the area in attempts to identify the resident. The Social Worker found the family member who reported the resident had just recently transferred to the long term care facility. Case Management placed a call to the facility and spoke with the Executive Director (ED), who was not aware the client was not in the facility. A call was placed back to the facility to speak with the bedside nurse. The nurse was surprised to learn the resident was in the ER, and argued he was at the facility since she had not sent him out. The nurse was informed the resident had gone into the community, was found by the local EMS, and brought to the ER. Lab results indicated the client was in [MEDICAL CONDITION] and the emergency department was trying to determine if that was new for the resident. A Social Work Assessment from a local hospital, dated 8/3/2020, indicated Resident B arrived to the ER after wandering outside. The resident was found with cash in excess of $500. Family was contacted after a name and phone number were found in Resident B's wallet. Family indicated Resident B had dementia, frequently wandered away, and the facility was supposed to have put an ankle location monitor on him. A Discharge Summary for Resident B from a local hospital, dated 8/4/2020, indicated the resident was brought to the ER by EMS after he was found wandering by a bystander and appeared to have fallen. The patient was deaf, and used American Sign Language (ASL). Using a sign language interpreter via iPad, the history was still hard to obtain. The ASL interpreter repeatedly mentioned that the patient appeared confused. Resident B's record was reviewed on 8/13/2020 at 9:20 a.m. [DIAGNOSES REDACTED]. An Admission Observation Tool for Resident B, dated 7/30/2020, indicated the resident's chief complaint was dementia without behavioral problems, and the resident was deaf. Behaviors to include exit seeking behaviors were not exhibited. The assessment indicated it was unknown if the resident had a history of [REDACTED]. physician's orders [REDACTED]. Assessments for Resident B, dated 7/30/2020 - 8/13/2020, indicated there was no elopement assessment. Review of Resident B's electronic medical record, dated 7/30/2020 - 8/2/2020, indicated there was no documentation or assessments observed by the social services department. A 48 hour Baseline Care Plan for Resident B, dated 7/30/2020, indicated the resident required extensive assistance of one for bed mobility, transfers, walking in the room, locomotion on the unit and toileting. Equipment needed included a wheelchair; alarms and restraints were not required. There was no documentation regarding risk for elopement. A Fall Risk Observation Tool for Resident B, dated 7/31/2020, indicated the resident had diminished safety awareness, was ambulatory without assistance, and had normal walking/striding without hesitation. No assistance was required for transfers. The resident was able to stand/walk, and maintain body alignment, and there was no fall history. The tool indicated, based on this assessment, the resident had been identified as a potential risk for falls. A Nurse's Note, dated 8/3/2020 at 9:42 a.m., indicated Resident B was discovered to be outside of the facility and was transported to a local hospital for evaluation and workup. An investigation revealed the resident had defeated the egress door on the terminal end of the unit. The resident had proceeded down the stairwell and exited the facility and was down at the curb. An employee statement by Certified Nursing Assistant (CNA) 9, dated 8/3/2020, indicated, I came in this morning around 8:00 a.m. I was called in was told no aide was upstairs .on either side .walked up and down halls collected trays. Passed ice water still haven't seen (Resident B). I did not see him the entire time being on (name of unit) .checked his room a few times still no sign of him I assumed he was (at an) appointment, at [MEDICAL TREATMENT], with therapy, etc. An employee statement by Registered Nurse (RN) 11, dated 8/3/2020, indicated, Early morning on August 3rd around 5:15 a.m. - 5:30 a.m. I finished bed check with LPN (Licensed Practical Nurse) 10 .I went to find CNA 22 to see if she was ok that I left early since my bed check was finished. I went to the other side of the (upstairs unit name) and CNA 22's bags and supplies were in the middle of the hall. I looked in a couple of rooms for her, but noticed the stair alarm going off and assumed that she had gone down the stairs for some reason. I turned off the alarm, and peeked in another room before going back to the other side of the building to tell LPN 10 that CNA 22 must be on a break or something because I couldn't find her. And asked that if she was ok I was going to go ahead and leave .she said that was fine so I left. An employee statement by RN 12, dated 8/3/2020, indicated, I (RN 12's name) came on the unit and was notified I had no CNA, but someone would be here to help soon. I got report from the nurse about critical patient and everyone else was fine. I began to pass trays, after I passed every tray I began to feed (Resident BB) until a CNA relieved me. I began my morning med pass, and was almost done when my DON asked me about (Resident B). I said he's in his room. I knew for sure because I had passed every single tray on this unit. I got a phone call that the emergency room had my patient, he was already gone before I got here, he had left building at 5:25 a.m. before my shift. Having never worked this particular unit I didn't know what resident looked like or anything. DON, family, facility was notified An employee statement by Licensed Practical Nurse (LPN) 10, dated 8/3/2020, indicated, I (LPN 10's name), was the nurse working on the (second floor unit name) on Sunday 8/2/2020. Alongside RN 11 and CNA 22. I had no knowledge of an elopement that took place during my shift. I am aware of the (company name) Elopement Protocol. During an interview on 8/13/2020 at 1:51 p.m., RN 12 indicated she was usually the night nurse on the upstairs unit, but on 8/3/2020 she picked up the day shift and had come in to work at 7:00 a.m. RN 12 had received report from LPN 10 and CNA 22, both who had indicated everyone was fine. CNA 22 reported she had worked alone and had personally checked and changed all residents by herself. LPN 10 indicated there were no dayshift CNAs, so RN 12 locked her medication cart, and along with the nurse on the other side of the upstairs units, both started to pass trays. RN 12 indicated she passed every single tray, did blood sugar checks, and was looking at the Medication Administration Record [REDACTED]. The ED indicated the resident had exited the facility. A nurse from the emergency room called and indicated Resident B had exited the facility, he was hot, and a passerby on the street attempted to talk with him, and since he was deaf and could not communicate, they called 911. The emergency room nurse indicated Resident B was hot and had signs of kidney failure. Resident B's family member called to