Every finding on record at Great Lakes Healthcare Center

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to wear the correct personal protective equipment (PPE) for a resident in enhanced barrier precautions for 1 of 1 resident with a peg tube (a tube inserted directly into the stomach for nutrition) and an indwelling Foley (urinary) catheter. (Resident S) Finding includes:During a random observation on 6/16/26 at 2:43 p.m., Resident S was observed in bed with an enteral tube feeding infusing at 65 cubic centimeters (cc) per hour on a pump. The resident had an indwelling Foley catheter hanging on the side of the bed that was very full of urine. CNA 1 and CNA 2 entered the room to provide incontinence care. At that time, they both donned clean gloves to both hands without performing hand hygiene and neither one of them donned an isolation gown. Both CNAs unfastened the incontinent brief and removed it, and CNA 1 wiped the resident's peri area, as there was bowel movement observed. They rolled the resident onto to her right side and CNA 2 provided incontinence care to remove the rest of the bowel movement.During an interview at that time, both CNAs were asked if they were aware they were supposed to be wearing an isolation gown while performing care and coming in contact with the resident. CNA 1 indicated she was aware and CNA 2 did not answer the question. Neither CNA stopped what they were doing and donned an isolation gown. At 2:48 p.m., CNA 1 removed her gloves, threw them away, left the room, performed hand hygiene from the hand sanitizer dispenser in the hallway and walked down the hall. CNA 1 came back to the room at 2:50 p.m. and donned a pair of clean gloves to both hands without performing hand hygiene. She did not don an isolation gown. She walked back over to the bed and continued to assist CNA 1 with incontinence care.At 2:53 p.m., CNA 2 opened the drawer on the night stand and inside was a cylinder to empty the Foley catheter, he squatted down, opened the flange and poured the urine into the cylinder, he did not don an isolation gown.The record for Resident S was reviewed on 6/16/26 at 1:31 p.m. Diagnoses included, but were not limited to, peg tube (a tube inserted directly into the stomach for nutrition) and obstructive and reflux uropathy (blockage of urinary flow).The 4/22/26 Significant Change Minimum Data Set (MDS) assessment indicated the resident was severely impaired for decision making. The resident had an indwelling Foley catheter.A Care Plan, dated 4/27/26, indicated the resident required enhanced barrier precautions for the peg tube and Foley catheter. The approaches were to were to don the appropriate PPE (personal protective equipment) during high contact care by care givers (dressing, bathing/showering, transferring in room or therapy gym, providing hygiene, changing linens, changing briefs or assisting with toileting).A Physician's Order, dated 5/21/26, indicated enhanced barrier precautions related to a Foley & enteral feeding when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting.During an interview on 6/16/26 at 3:15 p.m., the Regional Director of Clinical Operations indicated enhanced barrier precautions were to be implemented while providing care for the resident. The current Enhanced Barrier Precautions policy provided by the Administrator on 6/17/26 at 11:47 a.m., indicated Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employed hand hygiene, targeted gown and glove use during high contact resident care activities that include; Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring adressing.This citation relates to Intake 3018321.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure skin rashes were treated for 1 of 3 residents reviewed for non-pressure related skin conditions and medications were administered as ordered by the physician for 1 of 3 residents reviewed for pain. (Residents S and F)Findings include: 1. During a random observation on 6/16/26 at 2:43 p.m., Resident S was observed in bed. CNA 1 and CNA 2 entered the room to provide incontinence care. Both CNAs unfastened the incontinence brief and removed it. CNA 1 wiped the resident's peri area, as there was bowel movement observed. They rolled the resident onto to her right side, and there was a large bandage covering her sacral area that was dated 6/15/26. The skin surrounding the bandage was clean and pink. CNA 2 provided incontinence care to remove the rest of the bowel movement. CNA 2 removed the cap from a tube of Calmoseptine ointment (a moisture barrier ointment) and spread it on her buttocks below the bandage. The record for Resident S was reviewed on 6/16/26 at 1:31 p.m. Diagnoses included, but were not limited to, peg tube (a tube inserted directly into the stomach for nutrition), heart failure, and obstructive and reflux uropathy (a blockage in the urinary tract). The 4/22/26 Significant Change Minimum Data Set (MDS) assessment indicated the resident was severely impaired for decision making. A Care Plan, dated 1/27/26, indicated the resident was at risk for pressure ulcer development, impaired skin integrity, or at risk for altered skin integrity related to a decline in functional status. The approaches were to administer treatments as ordered by the medical provider. A Wound Nurse Practitioner (NP) Note, dated 5/11/26, indicated the resident had a new onset of irritant contact dermatitis on the inner buttocks. The wound base was 100% epithelial tissue (body tissue) and the edges were attached. The treatment recommendation was to cleanse the area with wound cleanser, apply Zinc Oxide Paste (a skin protectant) to the base of the wound, and leave open to air daily and as needed (PRN). There was no physician's order written or implemented for the wound cleanser treatment or Zinc Oxide paste to the inner buttocks. A Wound NP Note, dated 5/21/26, indicated to continue zinc oxide-based barrier cream to the contact dermatitis. A Physician's Order, dated 5/21/26, indicated Zinc Oxide External Ointment 20%, apply to affected area topically as needed (PRN) for dry skin. There was no daily scheduled Zinc Oxide administration order written and no wound cleanser treatment. The Wound NP Notes, dated 6/8/26 and 6/15/26, indicated the contact dermatitis remained with 100% epithelial tissue and the treatment remained the same. The dermatitis to the buttocks was improving. The Medication and Treatment Administration Records (MAR/TAR) for the months of 5/2026, and 6/2026 indicated the Zinc Oxide ointment was not signed out as being administered. During an interview on 6/16/26 at 3:45 p.m., the Wound Nurse indicated the dermatitis was right under the wound on the inner buttocks. She was unaware there was a treatment order for the dermatitis from the Wound NP for the Zinc Oxide. She had no additional information to provide. 2. During an interview on 6/15/26 at 1:45 p.m., Resident F indicated staff was not giving her the correct medications. When she questioned the staff, they would tell her she was wrong. She indicated on 6/14/26, the nurse tried to give her eight pills in the morning, but she was supposed to have seven. The nurse told her she was getting two Lasix (a diuretic, used to treat fluid retention) but she knew that was not right. The record for Resident F was reviewed on 6/15/26 at 9:46 a.m. Diagnoses included, but were not limited to, aftercare following joint replacement surgery, infection due to joint prosthesis, and diabetes. The Medicare-5 Day Minimum Data Set (MDS) assessment, dated 4/22/26, indicated the resident was cognitively intact for daily decision making and was dependent for activities of daily living (ADLs). A Physician's Order, dated 6/12/26, indicated Lasix 20 mg (milligrams), one tablet by mouth, one time a day. An Alert Charting Note, dated 6/14/26 at 6:51 p.m., indicated . Reason for assessment: Other. Description of other reason for assessment: Med [medication] error. Description of event or change: The patient reported receiving a medication cup from the day shift nurse that contained a large number of pills. When the patient requested clarification about the medications, the nurse did not provide additional information. Additionally, the patient observed that her scheduled evening medication was absent from the medication administration strip following the shift change. The situation was reported promptly to address the error and ensure patient safety.Interventions in use: Vital signs monitored Neuro checks initiatedNotifications Made: Provider notified Resident/Resident Representative notifiedResident is currently stable.New orders for the resident have not been received.Follow-up plan: n/aResident remains in the facility.Resident was seen by the Physician during the shift.Summary of outcome: n/a. During an interview on 6/17/26 at 12:30 p.m., the Regional Director of Clinical Operations indicated on 6/14/26, RN 1 dispensed two Lasix pills with the intent to administer to the resident, but she should only have given her one. The facility was investigating the medication error and RN 1 was suspended. This citation relates to Intakes 3012287 and 3018321. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure the head of the bed was elevated to at least a 30 degree angle for a resident with an enteral feeding (tube feeding) that was infusing for 1 of 1 resident randomly observed for tube feeding. (Resident S) Finding includes:During a random observation on 6/16/26 at 2:43 p.m., Resident S was observed in bed with a tube feeding infusing at 65 cubic centimeters (cc) per hour on a pump. CNA 1 and CNA 2 entered the room to provide incontinence care. CNA 2 took the remote control for the bed and laid the resident's head of the bed all the way down so she was completely flat in the bed. CNA 1 was asked if she had put the tube feeding on hold and she indicated she did not. CNA 2 was then instructed to raise the head of the bed immediately.During an interview at that time, CNA 2 was unaware the head of the bed was not supposed to be flat while the enteral feeding was infusing.The record for Resident S was reviewed on 6/16/26 at 1:31 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), peg tube (a tube inserted directly into the stomach for nutrition), heart failure, and chronic respiratory failure with hypoxia.The 4/22/26 Significant Change Minimum Data Set (MDS) assessment indicated the resident was severely impaired for decision making, had a peg tube, and received an enteral feeding. A Care Plan, dated 4/24/26, indicated the resident required a tube feeding. The approaches were to ensure the head of the bed was elevated to 30 degrees. A Physician's Order, dated 6/5/26, indicated Jevity 1.5 at 65 milliliters (ml) per hour for 20 hours via pump, on at 7:00 a.m. During an interview on 6/16/26 at 3:15 p.m., the Regional Director of Clinical Operations indicated the CNA should not have put the head of the bed down while the enteral feeding was infusing. CNA 2's Nurse Aide Orientation/Training Guide, dated 6/3/26, indicated the CNA was signed off as having demonstration and return demonstration of resident environment and safety of turning and repositioning with tubing. During an interview on 6/17/26 at 12:07 p.m., CNA 3 indicated she had trained CNA 2 during orientation. She had shown the CNA how to position tubing whether it was Foley or a peg tube so that it did not get pulled out during transfers. She also instructed the CNA not to ever lay the head of the bed down while the tube feeding was infusing. The current Enteral General Nutritional (tube feeding) Guidelines policy, provided by the Administrator on 6/17/26 at 11:47 a.m., indicated residents that received bolus and/or intermittent feeding would have the head of the bed elevated at least 30 degrees during feeding and 1 (one) hour post feedings to decrease the risk for respiratory aspiration. Residents receiving continuous meals would maintain the head of the bed at least 30 degrees to reduce aspiration.410 IAC (Indiana Administrative Code) 16.2-3.1-44(a)(2)

Based on observation, record review, and interview, the facility failed to ensure intravenous (IV) access sites were assessed and flushed regularly for 2 of 3 residents reviewed for IV therapy. (Residents J and H) Findings include:1. During an observation on 6/16/26 at 8:07 a.m., Resident J was resting in bed. She had an implanted port on her right upper chest, and an infusion was in progress via a pump. The record for Resident J was reviewed on 6/15/26 at 3:58 p.m. Diagnoses included, but were not limited to, diabetes, endometrial cancer, and nephrostomy (a tube inserted to drain the kidney).The Quarterly Minimum Data Set (MDS) assessment, dated 6/5/26, indicated the resident was cognitively intact for daily decision making, and required substantial assistance with activities of daily living (ADLs).A Care Plan, initiated on 4/4/25, indicated the resident had a right chest port. Interventions included to flush the site every 24 hours and visually inspect it each shift. A Physician's Order, dated 6/11/26, indicated Cipro (an antibiotic) IV (intravenously) twice a day, until 6/17/26. Start on 6/11/26 at 8:00 a.m.The Medication Administration Record (MAR) for June 2026 indicated the resident received the IV antibiotic twice a day from 6/11/26 through 6/16/26.The record lacked documentation of an assessment and flushing of the IV site (right chest port). During an interview on 6/16/26 at 10:05 a.m., the Regional Director of Clinical Operations and the Divisional Director of Clinical Services indicated the flushing and site assessment should be documented every shift. 2. During an observation on 6/16/26 at 8:45 a.m., Resident H was observed resting in bed. A PICC line (a temporary IV access) was observed in his right arm. At that time, there was no infusion in progress. The resident's record was reviewed on 6/16/26 at 9:42 a.m. Diagnoses included, but were not limited to, respiratory failure, diabetes, and pneumonia.The Medicare-5 Day Minimum Data Set (MDS) assessment, dated 5/13/26, indicated the resident was cognitively intact for daily decision making, and required substantial assistance with ADLs.A Care Plan, initiated on 3/23/26, indicated the resident had a PICC line in his right arm. Interventions included to flush the line and visually inspect the site each shift. Physician's Orders, dated 6/13/26, indicated Cresemba (an antifungal medication) IV daily and Zerbaxa (an antibiotic) IV three times a day for twenty days.The Medicaton Administration Record (MAR) for June 2026 indicated the resident received IV Cresemba on 6/13/26, 6/14/26, and 6/15/26 and the resident received IV Zerbaxa on 6/13/26 at 2:00 p.m. and 9:00 p.m., and 6/15/26 at 9:00 a.m., 2:00 p.m., and 9:00 p.m.The record lacked documentation of any assessment and flushing of the PICC site. During an interview on 6/16/26 at 10:05 a.m., the Regional Director of Clinical Operations and the Divisional Director of Clinical Services indicated the flushing and site assessment should be documented every shift.A policy titled, Intermittent Infusion, received from the Administrator as current on 6/16/26, indicated, . Flush venous access device with prescribed flushing agent . to maintain patency between intermittent infusions . Documentation in the medical record includes, but is not limited to . prescribed flushing agent(s) . site assessment .This citation relates to Intake 3018321.410 IAC (Indiana Administrative Code) 16.2-3.1-47(a)(2)

Based on record review and interview, the facility failed to ensure residents received medications as prescribed for 1 of 3 residents reviewed for pain and 1 of 3 residents reviewed for intravenous (IV) therapy. (Residents F and H) Findings include:1. During an interview on 6/15/26 at 1:45 p.m., Resident F indicated she was not getting her oxycodone (a narcotic pain reliever) every four hours as it was ordered. When she asked for it, the staff would say they did not have the medication or it was not available. The record for Resident F was reviewed on 6/15/26 at 9:46 a.m. Diagnoses included, but were not limited to, aftercare following joint replacement surgery, infection due to joint prosthesis, and diabetes.The Medicare-5 Day Minimum Data Set (MDS) assessment, dated 4/22/26, indicated the resident was cognitively intact for daily decision making, and was dependent in activities of daily living (ADLs). A Physician's Order, dated 4/29/26, indicated oxycodone 5 mg (milligrams) by mouth every four hours for pain.A Nurse's Note, dated 4/26/26 at 1:19 p.m., indicated the nurse contacted the pharmacy because the oxycodone was not available.A Nurse's Note, dated 4/29/26 at 5:03 p.m., indicated they were waiting for the pharmacy to deliver the oxycodone refill order. A Nurse's Note, dated 5/21/26 at 8:08 a.m., indicated an order was received to give the resident one dose of oxycodone 10 mg due to missing two prior doses. The Medication Administration Record (MAR) for May 2026 indicated the resident did not receive the scheduled doses of oxycodone on 5/21/26 at 2:00 a.m., 5/21/26 at 6:00 a.m., and 5/21/26 at 10:00 a.m.The MAR for June 2026 indicated the resident did not receive the scheduled doses of oxycodone on 6/6/26 at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m.; on 6/7/26 at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m.; on 6/8/26 at 2:00 a.m., 6:00 a.m., and 10:00 a.m.During an interview on 6/17/26 at 12:30 p.m., the Divisional Director of Clinical Services indicated they were having trouble with the resident's prescription for the oxycodone. 2. The record for Resident H was reviewed on 6/16/26 at 9:42 a.m. Diagnoses included, but were not limited to, respiratory failure, diabetes, and pneumonia.The Medicare-5 Day Minimum Data Set (MDS) assessment, dated 5/13/26, indicated the resident was cognitively intact for daily decision making and required substantial assistance with ADLs. A Physician's Order, dated 6/13/26, indicated Zerbaxa (an intravenous antibiotic), three times a day for pneumonia. The Medication Administration Record (MAR) for June 2026 indicated the resident did not receive the scheduled doses of Zerbaxa on 6/14/26 at 9:00 a.m., 2:00 p.m., and 9:00 p.m. A Nurse's Note, dated 6/14/26, indicated they were waiting for the medication to arrive from the pharmacy. During an interview on 6/16/26 at 10:11 a.m., RN 2 indicated if they ordered a medication from the pharmacy, it would take up to 24 hours to receive it. The timeframe was the same for all types of medications, weekends and weekdays. An informational sheet from the pharmacy, received from the Administrator on 6/17/26 at 9:10 a.m., indicated the pharmacy was available 24 hours/day, 7 days/week. If a medication was not available and needed prior to the next delivery, staff should call the pharmacy for a STAT delivery. A Care Plan, revised on 6/12/26, indicated the resident had PICC line (a temporary intravenous access). Interventions included administering intravenous medications as ordered. During an interview on 6/17/26 at 1:00 p.m., the Regional Director of Clinical Operations was informed of the findings and had no additional information to provide. This citation relates to Intake 3018321.410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)

Based on observation and interview, the facility failed to ensure the resident's environment was clean and in good repair related to dirty floors, bed rails, tables, and enteral feeding poles, as well as torn privacy curtains and uncontained wash basins, urinals and plastic cylinders for 3 of 3 units. (The South, West, and East units).Findings include:During the Environmental Tour on 3/24/26 at 10:45 a.m., with the Administrator, the Maintenance Director, the Housekeeping Director, and the District Manager of Housekeeping, the following was observed: South Unit a. room [ROOM NUMBER] - the return ceiling vent was dirty as well as the entire floor. The base of tube feeding pole observed by bed two had a large amount of dried enteral feeding on top on it. There were two residents who resided in the room. [NAME] Unit a. room [ROOM NUMBER] - the over bed table was dirty and there was a pink wash basin observed on the floor in the bathroom as well as a clear cylinder container on the back of the toilet. There were two residents who resided in the room and shared the bathroom. b. room [ROOM NUMBER] - the padding on the bed rails for bed two were cracked and dirty. There was a large amount of food crumbs in the bed as well. There were two residents who resided in the room. c, room [ROOM NUMBER] - there were clear plastic cylinders on the back of the toilet that were uncontained and a pink wash basin uncontained on the floor. The storage bins in the bathroom were dirty. There were two residents who used the bathroom. d. room [ROOM NUMBER] - The bed rails for bed one were dirty as well as the table where the television was placed. There was an uncontained urinal, a clear plastic cylinder and a wash basin on the floor. There were two residents who resided in the room and shared the bathroom. e. room [ROOM NUMBER] - the resident in bed one had some personal items stored in a bed pan on top of the closet shelf. There were two residents who resided in the room. f. room [ROOM NUMBER] - there were two uncontained clear plastic cylinders observed on the back of the toilet. There were two residents who shared the room. g. room [ROOM NUMBER] - the privacy curtains were falling off the hooks and ripped in several areas. There were two residents who resided in the room. h. room [ROOM NUMBER] - the bathroom floor was was stained behind the toilet and the floor by the heat register was peeling. There were two residents who resided in the room and shared the bathroom. East Unit a. room [ROOM NUMBER] - the base of the tube feeding pole was dirty with a large amount of dried enteral feeding. The floor in the residents room was dirty against the base board and the privacy curtain was not on some of the hooks. The white cloth chair was heavily soiled with brown stains. There was one resident who resided in the room. b. room [ROOM NUMBER] - the base of the IV pole was dirty with dried enteral feeding. There was an uncontained urinal on the floor by the night stand. There was one resident who resided in the room. c. room [ROOM NUMBER] - the white cloth chair in the room was heavily soiled with brown stains. There was one resident who resided in the room. d. room [ROOM NUMBER] - the white cloth chair in the room was heavily soiled with brown stains. There was one resident who resided in the room. During an interview on 3/24/26 at 11:00 a.m., the Administrator indicated all of the above was in need of cleaning and/or repair. During an interview on 3/24/26 at 1:45 p.m., the Regional Nurse Consultant indicated the facility had no policy for the storage of wash basins, cylinders, and urinals. The multi-use equipment should have been stored off the floor and contained in a plastic bag. 410 IAC (Indiana Administrative Code) 16.2-3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADLS) received the care and assistance needed related to showers, greasy hair, dirty fingernails, and facial hair for 5 of 12 residents reviewed for ADLS. (Residents 96, H, C, 95, and 19)Findings include: 1. During an interview on 3/16/26 at 4:03 p.m., Resident 96 indicated he does not always get a shower two times a week. The record for Resident 96 was reviewed on 3/19/26 at 10:16 a.m Diagnoses included, but were not limited to, stroke, need for assistance with personal care, depressive disorders, and depression. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 12/18/26, indicated the resident was moderately impaired for daily decision making and needed substantial to max assist for bathing and personal hygiene. The resident had a limited range of motion impairment to one side for both upper and lower extremities. A Care plan, revised on 12/18/25, indicated the resident had a behavior problem of refusing care such as showers. Shower sheets provided by the facility indicated at the top of the form, there was a section to check if the resident refused or accepted the shower/bed bath. There were shower sheets for the following days: 1/2, 1/6, 1/9, 1/12, 1/13, 1/16, 1/21, 1/22, 1/23, 1/27, 1/30, 2/3, 2/6, 2/10, 2/13, 2/17, 2/20, 2/24, 2/27, 3/3, 3/6, 3/10, 3/13, and 3/18/26, however, the only time there was a check mark in accepted the shower was on 1/12, 1/16, 1/22, 2/3, 2/24, 2/27, 3/3, and 3/18/26. During an interview on 3/23/23 at 9:00 a.m., the Director of Nursing had no additional information to provide. 2. During an interview on 3/16/26 at 3:23 p.m., Resident H indicated he needed assistance with eating, because his right arm was healing from an old fracture and he just recently fell at home and his left arm was in a sling and fractured as well. He indicated it was hard for him to eat and set up his meal tray by himself, and most times staff would just bring his tray in and place it in front of him and not help him eat or set it up. The resident indicated no staff had asked him if he wanted to brush his teeth or even set him up to brush his teeth. He also indicated staff had not helped him or provided morning care and he had been sweating a lot and needed to be cleaned up. During an observation on 3/18/26 at 8:05 a.m., the resident was observed eating his breakfast. At that time, there were no staff observed in the room assisting him with his food. During an interview on 3/19/26 at 9:20 a.m., the resident indicated no staff had helped him or provided oral care. The record for Resident H was reviewed on 3/18/26 at 2:30 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, fracture of left humerus, ileostomy, orthostatic hypotension, heart disease, chronic kidney disease, presence right artificial shoulder joint, and syncope. The admission Minimum Data Set (MDS) was still in progress. The 3/8/26 Nursing admission Assessment, indicated the resident was cognitively intact for daily decision making. A Care Plan, dated 3/12/26, indicated the resident had a fracture to the left humerus. The approaches were to provide assistance with ADLs. In the CNA task section there was no documentation oral care was provided on 3/16/26. Shower sheets, provided by the facility indicated the resident received a shower on 3/13 and 3/17/26. During an interview on 3/23/26 at 9:00 a.m., the Director of Nursing was given the information and had no additional information to provide. 