check on the resident, and RN 12 had to tell her that the resident had eloped. Upon head count Resident B's bed was observed to be perfectly made and his room spotless. RN 12 had been told in report that Resident B was independent, and there was no mention of him being an elopement risk. Management had observed cameras and saw RN 11 disarming the alarm. RN 11 had not told LPN 10 or CNA 22 or anyone else about the alarm sounding. To her knowledge RN 11 had not looked at the camera video, in resident rooms, or attempted to find out if any resident was missing. RN 12 indicated the alarms were loud, and if she had heard them she would have told the DON or called maintenance as she did not have access to disarm the alarm. RN 12 indicated the alarm was on the stairwell, and if it went off, that possibly meant someone went down the fire escape. The stairwell did not come out in the building; it went directly to the outside. RN 11 had not done a head count or called anyone. RN 11 should have automatically done a head count, and notified the other aide. When a head count was done, every room was checked, if a resident was seen in the room, the door was closed and the check mark was put in front of the door to alert others the resident was inside and safe. If a resident could not be found, the nurse should have called over the speaker system that there was an elopement, look at all the doors, look for the patient high and low. On 8/13/2020 at 2:22 p.m., the DON indicated, on 8/3/2020 upon review of the camera footage, Resident B was observed walking down the hallway. The resident made it to the end of the hallway on the back right end, and he pressed on the fire escape door for 15 seconds and defeated the lock. The resident had no wanderguard alarm as he had no history of elopement. Resident B walked down the stairwell holding onto the rail, and he exited out of the exterior door. A passerby found him on the side of the street and called 911. The resident was estimated to have been outside for approximately 30 minutes. He was assessed in the emergency room and found to have no injuries, and his labs were fine. The DON indicated there was no harm from the event. The resident went to a sister facility with a secured memory care unit when discharged from the hospital. The DON indicated he was not sure how the emergency room staff or EMS knew the resident was from their particular facility, but it could have been due to the location where he was found. There was an alarm on the fire door, it alarmed when the resident opened the door, and per staff the door had alarmed. Staff had responded after Resident B had already exited. The resident pushed on the door, the alarm sounded, RN 11 turned the alarm off, opened up the stairwell door, and per her statement she had called out in the stairwell, and when she saw no one there, returned to her duties. RN had not initiated looking for a resident, and she did not initiate a code silver to indicate there was a resident missing. DON was not sure why the night or day shifts had not identified the resident missing. The expectation for staff would be for the aides to do rounds every 2 hours, and the day nurses to do rounds upon arrival no later than 7:30 a.m. On 8/13/2020 at 2:25 p.m., the ED indicated on 8/3/2020 Resident B had been dressed in regular clothing when he eloped. The resident had not previously been on a secured unit at his previous facility as he had no history of wandering. The ED indicated they could identify when fire doors were disengaged as there was a system that monitored the time when the doors were opened. Resident B was estimated to have been outside approximately 30 minutes by the time the locks disengaged and the 911 call. There was an alarm on all fire doors with a sign indicating to push for 15 seconds to open the door. There was an expectation, if staff could not determine the cause of a fire alarm sounding, they would initiate a head count of residents in the facility. There was restricted access to who could reset alarms to the fire doors and access to the stairwells, and as a unit manager RN 11 had access to reset the alarms. On 8/14/2020 at 11:41 a.m., the Regional Nurse provided an Elopement Prevention Policy, reviewed 4/20/17, and indicated the policy was the one currently being used by the facility. The policy indicated, elopement is defined as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident/patient at harm or injury .Procedure: 1. Identify resident/patients who are at risk for elopement. a. All new admissions that are at risk for elopement will have interventions in place immediately until further assessment is complete. Interventions may include but are not limited to: Environmental modifications to prevent undetected exit such as wandering alerts, door alarms. Increased frequency of resident observation rounds. b. Any resident/patient admitted who is cognitively impaired and can self-ambulate is considered an elopement risk until determined otherwise. c. Any resident/patient that has a change in condition that places them at risk for elopement. 2. Obtain current photograph of resident/patient identified for risk of elopement. 3. Complete the Risk Alert: Elopement. 4. Place the Risk Alert: Elopement form in the elopement risk identification book. Maintain in an easily accessible area. 5. Develop the care plan with input for the interdisciplinary team and the resident patient and family/responsible party . On 8/14/2020 at 11:41 a.m., the Regional Nurse provided an Elopement Prevention and Management Overview Policy, reviewed date 5/30/2020, and indicated the policy was the one currently being used by the facility. The policy indicated, . Procedure: 1. Identify resident/patients who are at risk for elopement. 2. Determine elopement risk factors which may include, but not limited to: a. Acute or chronic confusion/disorientation, b. anxiety, c. dementia, or dementia related disease, d. History of purposeful wandering and/or elopement, e. new admission with adjustment difficulties, or a desire to return to previous living situation, f. restless, irritable. 3. Document factors. 4. Develop and document individualized interventions to manage risk factors. 5. Discuss interventions and goals with resident/patient and/or family responsible party. 6. Communicate risk factors and interventions to the caregiver staff. 7. Monitor and document resident/patient response to elopement risk reduction interventions. 8. Evaluate effectiveness of interventions during clinical meetings. 9. Modify goals and interventions as indicated and communicate changes to the caregiving team, resident/patient and/or family responsible party On 8/14/2020 at 11:41 a.m., the Regional Nurse provided the Missing Resident Policy, reviewed date 4/20/17, and indicated the policy was the one currently being used by the facility. The policy indicated, .definition of missing resident: not immediately available but not requiring immediate supervision - for example, a cognitively intact resident may be able to take a leave of absence (LOA), leaves the facility but forgets to sign out of the facility. This resident is missing, not an elopement. Elopement: cognitively impaired resident that requires supervision but wanders to an unsafe area unsupervised. Policy: 1. It is the policy of this facility to provide a safe environment for residents and staff will be aware of and responsible for the resident's location. 