3. On 3/16/26 at 12:47 p.m., 3/18/26 at 9:52 a.m., and 3/19/26 at 9:19 a.m., Resident C was observed lying in bed. The resident's fingernails were long and had a dark debris underneath them. Record review for Resident C was complete on 3/19/26 at 9:40 a.m. Diagnoses included, but were not limited to Parkinson's disease and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 2/11/26, indicated the resident was moderately cognitively impaired. The resident was dependent on staff for personal hygiene. During an interview on 3/19/26 at 2:11 p.m., the Divisional Director of Clinical Services indicated the staff should have observed the resident's fingernails were long and dirty and cleaned and offered to cut them. She could not provide any information the resident had refused to have them cleaned or cut. 4. On 3/17/26 at 2:02 p.m., 3/18/26 at 9:58 a.m., and 3/19/26 at 11:49 a.m., Resident 95 was observed sitting in a reclining geriatric chair. The resident's fingernail were long with a dark debris underneath them. His hair was not combed and his beard was long and unkempt. Record review for Resident 95 was completed on 3/19/26 at 11:07 a.m. Diagnosed included, but were not limited to, stroke, hemiplegia, and dementia. The Quarterly MDS assessment, dated 3/4/25, indicate the resident was cognitively impaired. The resident was dependent on staff for personal hygiene. During an interview on 3/19/26 at 2:11 p.m., the Divisional Director of Clinical Services indicated the staff should have observed the resident's fingernails were long and dirty and cleaned and offered to cut them. The resident's hair should have been combed and his beard trimmed. She could not provide any information the resident had refused to have his fingernails cleaned and cut or his beard cut. A facility policy titled, Routine Resident Care and provided as current from the facility on 3/23/26, indicated, 3. Unlicensed Staff: .b. Routine care by a nursing assistant included but is not limited to the following: i. Assisting or provides for personal care . 5. During a random observation on 3/16/26 at 3:28 p.m., Resident 19 had greasy hair and a strong smell of body odor. At that time, she indicated she had not had a shower in 2 weeks. She was supposed to get showers twice a week, but did not receive them, and she did not refuse care. The resident's record was reviewed 3/17/26 at 3:49 p.m. Diagnoses included, but were not limited to, hemiplegia (paralysis of one side of the body) due to a stroke. The Quarterly Minimum Data Set (MDS) assessment, dated 2/4/26, indicated the resident was cognitively intact for daily decision making, and was dependent in activities of daily living (ADLs). A Care Plan, revised on 8/8/25, indicated the resident had an ADL self-care deficit, and was totally dependent in bathing. The Shower Sheet and Body/Skin Inspection Form for Nurse Aides for February and March 2026 indicated the following: the week of 2/15/26 to 2/21/26 no showers were accepted or refused; the week of 2/22/26 to 2/28/26 one shower was offered and accepted; the week of 3/1/26 to 3/7/26 no showers were accepted or refused; and the week of 3/15/26 to 3/21/26 one shower was offered and accepted. During an interview on 3/23/26 at 9:30 a.m., the Administrator was informed of the findings and offered no additional information. 410 IAC (Indiana Administrative Code)16.2- 3.1-38(a)(2)(A) 410 IAC (Indiana Administrative Code)16.2- 3.1-38(a)(3)(A) 410 IAC (Indiana Administrative Code)16.2- 3.1-38(a)(3)(B) 410 IAC (Indiana Administrative Code)16.2- 3.1-38(a)(3)(C) 410 IAC (Indiana Administrative Code)16.2- 3.1-38(a)(3)(D) 410 IAC (Indiana Administrative Code)16.2- 3.1-38(a)(3)(E)

Based on record review and interview, the facility failed to ensure residents with dry scaly skin were treated, treatments were completed, and abrasions were assessed and monitored for 7 of 7 residents reviewed for non-pressure related skin conditions, interventions were in place for a resident with diarrhea for 1 of 1 resident reviewed for diarrhea, and medications were held and administered with and without parameters for 4 of 5 residents reviewed for unnecessary medications. (Residents J, H, F, E, B, G , C, D, L, K, and M)Findings include: 1. During random observations, on 3/16/26 at 10:44 a.m. and 3/17/26 at 11:03 a.m., Resident J was observed in bed wearing a short sleeved hospital gown. At those times both of her arms were noted with very dry and fragile skin. Her legs were hanging out over the linens and both legs were observed with very dry and scaly skin. During a random observation on 3/18/26 at 8:05 a.m., the resident was observed sitting up in a wheelchair with no pressure relieving cushion in the bottom of the chair. She was wearing short sleeves and her arms were observed with dry flaky skin. Her legs were also observed with dry flaky skin. At 2:00 p.m., 2 CNAs pushed the resident into her room and were going to put her bed using the Hoyer (mechanical) lift. The resident was placed into bed and her incontinent brief was removed. At that time, one of the CNAs provided incontinence care and patted her buttocks dry. LPN 7 entered the room with a tube of Calmoseptine lotion to apply to the resident's buttocks. At that time, the resident's legs were observed still dry with flaky skin. During a random observation on 3/19/26 at 9:25 a.m., 1:30 p.m., and 2:30 p.m. the resident was observed up in a wheelchair, dressed in a short sleeve shirt. There was no cushion in the wheelchair. At 3:30 p.m. on 3/19/26, LPN 3 went to open up the treatment cart to see if the resident's creams were inside the drawer. At that time, both of her creams were not available. The record for Resident J was reviewed on 3/178/26 at 4:51 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, dysphagia (difficulty swallowing), hemiplegia, aphasia, peg tube (a tube inserted directly into the stomach for nutrition), Alzheimer's disease, peripheral vascular disease and high blood pressure. The admission Minimum Data Set (MDS) assessment, dated 2/25/26, indicated the resident was not cognitively intact for daily decision making. The resident was dependent on staff for ADLS and had a feeding tube. The resident had no pressure reducing device for the chair, and received applications or ointments other than to feet. A Care Plan, dated 2/20/26, indicated the resident was at risk for pressure ulcer development, impaired skin integrity, or at risk for altered skin integrity. The approaches were to administer treatments as ordered by the medical provider. Physicians' Orders, dated 2/23/26, indicated to cleanse buttocks with soap and water and apply Zinc Oxide every shift and leave open to air. Apply Ammonia Lactate lotion to bilateral feet every shift and leave open to air. The Treatment Administration Record (TAR) for 2/2026 indicated both treatments were signed out every shift as completed. The TAR for 3/2026 for both treatments indicated they were blank and not completed on 3/4 all shifts, and 3/8 and 3/16/26 for the evening shift. A Wound NP Note, dated 2/26/26, indicated the resident has no notable wounds, however would recommend Triad cream to Sacrum/ Buttocks every shift and prn (as needed) as preventative. Also recommend arm protectors, geri sleeves and pants to help prevent skin tears. Recommend the use of an emollient daily to the resident's skin routinely as the resident was was noted to have dry skin to the lower extremities. During an interview 3/19/26 at 4:00 p.m., LPN 3, the Director of Nursing, and the Assistant Director of Nursing were made aware of the resident's dry scaly skin to her arms, feet and legs, no cushion to the wheelchair, and that LPN 7 gave the CNA Calmoseptine lotion to put on the resident's buttocks. They had no additional information to provide. 2. During an interview on 3/16/26 at 3:33 p.m., Resident H indicated his bandage had not been changed since last week. At that time, LPN 2 and PTA 2 were asked to stand the resident up so his bandage could be observed. The resident was assisted to stand up and LPN 2 removed his pants. The bandage his right buttock abscess was dated 3/12/26. During an observation on 3/23/26 at 3:20 p.m., the Wound Nurse removed the resident's bandage from his buttocks area. The open wound on his buttocks was pink and red in color with minimal drainage. She performed the treatment as ordered. The record for Resident H was reviewed on 3/18/26 at 2:30 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, fracture of left humerus, ileostomy, orthostatic hypotension, heart disease, chronic kidney disease, presence right artificial shoulder joint, and syncope. The admission Minimum Data Set (MDS) was still in progress. The 3/8/26 Nursing admission Assessment indicated the resident was cognitively intact for daily decision making. A Care Plan, dated 3/13/26, indicated the resident was at risk for pressure ulcer development, impaired skin integrity, or at risk for altered skin integrity. The approaches were to administer treatments as ordered. A Wound NP Note, dated 3/12/26, indicated the resident had an abscess to the right inner buttock that was present on admission and measured 3 centimeters (cm) in length by 0.5 cm in width, by 3.5 cm in depth. The wound base was 100% granulation tissue. The treatment was to cleanse the right inner buttock with wound cleanser, apply Calcium Alginate with Silver to base of the wound, and secure with silicone bordered gauze every day and prn. A Skin/Wound Note, dated 3/16/26 at 4:31 p.m., indicated the right inner buttock measured 2.8 cm in length, by 0.3 cm in width, and 2.8 cm in depth. A Physician's Order, dated 3/12/26, indicated cleanse the right inner buttock with wound cleanser, apply Calcium Alginate with Silver to base of the wound, and secure with silicone bordered gauze every day and prn. The Treatment Administration Record (TAR) for the month of 3/2026, indicated the right inner buttock treatment was blank and not signed out as being completed on 3/15 and 3/16/26. The treatment was signed out as being completed on 3/13 and 3/14/26. During an interview on 3/16/26 at 3:45 p.m., the Wound Nurse indicated she did the bandage change with the wound NP last week on 3/12/26 and had not done the treatment since then. During an interview on 3/23/26 at 9:00 a.m., the Director of Nursing had no additional information to provide. 3. During an observation on 3/19/26 at 9:25 a.m., Resident F was observed in bed with his eyes closed. At that time, an IV was infusing into a port in his right chest. CNA 5 and CNA 6 entered the room to reposition the resident in bed. The CNAs positioned the resident onto his left side and there was a drainage bag observed. CNA 5 lifted up the resident's gown and the tube was observed with sutures in the abdomen. There was no bandage covering the sutures. The record for Resident F was reviewed on 3/18/26 at 9:10 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, colon, liver, rectal and large intestine cancer, severe protein malnutrition, adult failure to thrive, obstruction of bile duct, dysphagia, pressure ulcer of sacral region, and electrolyte and fluid balance disorder. The Modification of the admission Minimum Data Set (MDS) assessment, dated 3/3/26, indicated the resident was moderately impaired for daily decision making and had a pressure ulcer on admission. A Care Plan, dated 2/25/26, indicated the resident had an alteration in liver functioning and gastrointestinal status related to a left biliary drain in place. An MDS Note, dated 2/25/26, indicated the resident had left biliary drain in his abdomen. A Physician's Order, dated 3/12/26, indicated to record biliary drain output every shift and monitor the site for signs and symptoms of infection. A Physician's Order, dated 3/13/26, indicated to cleanse the biliary drain site with normal saline, pat dry, and cover with dry dressing every day shift. There were no orders to empty the drain and record the output or clean the biliary site prior to 3/12/26. The Treatment Administration Record (TAR) for 3/2026, indicated the output for the drain was not recorded for day shift on 3/15/26 and evening shift on 3/16/26. During an interview on 3/19/26 at 4:20 p.m., the Director of Nursing had no additional information to provide. 4. During a random observation on 3/18/26 at 9:17 a.m., CNA 2 was observed providing morning care for the resident. The resident was observed with extremely dry, flaky, and scaly skin to his lower extremities and both of his feet. There were large flakes of skin observed on the floor under the foot of the bed. During a random observation on 3/19/26 at 11:00 a.m., CNA 1 was asked to remove the linens from the resident's legs. At that time, the resident was observed with extremely dry, flaky, and scaly skin to his lower extremities and both of his feet. There were large flakes of skin observed on the floor under the foot of the bed. During a treatment observation on 3/20/26 at 1:43 p.m., the Assistant Director of Nursing lifted the bed linens and was able to observe the resident's dry skin as well as the flakes of skin on the floor under the foot of the bed. The record for Resident E was reviewed on 3/19/26 at 11:55 a.m. Diagnoses included but were not limited to, stroke, dysphagia (difficulty swallowing) and peg tube. The 1/28/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had no pressure ulcers. A Care Plan, dated 10/30/25, indicated the resident had impaired skin integrity, or at risk for altered skin integrity related to skin tears to his buttocks. There were no physician orders for any type of moisturizing cream for the resident's feet or legs. A Wound NP Progress Note, dated 2/16/26, indicated the patient was noted to have dry skin to the lower extremities and feet. Recommend use of emollient daily to the legs and feet. During an interview on 3/20/26 at 2:00 p.m., the Assistant Director of Nursing indicated the resident's feet and legs were dry. She observed the flakes of dry skin on the floor below the foot of the bed. During an interview on 3/23/26 at 9:00 a.m., the Director of Nursing had no additional information to provide. 5. During a random observation on 3/17/26 at 8:40 a.m., CNA 1 was asked to remove the bed linens from Resident B so his lower extremities could be observed. At that time, the resident was observed with extremely dry, scaly and flaky skin to both legs and feet. During a wound treatment on 3/20/26 at 1:53 p.m., both the Wound Nurse and the Assistant Director of Nursing were shown the resident's dry scaly skin to his feet and legs. The record for Resident B was reviewed on 3/19/26 at 1:30 p.m. The resident was admitted to the facility on [DATE], discharged to hospital on 3/3/26 and returned on 3/10/26. Diagnoses included, but were not limited to, type 2 diabetes, severe protein malnutrition, stroke, psychotic disorder, major depressive disorder, pressure ulcer, contracture of right lower leg, anxiety disorder, depressive disorder, seizures. The Modification of the Significant Change Minimum Data Set (MDS) assessment, dated 3/3/26, indicated the resident was not cognitively intact for daily decision making and was dependent on staff for activities of daily living. The resident had a limited range of motion to both of his lower extremities and had one unstageable pressure ulcer. A Care Plan, revised on 12/31/25, indicated the resident was at risk for pressure ulcer development, impaired skin integrity, or at risk for altered skin integrity. There were no orders for any type of skin moisturizer for the resident's legs and feet. A Wound NP note, dated 2/2/26, indicated to apply moisturizer to resident's skin routinely. During an interview on 3/20/26 at 2:30 p.m., the Wound Nurse indicated the resident had no orders for any type of moisturizing cream or lotion for his dry flaky skin to his legs and feet. During an interview on 3/23/26 at 9:00 a.m., the Director of Nursing had no additional information to provide. 