2. In the event a resident cannot be accounted for on the unit, the following procedure will be implemented to locate the missing resident as quickly as possible. Procedure: 1. Identify that the resident is not on the unit noting that time is a critical factor for discovery. 2. Determine if the resident has been taken off the unit by family or a staff member of another department .3. If the resident cannot be immediately located, the nurse will organize a search of the center and surrounding grounds including but not limited to .4. If search fails to locate resident within 15 minutes .5. Provide police the following information . The Past Noncompliance Immediate Jeopardy began on 8/3/2020. The Immediate Jeopardy was removed and the deficient practice corrected on 8/7/2020 when the facility implemented a systemic plan that included transfer of the affected resident to another facility, interviewed all residents to assess for potential elopement risk, wander/elopement assessments were completed on residents identified at risk, care plans were updated with interventions to prevent elopement, and each identified residents' information was added to the elopement binder. Staff were in-serviced on elopement prevention and management to include the wandering/elopement/missing person drill policy and procedure. This Federal tag relates to Complaint IN 184. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to provide nutritional care and services including the failure to obtain weekly weights, failure to provide assistance with meals and alternative food/supplement choices and failure to notify the physician and address the resident's refusal of nutritional supplements and poor intakes, for 1 of 3 residents reviewed for nutrition (Resident V). This resulted in a severe weight loss of 23 percent in less than 2 months and a change in body mass index (BMI) from normal to underweight. Findings include: During a random observation, on 8/11/20 at 11:30 a.m., Resident V was observed lying on a low air loss mattress covered with a blanket. During a wound dressing change observation, on 8/13/20 at 11:52 a.m., Licensed Practical Nurse (LPN) 29 provided wound care to Resident V. The resident's overall body appearance was thin, ashy in color, and gaunt in appearance that included protruding bony prominences (areas where bones are close to the surface) to the hips, knees, elbows, and wrists. During a Hoyer lift observation, on 8/13/20 at 3:15 p.m., Resident V was observed to be weighed. At this time, the Hoyer lift scale indicated 99.9 pounds (lbs.). During an observation, on 8/14/20 at 7:45 a.m., Resident V was observed lying in bed propped on his right side with a pillow. An uncovered breakfast tray was observed with bacon, eggs, and oatmeal on an over the bed table on the left side of the resident's bed, regular silverware still wrapped in a paper napkin. The resident was alert and talkative, and at this time indicated he would like to eat but needed to be straightened up in the bed first. Resident requested assistance finding his red button (call light) to be found. The call light was observed on the floor beside the bed. Resident V indicated, he had not had the call light since the night before. Resident V's record was reviewed on 8/11/20 at 1:54 p.m. An admission Minimum Data Set (MDS) assessment, dated 6/25/20, indicated the resident required limited assist of one for eating. The resident's height was 67 inches, and weight was 130 lbs. [DIAGNOSES REDACTED]. A hospital facility to facility report, dated 6/18/20, indicated the resident weighed 135.5 lbs. and nutritional intake had been marginal and patient needed encouragement. A physician's orders [REDACTED]. The order was discontinued on 6/26/20. A nutritional assessment, dated 6/25/20, indicated the resident was on a regular diet, regular texture with thin liquids. Resident received medical food supplement of ensure three times daily and intake of 50-100%. Limited assist for dining and no adaptive equipment used for eating. Anthropometrical measurements indicated 67 inches height, 128 lbs weight (58.2 kg), BMI 20 (low normal). No nutrition [DIAGNOSES REDACTED]. Nutrition monitoring and evaluation: weights, labs, and intakes. A physician's orders [REDACTED]. The resident's clinical record lacked documentation of weekly weights between 6/29/20 and 7/27/20. A physician progress notes [REDACTED]. The objective indicated the resident had severe hand contractures and decreased range of motion to bilateral lower extremities. A weight flow sheet, indicated the following weights: On 6/18/20, 128 lbs via wheelchair scale. On 6/25/20, 130 lbs via mechanical lift. On 8/13/20, 99.9 lbs via mechanical lift. Reweight was 104.6 lbs via wheelchair scale. A care plan, initiated on 6/25/20, indicated the resident was at risk for nutritional decline related to a [DIAGNOSES REDACTED]. The goals included, but were not limited to, resident will consume an average of >50 % of food and beverages at meals, will consume >50% of medical food supplements. Interventions included, but were not limited to, give appetite stimulant as ordered, administer vitamin/mineral supplement per physician order, provide feeding/dining assistance as needed, and monitor and evaluate weight /weight changes. A care plan, initiated on 6/19/20 and revised on 8/11/20, indicated the resident admitted with 9 pressure ulcers with slough and or eschar on right outer ankle, sacrum, hips, iliac crest right side. Ulcers related to thin fragile skin, limited mobility, incontinence, skin desensitized to pain or pressure. Interventions included, but were not limited to, prevalon boots, monitor nutritional status. Serve diet as ordered, monitor intake and record. A food consumption report, dated June 2020, indicated 0) 0-25% consumed and no substitute accepted, on 6/19/20 at 9:00 a.m. and 1:00 p.m., 6/20/20 at 1:00 p.m., 6/21/20 at 1:00 p.m., 6/24/20 at 6:00 p.m., 6/25/20 at 1:00 p.m., 6/27/20 at 6:00 p.m., 6/28/20 at 9:00 a.m. and 1:00 p.m. The report lacked documentation for eating self-performance and support provided. A dietician note, dated 7/2/20, indicated the resident had refused weights, and weekly weights were not appropriate. Resident does appear to be losing weight. Resident had indicated no artificial nutrition, and to continue regular diet and ensure three times daily and Juven every day. The resident's medical record lacked documentation the physician had been notified of the dietician's note that weekly weights were not appropriate, and lacked documentation the order for weekly weights had been discontinued. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The medical record lacked documentation the physician had been notified the resident's weight had not been obtained on 7/6 and 7/13, and the resident had refused on 7/20/20. A MAR, dated July 2020, indicated Ensure with meals for supplement was unavailable on the following dates: at 9:30 a.m. on 7/13 and 7/18, at 12:00 p.m. on 7/13, 7/15, and 7/18, and at 5:00 p.m. on 7/14. The MAR indicated [REDACTED]. A MAR, dated July 2020, indicated Juven every day shift. The MAR indicated [REDACTED]. The resident's medical record lacked documentation the physician had been notified of the refusals. A food consumption report, dated July 2020, indicated 0) 0-25% consumed and no substitute accepted, on 7/1 at 1:00 p.m. and 6:00 p.m., 7/2/20 at 9:00 a.m. and 1:00 p.m. the 6:00 p.m. meal lacked any documentation, 7/3/20 at 9:00 a.m. and 1:00 p.m., 7/4/20 at 9:00 a.m. and 1:00 p.m., 7/5/20 at 9:00 a.m. and 1:00 p.m., 7/6/20 at 6:00 p.m., 7/8/20 at 9:00 a.m. and 1:00 p.m. meals lacked any documentation, 7/9/20 at 9:00 a.m., 7/11/20 at 9:00 a.m. and 1:00 p.m., 7/12/20 at 9:00 a.m. and 1:00 p.m., 7/14/20 at 9:00 a.m. and 1:00 p.m., 7/15/20 at 9:00 a.m., 1:00 p.m., and 6:00 p.m., 7/17/20 at 9:00 a.m. and 1:00 p.m., 7/20/20 at 9:00 a.m. and 1:00 p.m., 7/22/20 at 9:00 a.m., 7/24/20 at 9:00 a.m., and 1:00 p.m., 7/25/20 at 9:00 a.m., 7/27/20 at 9:00 a.m., and 1:00 p.m., 7/29/20 at 9:00 a.m., and 7/30/20 at 9:00 a.m., and 1:00 p.m. A food consumption report, dated August 2020, lacked documentation of percentage eaten and eating self-performance and support provided, on 8/1/20, for breakfast and lunch. The document indicated 0) 0-25% consumed and no substitute accepted with limited assistance of 1, on 8/3/20 at 1:00 p.m., 8/4/20 at 9:00 (supervision, set up only) and 1:00 p.m. (supervision, setup only), 8/5/20 at 9:00 (supervision, setup only, 1:00 p.m. (supervision, setup only), and 6:00 p.m. (limited assist of 1), 8/6/20 at 6:00 p.m. (limited assist of 1), 8/9/20 at 9:00 (supervision, setup only) and 1:00 p.m. (supervision, setup only), 8/11/20 at 900 a.m., and 8/12/20 at 9:00 a.m. (supervision, setup only) and 6:00 p.m. (supervision, setup only). A MAR, dated August 2020, indicated the resident refused Juven on 8/2, 8/3, 8/5, 8/6, 8/7, 8/10-8/12. The record lacked documentation the physician had been notified. A notification form for physician or nurse practitioners, undated, indicated the Assistant Director of Nursing (ADON) had been notified the resident refused juven at least 3-4 times per week and could they look into changing the order. The documentation lacked any response from the physician or a date. A progress note, dated 8/13/20 at 4:53 p.m., indicated the resident's weight was obtained and weight loss was noted. The Hoyer lift weight was 99.9 lbs and a reweight obtained was 104.6 lbs. A progress note, dated 8/14/20 at 10:37 a.m., indicated the physician was notified of weight loss. A progress note, dated 8/14/20 at 10:44 a.m., indicated the resident's BMI was 16.4 (underweight). During an interview, on 8/13/20 at 2:05 p.m., the Director of Nursing (DON) indicated he was unable to find where the physician had been notified of the registered dietician's recommendation for weekly weights not to be obtained and the order was never discontinued. He could not find where the physician had been notified the resident at times refused nutritional supplements, and the physician should have been notified of the weekly weights not being obtained and of the refusals. He was also unaware the supplements had been unavailable and when that happened an alternative supplement should have been offered. During an interview, on 8/13/20 at 2:23 p.m., the ADON indicated she could not find documentation where the physician had been notified of the resident's refusals to be weighed. If the order for weekly weights had been stopped, the order should have been discontinued and was not. During an interview, on 8/14/20 at 12:56 p.m., the DON indicated the resident's BMI was 16.4 and considered underweight. On 8/13/20 at 1:54 p.m., the Assistant Director of Nursing (ADON) provided a policy, revised 4/1/17, and titled, Standard Precautions, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure for Hand Hygiene .B. Using liquid soap and water . 5. Rinse hands with water from wrists to finger .6. Dry hands thoroughly with a clean paper towel. 7. Turn off faucet with paper towel and discard On 8/13/20 at 2:07 p.m., the ADON provided a policy, dated 2/18/19, and titled, Refusal of Care and Treatment, and indicated it was the policy currently being used by the facility. The policy indicated, .Low Risk (non-emergency) refusal of care. A. Education the resident/family/representative for non-emergency refusals to assist with potential reasons and assistance with refusals. i. For on-going refusals, a care conference will be used to address on-going concerns for care and treatments, and possible solutions. C. Notify the ordering physician after three refusals of care for treatment or medications. D. Document refusal and reasons if known, in progress notes. IV. Document: a. Education provided to the resident/family/representative regarding risks and benefits of the care or treatment. B. attempts made to resolve the refusal including but not limited to other routes, other times, other methods that the resident is in agreement with. C. Contact attempts to the provider/ordering physician for all high-risk refusals of care. D. Contact attempts to Medical Director if applicable On 8/13/20 at 2:07 p.m., the ADON provided a policy, dated 5/19/16, and titled, Resident Weight, and indicated it was the policy currently being used by the facility. The policy indicated, It is the policy of this facility that a resident's weight will be accurately obtained . as ordered by the physician or practitioner .3. On Admission .b) obtain weekly weights times 4 weeks for baseline. C) stable residents will be weighed monthly thereafter, unless physician or [DIAGNOSES REDACTED]. This Federal Finding relates to Complaints IN 901, and IN 845. 3.1-46(a)(1)