6. The record for Resident G was reviewed on 3/23/26 at 8:30 a.m. Diagnoses included but were not limited to, diabetes, high blood pressure, heart disease and chronic kidney disease. The Modification of the admission Minimum Data Set (MDS) assessment, dated 12/23/25, indicated the resident was not cognitively intact for daily decision making. A Physician's Order, dated 12/18/25, indicated Lisinopril 5 milligrams (mg), give one tablet by mouth one time a day. The 1/2026 Medication Administration Record (MAR) indicated the Lisinopril was coded with a 9 meaning see nursing notes and was not administered. The resident's blood pressure was 115/56. The 2/2026 MAR indicated the Lisinopril was coded with a 5 meaning hold see nursing notes and was not administered. The resident's blood pressure was 110/50. The 3/2026 MAR indicated the Lisinopril was coded with a 9 on 3/8/26 and 3/9/26 and the medication was not administered. The resident's blood pressure was 103/56 on 3/8/26 and 99/56 on 3/9/26. A Nurses' Note, dated 1/7/26 at 9:46 a.m., indicated the medication was held because there was no high blood pressure noted. A Nurses' Note, dated 3/8/26 at 10:38 a.m., indicated the medication was held for low blood pressure per physician orders. There were no blood pressure parameters ordered by the physician to hold the Lisinopril. During an interview on 3/23/26 at 2:45 p.m., the Regional Director of Clinical Operations indicated she had no additional information on why the medication was held. 7. On 3/16/26 at 12:47 p.m., 3/18/26 at 9:52 a.m., and 3/19/26 at 9:19 a.m., Resident C was observed lying in bed. The resident had reddened scabbed areas to the tops of both hands. The top of his left hand had skin peeling. The resident had reddened abrasions to his outer right elbow and upper right arm. Record review for Resident C was complete on 3/19/26 at 9:40 a.m. Diagnoses included, but were not limited to Parkinson's disease and hypertension. The Significant Change Minimum Data Set (MDS) assessment, dated 2/11/26, indicated the resident was moderately cognitively impaired. The resident was dependent on staff for dressing, personal hygiene, bed mobility, and transfers. A Care Plan, dated 8/12/22 and revised 1/29/26, indicated the resident was at risk for impaired skin integrity related to decline in functional status and Parkinson's disease. An intervention included to complete skin at risk assessments as needed. A Weekly Skin Check, dated 3/13/26, indicated the resident had no skin issues noted. Shower Sheets, dated 3/13/26 and 3/17/26, indicated the resident was showered and no skin concerns were documented. There was a lack of documentation to indicate the resident's reddened and scabbed areas on his skin were assessed and or monitored. During an interview on 3/19/26 at 2:35 p.m., the Divisional Director of Clinical Services indicated she could not provide any documentation the resident's skin issues had been assessed or were being monitored. 8. Record review for Resident D was completed on 3/18/26 at 1:42 p.m. Diagnoses included, but were not limited to atrial fibrillation, hypertension, and hypotension. A Physician's Order, dated 1/26/26, indicated to give metoprolol tartrate (medication to lower your blood pressure) 50 mg (milligrams) two times a day for hypertension. Hold for SBP (systolic blood pressure, top number of blood pressure reading) less than 100. Hold for a heart rate less then 60. The February and March 2026 Medication Administration Records (MAR) indicated the metoprolol was given when the blood pressure (BP) was out of parameters on the following dates and times:-2/2/26 PM: the BP was 91/59 and the metoprolol was given-2/6/26 PM: the BP was 90/61 and the metoprolol was given-2/8/26 PM: the BP was 92/68 and the metoprolol was given-2/22/26 PM: the BP was 98/62 and the metoprolol was given-2/23/26 AM: the BP was 92/62 and the metoprolol was given-2/27/26 AM: the BP was 99/66 and the metoprolol was given-3/13/26 AM: the BP was 87/58 and the metoprolol was given-3/18/26 AM: the BP was 97/67 and the metoprolol was given A Physician's Order, dated 1/26/26, indicated to give midodrine hcl (medication to treat low blood pressure) 10 mg three times a day for hypotension. Hold if greater then 120. The February and March 2026 MARs indicated the midodrine was given when the BP was out of parameter on the following dates and times:-2/1/26 Afternoon: BP was 132/76 and the midodrine was given-2/1/26 PM: BP was 127/72 and the midodrine was given-2/15/26 AM: BP was 127/66 and the midodrine was given-2/15/26 Afternoon: BP was 127/66 and the midodrine was given-2/15/26 PM: BP was 133/65 and the midodrine was given-2/16/26 PM: BP was 125/83 and the midodrine was given-2/24/26 PM: BP was 122/57 and the midodrine was given-2/25/26 Afternoon: BP was 123/72 and the midodrine was given-2/26/26 PM: BP was 124/80 and the midodrine was given-3/3/26 Afternoon: BP was 123/78 and the midodrine was given-3/3/26 PM: BP was 130/72 and the midodrine was given-3/7/26 PM: BP was 127/64 and the midodrine was given During an interview on 3/19/26 at 2:11 p.m., the Divisional Director of Clinical Services indicated she was unable to provide any documentation why the medications were given outside of the parameters when they should not have been given. 9. During an interview on 3/18/26 at 9:25 a.m., Resident L indicated she had diarrhea after dinner the previous night. She told the nurse about it, and she thought the nurse gave her an anti-diarrheal medication. She had frequent bouts of diarrhea, but medicine usually helped. The record for Resident L was reviewed on 3/18/26 at 2:50 p.m. Diagnoses included, but were not limited to, diabetes. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact for daily decision making, and required maximal assistance with activities of daily living (ADLs). a. A Physician's Order, dated 11/28/25, indicated Loperamide HCl (an anti-diarrheal) every 6 hours as needed. The Point-of-Care CNA documentation indicated the resident had watery stools on 3/6/26, 3/7/26 for 2 shifts, 3/12/26, and 3/18/26. A 3/9/26 Alert Charting Note indicated the resident complained of diarrhea. Follow-up included giving Loperamide as needed. The Medication Administration Record (MAR) for March 2026 indicated the resident had not received any doses of Loperamide. b. A Physician's Order, dated 9/10/25, indicated Lantus (a long-acting insulin), 70 units to be given at bedtime. There were no parameters for holding the medication. The Medication Administration Record (MAR) indicated the Lantus was not given on 2/2/26, 2/23/26, 3/13/26, and 3/15/26. A Physician's Order, dated 11/9/25, indicated Insulin NPH and regular insulin 70/30 (a mix of short and long-acting insulins), 20 units to be given twice a day. There were no parameters for holding the medication. The Medication Administration Record (MAR) indicated the 70/30 insulin evening dose was not given on 2/13/26, 2/22/26, and 2/27/26. The morning dose was not given on 3/15/26. A Physician's Order, dated 9/30/25, indicated Novolog (a fast-acting insulin), 100 units to be given three times a day. There were no parameters for holding the medication. A Care Plan, updated 2/18/26, indicated the resident was diabetic. Interventions included administering insulin as ordered. The Medication Administration Record (MAR) indicated the afternoon Novolog was not given on 2/9/26, 2/13/26, 2/14/26, 2/20/26, 3/5/26, 3/8/26, and 3/15/26. The evening dose was not given on 2/16/26 and 2/27/26. A Physician's Order, dated 9/9/25, indicated Humalog (a fast-acting insulin), three times a day per the following sliding scale: if blood sugar 181 - 230 = 4 units; 231 - 280 = 7 units; 281 - 330 = 10 units; 331 - 350 = 13 units; 351 - 400 = call MD, The February and March MAR indicated no Humalog was givenas follows: on 2/1/26, the morning blood sugar was 399, the afternoon blood sugar was 228; On 2/3/26, the morning blood sugar was 371, the afternoon blood sugar was 189; On 2/6/26, the morning blood sugar was 252, the afternoon blood sugar was 400; On 2/10/26, the morning blood sugar was 400, the afternoon blood sugar was 330; On 2/15/26, the morning blood sugar was 365, the afternoon blood sugar was 183; On 2/20/26, the morning blood sugar was 400; On 2/23/26, the morning blood sugar was 219, the afternoon blood sugar was 226; On 2/24/26 the morning blood sugar was 400, the afternoon blood sugar was 267; On 2/28/26, the morning blood sugar was 400, the evening blood sugar was 294; On 3/1/26, the morning blood sugar was 400, the afternoon blood sugar was 208. During an interview on 3/24/26 at 10:10 a.m., the Regional Director of Clinical Operations was informed of the findings and had no additional information to provide. 10. The record for Resident K was reviewed on 3/18/26 at 10:38 a.m. Diagnoses included, but were not limited to, acute cor pulmonale (right sided heart failure) and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 1/20/26, indicated the resident had severe cognitive impairment, required maximal assistance with ADLs, and received all medications and nutrition via a feeding tube. A Physician's Order, dated 1/11/26, indicated Metoprolol Tartrate (a medication used to treat high blood pressure and heart failure) 25 milligrams twice a day. There were no parameters for holding the medication. The February and March MARs indicated the nurse held the following doses of the Metoprolol: 2/9/26 p.m., 2/13/26 p.m., 2/14/26 a.m., 2/23/26 a.m., 2/24/26 p.m., 3/1/26 a.m., 3/13/26 a.m., 3/14/26 a.m., and 3/15/26 a.m. and p.m. During an interview on 3/19/26 at 10:55 a.m., LPN 1 indicated if there was not a specific ordered parameter, she would hold a blood pressure lowering medication for any resident if their systolic (top number of a blood pressure reading) blood pressure was less than 120. When informed of the findings on 3/24/25, the Director of Nursing and Regional Director of Clinical Operations offered no additional information. 11. The record for Resident M was reviewed on 3/20/26 at 10:12 a.m. Diagnoses included, but were not limited to, quadriplegia, diabetes, and peripheral vascular disease. The Quarterly Minimum Data Set (MDS) assessment, dated 3/7/26, indicated the resident had severe cognitive impairment, was dependent in activities of daily living (ADLs) and had an arterial ulcer (a wound caused by poor blood flow). A Physician's Order, dated 2/3/26, indicated to cleanse the right foot / heel with wound cleanser, pat dry with gauze, apply betadine-moistened gauze, cover with pad and rolled gauze, and secure with tape every day shift for wound care. The record lacked documentation of wound care completed or refused on 3/1/26, 3/6/26, 3/7/26, 3/14/26, 3/15/26, and 3/21/26. During an interview on 3/24/26 at 10:10 a.m., when informed of the findings, the Regional Director of Clinical Operations indicated she had no additional information to provide. This citation is related to Intake 2794393. 410 IAC (Indiana Administrative Code) 16.2 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure over the counter medications and creams were labeled correctly related to resident names and directions for use for 1 of 1 treatment cart and 1 of 3 medications carts observed. (The East Unit treatment and medication carts)Findings include:1. During an observation on 3/19/26 at 2:24 p.m., the East Unit medication cart had an over the counter bottle of Extra Strength pain relief medication. The bottle was labeled with only the resident's name and room number. There were no directions for use or the physician's name on it. During an interview at that time, the Assistant Director of Nursing indicated there bottle should have been labeled with the directions for use. 2. During a random observation on 3/19/26 at 3:30 p.m., LPN 3 was asked to open the treatment cart. At that time, there were seven opened creams and ointments from the pharmacy with no label or name on them. The creams identified were Zinc Oxide, Calmoseptine, and Voltaren gel. During an interview at 3:45 p.m., the Divisional Director of Clinical Operations the creams/ointments were from the facility's pharmacy and should not be in the cart without a resident's name on them. The current 9/2025 Storage of Medications policy, provided by the Regional Director of Clinical Operations on 3/23/26 at 4:31 p.m., indicated all medications dispensed by the pharmacy were stored in a container with the pharmacy label. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(j)

Based on record review and interview, the facility failed deliver snacks to the residents who wanted them for 1 of 1 bedbound resident reviewed for nutrition and 3 of 5 residents in the Resident Council meeting. (Residents L, 44, 86, 121)Findings include:1. During an interview on 3/16/26 at 11:25 a.m., Resident L indicated if she asked for snacks, the CNAs routinely did not bring them to her. The resident's record was reviewed on 3/18/26 at 2:50 p.m. Diagnoses included, but were not limited to, diabetes, and need for assistance with personal care. A Care Plan, updated 3/25/25, indicated the resident had a behavior problem of not wanting to get out of bed. Interventions included offering snacks.A Care Plan, updated 10/17/25, indicated the resident had acute and chronic pain. Interventions included non-pharmacological measures including offering fluids and snacks. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact for daily decision making, and required maximal assistance with activities of daily living (ADLs). The record lacked documentation of snacks being provided or offered.During an interview on 3/20/26 at 10:21 a.m., the Kitchen Manager indicated snacks were always available on the nursing units. If a resident wanted a snack, the CNAs should deliver one to them. 2. During a meeting with the Resident Council on 3/19/26 at 1:14 p.m., Residents 44, 86, and 121 indicated that trays of snacks are left at end of hall, and staff does not deliver them to the residents. All three residents indicated they had each asked for snacks several times in the past and been told there were no snacks available. During an interview on 3/24/26 at 9:35 a.m., Resident 44 indicated a CNA told him again on the previous night that no snacks were available, but that when he wheeled himself down the hall, he could see a tray of snacks in the kitchenette. During an interview on 3/19/26 at 4:34 p.m., the Regional Nurse Consultant was informed of the findings and indicated she had no additional information to provide. 410 IAC (Indiana Administrative Code) 16.2 1.3-21(e)

Based on observation, record review, and interview, the facility failed to ensure food was served under sanitary conditions related passing food and beverages that were uncovered down the hallway for 2 of 2 meals observed and for 1 of 3 units observed. (The lunch and breakfast meal and the East unit)Findings include: 1. During the lunch meal observation on the East Unit on 3/16/26 at 12:36 p.m., a dietary employee brought a large covered cart to the unit with the lunch trays. At that time, staff took the cart and pushed it down the hallway and started to pass the room trays to the residents in their rooms. They carried the tray down the hall to the room, rather than pushing the cart door to door. The dessert was uncovered on the lunch tray. The staff continued to pass the trays down all three hallways until the cart was empty. None of the trays had the dessert covered. 2. During the breakfast meal observation on 3/18/26 at 8:17 a.m., staff on the East Unit were observed passing breakfast trays. There was a large covered cart that was parked on one of the hallways with the breakfast trays. At that time, staff were pulling a tray out of the cart, pouring coffee (from the beverage cart) into a cup and walking down the hallway with the meal tray to the resident's room. The coffee cup was not covered as there were no lids for staff to put over them. Staff continued to pass the trays with the coffee cups uncovered for all of the trays. During an interview on 3/18/26 at 8:30 a.m., the Regional Director of Clinical Operations was made aware of the issue and provided the policy for passing meal trays to residents in their rooms. The revised and current 2/2023 Meal Distribution policy, provided by the Regional Director of Clinical Operations on 3/18/26 at 8:54 a.m., indicated all food that was transported to dining areas that was not adjacent to the kitchen was to be covered. 