Based on record review, and interview, the facility failed to supervise a resident with a [DIAGNOSES REDACTED]. The immediate jeopardy began on 3/19/19 when Resident H eloped from the facility. The Administrator, Director of Nursing, and Clinical Regional Consultant were notified of the immediate jeopardy on 4/3/19 at 2:30 p.m. The immediate jeopardy was removed and the deficient practice corrected on 4/4/19. Findings include: On 4/2/19 at 1:00 p.m., the past three months of facility state reportable incidents were reviewed and indicated, on 3/20/19 at 9:09 a.m., the facility self-reported, Resident H exited the building and went to a nearby store. On 4/2/19 at 1:47 p.m. a record review for Resident H was completed. The most recent comprehensive assessment was a 5-day MDS (minimum data set) assessment dated [DATE]. The MDS indicated Resident H was admitted to the facility on [DATE] after an acute hospital stay, was independent or required limited assistance with all ADLs (activities of daily living), and had [DIAGNOSES REDACTED]. Resident H's physician orders [REDACTED]. A Hospital H&P (history and physical) report was provided by the Clinical Regional Consultant (CRC) on 4/3/19 at 9:30 a.m. The report indicated Resident H had a [DIAGNOSES REDACTED].due to increasing difficulty with memory Per (family member) patient had been experiencing trouble with memory over the past couple of years, but she had really noticed a decline over the last 3 months or so. Patient has trouble with memory . had neuropsych testing performed on 10/26/18 which suggested mild neurocognitive disorder . patient has been living with (family member) for the past month and per (family member) has not been taking care of herself. Per (family member) (Resident H) would sit in chair naked except for jacket all day. Refused to bathe or wear briefs for urinary incontinence. Trouble with ADLs except feeding self. Despite this patient insisted she return home and did so a couple days ago. Initially she would answer (family members) call to check in but yesterday didn't answer. (Family member) went to check on her and found her sitting in dark room in urine .(family member) decided to being her in for toe pain, and decline in mental status A copy of a document titled, Inter-facility Transfer After Visit Summary dated 3/14/19, indicated Resident H was admitted to the hospital on [DATE] for Dementia, and the physician certified, .the patient is homebound due to the following reasons: absences from home require considerable and taxing effort An admission list of Resident H's active [DIAGNOSES REDACTED]. A copy of a baseline care plan for Resident H was provided by the CRC on 4/3/19 at 9:30 a.m. The Baseline care plan was dated 3/14/19, but did not include any information regarding Resident H's [DIAGNOSES REDACTED]. Although admitted to the facility for dementia, an admission assessment titled, Wandering Observation Tool dated, 3/14/19, indicated Resident H did not have a [DIAGNOSES REDACTED]. An admission nursing progress note was provided by the CRC on 4/3/19 at 9:30 a.m. The progress note was dated, 3/14/19 at 10:08 p.m., and indicated, . resident received via (name of hospital) transportation . she was admitted to hospital with c/o (complaint of) altered mental status A second nursing progress note was provided by the CRC on 4/3/19 at 9:30 a.m. The progress note was dated 3/15/19 at 4:48 p.m., and indicated, . writer continually re-educated resident to surrounding and time; intermittent confusion noted . resident enjoys walking . resident stated being restless with nothing to do causes her to be angry A Medical Doctor (MD) progress note was provided by the CRC on 4/3/19 at 9:30 a.m. The MD note was dated 3/18/19, and indicated, . (Resident H) with dementia . was found to have continued functional deficits and therefore was recommended for further therapy and then transferred to (name of facility) Patient has a surrogate decision-maker . history of dementia During an interview with the CRC, on 4/3/19 at 9:30 a.m., the CRC provided a copy of an Elopement Incident report, dated 3/19/19. The report indicated, a review of camera footage which showed Resident H exiting the facility via the front door on 3/14/19 at 1:58 p.m., and was returned to the facility at 3:27 p.m., a total of 1 hour and 29 minutes. The CRC indicated Resident H was absent from the building for an unapproved extended amount of time, staff did not know she was missing, and after a review of the video footage, it was determined that no one was at the front desk at the time Resident H walked out the front door. The CRC indicated no police report had been filed. During an interview with the Administrator (ADMN), on 4/2/19 at 12:00 p.m., he indicated Resident H had eloped from the facility through the front door, and had apparently walked to a nearby store. The facility had been unaware Resident H was missing, until Resident H's family member called the facility and notified them, Resident H was with the police at the nearby location. The administrator was not in the building at the time Resident H eloped, but had been notified by facility staff. During an interview with the Social Services Director (SSD), on 4/3/19 at 10:20 a.m., she indicated she was working the day Resident H eloped. The SSD was notified by the receptionist that Resident H's family member was on the phone to notify the facility that Resident H needed to be picked up from a nearby location. When she arrived, Resident H was leaning against the police car, and indicated she just wanted to go for a walk to get some fresh air. The SSD indicated she remembered Resident H was very busy, and often walked up and down the halls, and going from place to place. During an interview with the Bus Driver, on 4/3/19 at 10:30 a.m., he indicated, he and the SSD went to pick Resident H at a nearby store. Resident H was with the police when he arrived, and when he asked Resident H what happened, Resident H indicated she went for a walk. During an interview with the CRC, on 4/3/19 at 2:03 p.m., she indicated, the purpose of the baseline care plan was to accurately assess a resident upon admission, and put immediate necessary plans in place for that resident's care and safety. Staff should have looked at that hospital-stay summary and understood the resident had been in the hospital for a reason, altered mental status. Now she was here, at the facility, so staff should have considered what care this resident required, and hopefully prevent something like this from happening. Resident H should not have been able to leave the facility without staff knowledge or assistance. During an interview with the Bus Driver, on, 4/4/19 @ 10:40 a.m., he indicated, as the facilities Bus Driver, Resident H was found in the parking lot of the nearby store, which was on the corner of a busy and heavily congested traffic intersection. The intersection at the stores location consisted of 4 lanes of traffic, coming from 4 directions, and had a 4 way stoplight system, which would be potentially dangerous for anyone to cross, but especially Resident H since she was apparently confused. During an interview with the SSD on 4/4/19 1:47 p.m., she provided a copy of a fax cover sheet for a receiving facility to review and admit Resident H. The note indicated, . Resident (H) in need of secure unit with higher level of protection then we can provide SSD indicated it was determined Resident H needed a higher level of security and more one on one attention. During an interview with the Interim Director of Nursing (IDON), on 4/4/19 at 1:55 p.m., she indicated she was not in the building at the time Resident H eloped, but was familiar with the resident. Resident H liked to keep busy and would often walk up and down the halls, in and out of activities, and go from place to place. During an interview with Licensed Practical Nurse 5 (LPN) on 4/4/19 at 2:02 p.m., she indicated she worked with Resident H the day after her admission. Resident H had intermittent confusion. She was very busy, and would often be out of her room, and go throughout the facility. During an interview with the Activity Director (AD) on 4/4/19 at 2:10 p.m., she indicated Resident H was a very memorable resident. Resident H was very busy, and often seen walking the halls. During an interview with the CRC on 4/4/19 at 9:15 a.m., she indicated there was no facility policy to address the prevention of accidents, but indicated the facility should have more thoroughly assessed Resident H, been aware of her worsening dementia diagnosis, and put interventions in pace to prevent her from being able to exit the facility. The immediate jeopardy that began on 3/19/19 was removed and the deficient practice corrected on 4/4/19 when the facility provided direct one on one training and re-education to all front desk staff, on how to ensure residents did not leave the facility unattended. Additionally, the main entrance front doors were secured with a new automatic locking mechanism, and all facility staff was re-inserviced on the facilities Elopement policy and procedures. This Federal tag relates to Complaint IN 249. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide treatment and care to prevent a significant medication error resulting in a resident's hospitalization for 1 of 2 residents reviewed for medication errors. (Resident 6). Findings include: 1. On 1/04/19 at 02:51 p.m., Resident 6's medical records were reviewed. The [DIAGNOSES REDACTED]. A review of the medication administration notes indicated the following medications were not given: a. On 10/24/18 at 10:23 a.m., Multivitamin one tablet in the morning, the medication was not in and the pharmacy was aware. b. On 10/25/18 at 10:19 a.m., Neupro patch 6 mg (milligram) /24 hour for anti [MEDICAL CONDITION], the facility was awaiting pharmacy delivery. c. On 11/11/18 at 12:01 p.m., [MEDICATION NAME]-[MEDICATION NAME] tablet 25-250 mg give one tablet every four hours related to [MEDICAL CONDITION], the medication was unavailable. d. On 11/11/18 at 6:22 p.m., [MEDICATION NAME]-[MEDICATION NAME] tablet 25-250 mg , give one tablet every four hours related to [MEDICAL CONDITION], the medication was unavailable. e. On 11/11/18 at 8:28 p.m., [MEDICATION NAME]-[MEDICATION NAME] tablet 25-250 mg , give one tablet every four hours related to [MEDICAL CONDITION], the medication was reordered from (name of pharmacy). f. On 11/11/18 at 11:58 p.m., [MEDICATION NAME]-[MEDICATION NAME] tablet 25-250 mg , give one tablet every four hours related to [MEDICAL CONDITION], the medication was on order. g. On 11/12/18 at 5:03 a.m., [MEDICATION NAME]-[MEDICATION NAME] tablet 25-250 mg , give one tablet every four hours related to [MEDICAL CONDITION], the medication was reordered. h. On 11/12/18 at 10:57 a.m., [MEDICATION NAME]-[MEDICATION NAME] tablet 25-250 mg , give one tablet every four hours related to [MEDICAL CONDITION], the medication was not on hand and a request was faxed to (name of pharmacy). i. On 11/21/18 at 10:21 a.m., 60 cc (cubic centimeters, a measure of volume) Med Pass (a nutritional supplement) three times a day, the supplement was not available. j. On 11/21/18 at 12:01 p.m., 60 cc Med Pass three times a day, the supplement was not available. k. On 11/26/18 at 10:13 a.m., 60 cc Med Pass three times a day, the supplement was not available. l. On 11/26/18 at 10:18 a.m., Multivitamin one tablet in the morning, the vitamin was not in and the pharmacy was to deliver. m. On 11/27/18 at 9:59 a.m., 60 cc Med Pass three times a day, the supplement was not available. n. On 11/27/18 at 11:56 a.m., 60 cc Med Pass three times a day, the supplement was not available. o. On 12/02/18 at 8:27 a.m., Multivitamin one tablet in the morning, the vitamin was not in and the pharmacy was deliver. p. On 12/3/18 at 9:00 a.m., Multivitamin one tablet in the morning, the vitamin was not in and the pharmacy was to deliver. q. On 12/05/18 at 10:39 a.m., Multivitamin one tablet in the morning, the vitamin was not in and the pharmacy was to deliver. r. On 12/07/18 at 9:30 a.m., Multivitamin one tablet in the morning, the vitamin was not in and the pharmacy was to deliver. s. On 12/12/18 at 07:32 a.m., Sitagliptin [MEDICATION NAME] (diabetic supplement medication) 100 mg one in the morning for antidiabetic supplement, the facility was awaiting the pharmacy to deliver. A review the MAR (Medication Administration Record) for the month of (MONTH) had eleven (11) doses of Carbodopa-[MEDICATION NAME] 25-250 mg without a nurse's signature for administration and no corresponding note ( 11/4/18, 2 doses, 11/15/18, 2 doses, 11/22/18, 1 dose, 11/25/18, 2 doses, 11/26/18, 2 doses, and 11/28/18, 2 doses). The month of (MONTH) had six doses of Carbodopa-[MEDICATION NAME] 25-250 mg without a nurse signature for administration and no corresponding note ( 12/14/18, 1 dose, 12/16/18, 1 dose, 12/20/18, 1 dose, 12/21/18 1 dose, 12/23/18, 1 dose, and 12/28/18, 1 dose). On 1/8/19 at 10:42 a.m., in an interview the Clinical Consultant indicated she did not know if the medications not signed off on the MAR indicated [REDACTED]. Without a progress note there is no information. Administered medications should have been signed off. On 11/12/18 at 12:01 p.m., a Medication Administration Note indicated, a four day supply picked up from (name of pharmacy) by nurse management and delivered to assigned staff nurse. On 12/9/2018 at 2:38 p.m., a Nurse's Note Text indicated Guest was found unresponsive during breakfast time. Tried talking to him with no responsive. V/S (vital signs) bp (blood pressure) 110/56mmofhg (measurement), t (temperature) 97.1, p (pulse) 62, r (respirations) 14 b/m (breaths per minute), spo2 (oxygen saturation) 99% (percent) abd bs (blood sugar) 140. He was not able to have his medication and breakfast. He is in (name of hospital) . On call doctor and POA (power of attorney) informed. On 12/9/2018 at 5:00 p.m., a Nurses Note Note Text, indicated, POA, (name of power of attorney), called. States hospital is going to admit guest for observation d/t (due to) [MEDICAL CONDITION] complication. On 12/09/18 a (name of hospital) discharge summary report note by the consulting Neurology Resident indicated, I have reviewed the patient's history, personally examined the patient and reviewed the findings in Dr. (name of other physician). I agree with the physical findings and plan as outlined in the note above. The patient seems to be more alert and interactive than what was described on admission. He is more oriented and demonstrates some parkinsonian features on exam. I suspect he has had inadequate dosing of [MEDICATION NAME] (carbodopa-levdopa). I will observe on current dose for now and determine if a dose increase is appropriate . On 1/04/19 at 02:50 p.m., during an interview, the MDS (Minimum Data Set) Coordinator, indicated, there were two ways to reorder medications. There was a button the nurse could click, on the computer, when documenting medications that will reorder, or the nurse could pull a sticker from the medication card, and fax it to the pharmacy. On the medication card there was an indicator when you got to the last row to reorder at that time. The nurse should not wait until they are out of meds to reorder. On 1/08/19 at 10:30 a.m., during a telephone interview with Pharmacist 7, she indicated the facility could reorder medication by electronic resupply, on their electronic system, or they could pull the reorder strip from the medication administration card and fax it over on a reorder sheet. Monday-Friday there were three delivery times. Reorders were sent out within the 1 to 2 delivery times. On weekends there was one late evening delivery, on each day, for anything ordered after the week day deliveries were completed. All orders would be processed and sent out within 24 hours. It could take longer on the weekend, but never more than two days to receive any order. On 1/3/19 at 1:47 p.m., the Director of Nursing Services provided a current policy titled Medication Administration. This policy indicated It is the policy of this facility to provide resident centered care that meets the psychological, physical and emotion needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care. There is no policy for the omission of medication, the facility follows standards of care practice. Residents should receive ordered medications. 3.1-48(c)(2)

Based on record review and interview, the facility failed to identify pressure ulcers on admission, failed to obtain a treatment order for the pressure ulcers until the 12th day of admission, and failed to make treatment changes when weekly monitoring indicated deterioration of the pressure ulcers resulting in the hospitalization of the resident for 1 of 7 residents identified as having pressure ulcers (Resident B). The immediate jeopardy began on 9/25/17 when the resident was admitted with pressure ulcers, the admission pressure ulcer assessment was not completed, and treatment for [REDACTED]. The Administrator and Director of Nursing were notified of the immediate jeopardy at 2:00 p.m. on 11/7/17. The immediate jeopardy was removed, and the deficient practice corrected on 11/9/17. Findings include: The record for Resident B was reviewed on 11/6/17 at 10:55 a.m. Resident B's [DIAGNOSES REDACTED]. On admission, 9/25/17, a Nursing Admission Assessment was documented. The initial skin assessment indicated the resident had an area on the coccyx covered with yellow brown slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or was mucinous), also 2 areas on the right buttock one covered with brown slough, the other with yellow slough. In addition, there were 2 areas on the left buttock covered with yellow slough, and an area of shearing measuring 2 cm (centimeters) by 3 cm. The Skilled Documentation, dated 9/27/17 at 10:32 p.m. indicated Has oa (open area) to bilat (bilateral) buttocks. New treatment applied . There was no physician's order for treatment. The Skilled Documentation, dated 9/30/17 at 9:36 a.m., indicated Has open areas to bilat buttocks and coccyx. Dressing applied. There was no physician's order for treatment. On 10/1/17 at 2:25 p.m., the nurse indicated on the Skilled Documentation .continues to have open areas to bilat buttocks and coccyx that have worsened (since Friday 9/30) (sic) . The first Ulcer/Wound Documentation by the wound team was on 10/4/17. The coccyx wound measured 6.4 cm by 2.9 cm by 0.1 cm. No stage was identified. The description of the wound was slough. On 10/11/17, the next documentation of the coccyx ulcer by the wound team indicated the measurement was 7 cm by 3 cm by 2 cm and the wound was unstageable, with the same wound description. On 10/18/17 the coccyx wound measured 8 cm by 5.8 cm by 4.5 cm and was unstageable, with the same description. Wound documentation for the right buttock began on 10/4/17 by the wound team. The right buttock measured 1.3 cm by 1.3 cm and was unstageable. The description indicated it was necrotic tissue (eschar - it was black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). On 10/18/17 the right buttock was 3 cm by 2.8 cm by 0.2 cm and unstageable, identified as slough. On 10/11/17 the right buttock wound was identified as inner right buttock 3.1 cm by 2.4 cm by 0.1 cm, slough. The outer right buttock measured 2.4 cm by 2 cm by 0.1 cm, slough. On 10/4/17 the left buttock wound was measured at 1.4 cm by 0.9 cm with necrotic tissue. Another left buttock ulcer was measured at 2.2 cm by 1.4 cm, necrotic tissue. On 10/11 17 these wounds were identified as upper left buttock, 1.1 cm by 1.5 cm by 0.1 cm, unstageable, slough. The second wound was lower left buttock, 0.2 cm by 0.4 cm by 0.1 cm, unstageable, slough. On the 10/18/17 documentation by the wound team the wound was identified as left buttock, 5.4 cm by 4.2 cm by 0.3 cm, unstageable, slough. A physician's order was received on 10/6/17 for Santyl (wound [MEDICATION NAME] ointment) to ulcers with no frequency or directions. On 10/10/17 an order was received for a wound clinic consultation. The wound clinic could not see the resident until 10/19/17. The October, 2017, MAR (Medication Administration Record) indicated the Santyl treatment was initiated on 10/7/17. The September and October, 2017 MARs do not document any treatment to the pressure ulcers prior to 10/7/17. Resident B was taken to the wound clinic consultation on 10/19/17, sent to the hospital from the consultation and admitted to the hospital for treatment of [REDACTED].presents to ED for evaluation of wound infection on sacral area x 3 weeks Skin: 6 x 5 cm decubitus sacral ulcer that is unstageable with necrotic tissue and foul smelling discharge, surrounding [DIAGNOSES REDACTED] (redness) and multiple other ulcerations Impression and Plan infected sacral decubitus with concern for osteo[DIAGNOSES REDACTED]. The hospital Discharge Summary, dated 10/28/17, noted Discharge Diagnosis: [REDACTED]. During an interview with the Physician's Assistant (PA) on 11/7/17 at 12:40 p.m., she indicated she had not been informed the resident had pressure ulcers on her coccyx and buttocks until informed by the wound team on 10/6/17. On 11/7/17 at 12:42 p.m., the DON indicated the wound team had seen Resident B on 9/27/17 rounds for the foot and toe wounds, but the team had not been informed of any coccyx or buttock wounds, the team had not been notified of the coccyx and buttock wounds until 10/4/17 rounds. The DON also indicated the skin assessment section of the Nursing Admission Assessment, dated 9/25/17, had not been completed by the admitting nurse until 10/19/17 when the skin condition was documented. During an interview on 11/6/17 at 1:40 p.m., LPN #1 indicated she was aware of open areas on Resident B's coccyx and buttocks on admission. On 11/8/17 at 9:30 a.m., LPN # 1 indicated she started the Nursing Admission Assessment when Resident B was admitted on [DATE], but did not finish it. She did not document the initial skin assessment on Resident B's Admission Assessment until 10/19/17, but she had done the actual assessment on admission 9/25/17. She also indicated she had informed the nurse manager of the need for a low air loss mattress for Resident B on 10/2/17. During an interview on 11/9/17 at 1:20 p.m., LPN #1 indicated she did not remember for sure what treatment she had placed on Resident B prior to the order for Santyl on 10/6/17, but thought it was an occlusive dressing. She also indicated there should have been an order for [REDACTED]. A Care Plan was initiated for impaired skin integrity on 11/7/17. The care plan interventions included a protein supplement, need to turn and reposition every 2 hours, pressure reducing devices on the bed and in the wheel chair. No previous care plan was provided by the DON (Director of Nursing). A current facility policy, dated 2/27/17, titled Wound & Ulcer Policy and Procedure was provided by the Administrator on 11/7/17 at 1:00 p.m. The policy indicated .When a resident is found to have a wound or ulcer, either on admission or during their stay, the following will be completed by licensed nurse(s): Document assessment of the wound/ulcer in the medical record. Initiate the treatment protocol appropriate for the stage assessed Document wound/ulcer treatment provision on the treatment administration record (eTAR). Notification of the physician, documenting, and initiating ordered treatment Care interventions for staff involved in the resident's care are communicated via the resident care plan. Assessment of progress toward healing is completed at least weekly and the physician is notified at least monthly of progress of healing. If there is regression, the physician is notified of the condition change The immediate jeopardy that began on 9/25/17 was removed on 11/9/17 when the facility assessed all residents' skin, clinical staff were in-serviced on the policy and procedures for documenting Resident Skin Assessments, all non-clinical staff were in-serviced on pressure ulcer prevention and management, and interviewed clinical staff identified the contact person for new skin impairments identified and where to document the new skin impairment. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility need for continued monitoring. This Federal tag relates to Complaint IN 441. 3.1-40(a)(2)

Based on record review and interview, the facility failed to monitor and assess a resident who exhibited abnormal vital signs and was administered medication known to lower blood pressure. This deficient practice resulted in harm with an emergency transport to an acute care hospital and delayed treatment for [REDACTED]. Findings include: Resident C's record was reviewed on 4/9/15 at 11:20 a.m. Resident C had [DIAGNOSES REDACTED]. The record indicated Resident C was a full code. A Minimum Data Set (MDS) assessment tool dated 1/20/15, indicated Resident C was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. A nurse's note dated 1/26/15 at 2:26 p.m., indicated a physician was notified and informed Resident C's heart rate was 140 beats per minute. This note further indicated the physician ordered [MEDICATION NAME] 3.125 Milligrams twice a day (beta blocker used to slow the heart rate and also decrease blood pressure). An untimed telephone physician's orders [REDACTED]. A nurse's note dated 1/26/15 at 5:45 p.m., indicated on 1/26/15 at 4:00 p.m., Resident C was assessed and noted to have a blood pressure of 98/63, a heart rate that was tachy (heart rate beating too fast) at 141 beats per minute, respirations of 20, and an elevated temperature of 99.4. This note indicated a physician was notified and orders were obtained for [MEDICATION NAME] and at 4:45 p.m., the [MEDICATION NAME] was administered. This note indicated at 5:45 p.m., Resident C's heart rate continued to be tachy at 139 beats per minute. This note indicated Licensed Practical Nurse (LPN) #2 had another nurse assess Resident C and was informed that his heart rate continued to be tachy. This note indicated Resident C's son called the facility with concerns regarding his father's elevated heart rate. This note further indicated at 7:45 p.m., Resident C indicated to LPN #2 he felt like he had a temperature. LPN #2 assessed his temperature and indicated it was 101.6. The record lacked indication Resident C's blood pressure was reassessed after the [MEDICATION NAME] was administered and lacked indication Resident C's pulse was reassessed after LPN #2 informed LPN #1 Resident C's heart rate continued to be tachy. A late entry nurse's note dated 1/27/15 at 2:39 p.m., indicated on 1/26/15 at 6:15 p.m., LPN #2 assessed Resident C's heart rate and indicated it was beating in the low to mid 90's. This note further indicated LPN #1 reported his findings to LPN #1. A nurse's note dated 1/26/15 at 8:44 p.m., indicated Resident C called 911 from his room and demanded to be taken to the hospital. A run report document from the fire department dated 1/26/15, indicated at 8:12 p.m., the Emergency Medical Technicians arrived at the facility and assessed Resident C. This note indicated at 8:12 p.m., Resident C's blood pressure was 72/56, his heart rate was 200. This note further indicated a 12 lead EKG (diagnostic test for the heart) indicated MI ([MEDICAL CONDITION] infarct) Suspected.complex [MEDICAL CONDITION] 142. During an interview on 4/13/15 at 12:08 p.m., LPN #1 indicated he was asked by LPN #2 to assess Resident C's heart rate. LPN #1 indicated at approximately 6:00 p.m., he assessed Resident C's heart rate and reported to LPN #2 his heart rate remained tachy in the 90s. He indicated a tachy heart rate in the 90s bears watching. LPN #1 indicated he did not check Resident C's blood pressure. He indicated he was assigned to another hall and did not re-assess Resident C's status again. During an interview on 4/13/15 at 1:11 P.M., LPN #2 indicated she was informed by LPN #1 that Resident C's heart rate remained tachy in the 90's. She indicated it was the end of her shift and she left without reassessing Resident C's status. She indicated she did not take his blood pressure after the [MEDICATION NAME] was administered. During an interview on 4/13/15 at 12:20 p.m., the Director of Nursing (DON) indicated she would have expected Resident C's blood pressure to be monitored after he was administered the beta blocker. During the exit conference on 4/13/15 at 1:30 p.m., with the Administrator and DON present, the DON indicated she did not have indication Resident C's status was assessed after LPN #1 assessed him and prior to the Emergency Medical Technicians arrived at the facility at 8:12 p.m. A policy titled Vital Signs. and identified as current by the Administrator on 4/13/15 at 12:57 p.m., indicated, .objective: To monitor resident status. To determine resident's response to treatment. To assess a potential change in condition. It is the policy of this facility to maintain the highest quality of care for its residents in regards to vital signs. This Federal tag relates to Complaint IN 684. 3.1-37(a)