410 IAC (Indiana Administrative Code) 16.2-3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a bolus enteral feeding was administered correctly for 1 of 3 residents reviewed for Tube Feeding. (Resident K)Finding includes: The record for Resident K was reviewed on 3/18/26 at 10:38 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), gastrostomy (a feeding tube inserted through the abdomen), and protein calorie malnutrition.The Quarterly Minimum Data Set (MDS) assessment, dated 1/20/26, indicated the resident had severe cognitive impairment, required maximal assistance with ADLs, and received all nutrition via a feeding tube.During observation of a bolus tube feeding administration on 3/19/26 at 10:43 a.m., LPN 1 flushed Resident K's feeding tube with water, plunged through a syringe. She then administered 237 ml (milliliters) of tube feeding formula, plunged via a syringe, followed by another plunged water flush. At that time, LPN 1 indicated she administered all feeding tube bolus feedings, flushes, and medications, by plunging with a syringe, not via gravity. During an interview on 3/19/26 at 11:34 a.m., the Director of Nursing was informed of the finding and indicated she would check the policy. During an interview on 3/19/26 at 11:54 a.m., the Regional Director of Clinical Operations indicated bolus feedings should not be forced, and that the nurse would be educated. A policy, titled, Enteral General Nutritional (tube feeding) Guidelines, received as current from the Regional Director of Clinical Operations on 3/19/26 at 11:56 a.m., indicated, . Begin pouring prescribed tube feeding bolus amount slowly into the 60cc piston syringe allowing the formula to flow through the G-Tube or PEG tube maintaining fluid level in syringe until delivery is complete . Do not force solution with plunger .410 IAC (Indiana Administrative Code) 16.2-3.1-44(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded related to the resident's use of oxygen for 1 of 26 resident records reviewed. (Resident M)Finding includes:During random observations on 3/17/26 at 11:00 a.m., 3/18/26 at 10:17 a.m., 3/19/26 at 2:25 p.m., and 3/20/26 at 10:00 a.m., Resident M was observed wearing oxygen via a nasal cannula. During an interview on 3/20/26 at 10:01 a.m., LPN 6 indicated the resident always wore oxygen. The record for Resident M was reviewed on 3/20/26 at 10:12 a.m. Diagnoses included, but were not limited to, quadriplegia.A Physician's Order, dated 2/17/26, indicated oxygen to be delivered at 2 liters per minute per nasal cannula.The Quarterly Minimum Data Set (MDS) assessment, dated 3/7/26, indicated the resident had severe cognitive impairment, and was dependent in activities of daily living (ADLs). The MDS assessment did not indicate the resident was on oxygen. There was no care plan for oxygen.During an interview on 3/24/26 at 11:05 a.m., MDS 1 indicated she coded that the resident did not use oxygen because she found two progress notes that indicated the resident did not require supplemental oxygen, but she could not recall if she observed the resident to determine if she used oxygen. During an interview on 3/24/26 at 11:15 a.m., the Regional Director of Clinical Operations indicated a visual observation should have been completed when the MDS assessment was done. 410 IAC (Indiana Administrative Code) 16.2-3.1-31(i)

Based on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to a CNA placing an enteral tube feeding on hold before a change in position for 1 of 3 residents reviewed for tube feeding. (Resident E)Finding includes:During a pressure ulcer treatment observation on 3/20/26 at 2:45 p.m., CNA 3 and CNA 4 were in Resident E's room to help the Wound Nurse with a bandage change. The resident was lying in bed with an enteral tube feeding infusing into the peg tube (a tube that was directly inserted into the stomach for nutrition) and his head of the bed was elevated to 45 degrees. At that time, the Wound Nurse told the CNAs they could position the resident onto to his right side. CNA 3 then walked over to the tube feeding pump and placed it on hold. She lowered the head of the bed to a flat position and both CNAs repositioned the resident onto his right side. The record for Resident E was reviewed on 3/19/26 at 11:55 a.m. Diagnoses included but were not limited to, stroke, dysphagia (difficulty swallowing) and peg tube.The 1/28/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident had issues with coughing while eating and had a peg tube, which he received 51% or more of total calories a day. The resident had no pressure ulcers.A Physician's Order, dated 3/17/26, indicated enteral feed of Jevity 1.2 at 85 milliliters (ml) per hour, up at 1:00 p.m., and when total volume reached 1530 ml take down. During an interview on 3/20/26 at 2:47 p.m., the Wound Nurse indicated the CNA was not supposed to turn off or place the peg tube on hold.During an interview on 3/23/26 at 9:00 a.m., the Director of Nursing had no additional information to provide.The undated, but identified as current, Routine Resident Care policy, provided by the Regional Clinical Director of Operations on 3/23/26 at 2:44 p.m., indicated licensed staff will include the following services based on their scope of practice: tube feedings. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(g)(2)

Based on record review and interview, the facility failed to ensure cardiopulmonary resuscitation (CPR) was not initiated as requested by the resident who had a signed Do Not Attempt Resuscitation (DNR) form for 1 of 1 resident reviewed for death. (Resident 119) Finding includes:Record review for Resident 119 was completed on [DATE] at 10:59 a.m. Diagnoses included, but were not limited to, stroke, hypertension, end stage renal disease, and diabetes mellitus.An Indiana Physician Orders For Scope Of Treatment (POST), form indicated it was a physician's order for scope of treatment based on the patient's current medical condition and preferences. The form had the section CPR: patient had no pulse and not breathing. The CPR section was not checked. The DNR section was checked. The form was signed and name printed by the resident on [DATE]. The form was also signed by the treating Physician.The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact. A Physician's Order, dated [DATE], indicated CPR.A Nurses Note, dated [DATE] at 12:50 a.m., indicated while doing rounds the resident was unresponsive. The resident had no carotid pulse felt. A sternum chest rub was given and no response. Vital signs were checked and unable to obtain. Oxygen at 2 liters was applied, CPR initiated, and 911 contacted.A Nurses Note, dated [DATE] at 1:39 a.m., indicated 911 was in the building and transfer of life saving measures (CPR) was surrendered to 911 paramedics and CPR continued. The resident was unable to be revived.During an interview on [DATE] at 2:10 p.m., the Regional Director of Clinical Operations indicated the physician's orders were not updated to include the DNR status because the physician did not date the POST form after signing it. The staff should have clarified the POST form the resident signed on [DATE] with the physician prior to the resident's death on [DATE].A facility policy titled, Advance Directive (Resident's Right to Choose) received as current from the facility on [DATE], indicated, .10. Any decision making regarding the resident's choices in their medical order for life-sustaining treatment and/or their advance directive will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care .410 IAC (Indiana Administrative Code) 16.2-3.1-4(f)(5)

Based on observation, record review, and interview, the facility failed to ensure a resident who had a pressure ulcer received the care and services to promote healing related to treatments not being completed as ordered by the physician and signed out on the treatment records for 3 of 6 residents reviewed for pressure ulcers. (Residents F, E, B)Findings include:1. During an observation on 3/19/26 at 9:25 a.m., Resident F was observed in bed with his eyes closed. At that time an IV was infusing into a port in his right chest. CNA 5 and CNA 6 entered the room to reposition the resident in bed. The CNAs positioned the resident onto his left side and removed his brief. At that time there was an open bloody wound on the resident's coccyx area. There was no evidence of any cream or a bandage covering the wound. The record for Resident F was reviewed on 3/18/26 at 9:10 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, severe protein malnutrition, adult failure to thrive, dysphagia, pressure ulcer of sacral region, and electrolyte and fluid balance disorder. The Modification of the admission Minimum Data Set (MDS) assessment, dated 3/3/26, indicated the resident was moderately impaired for daily decision making and had a pressure ulcer on admission. The Care Plan, dated 2/25/26, indicated the resident was at risk for the development of a pressure ulcer. The approaches were to provide treatments as ordered by the physician. A Wound Nurse Practitioner (NP) note, dated 2/26/26, indicated the resident had a Stage 2 pressure ulcer (a partial-thickness skin loss involving the epidermis and dermis, presenting as a shallow, open, pink/red wound or a ruptured blister) to the sacrum/buttocks area that was present on admission. The ulcer measured 11 centimeters (cm) in length, by 5.5 cm in width, by 0.1 cm in depth. The wound base was 100% epithelial tissue (a primary tissue type composed of tightly packed cells arranged in continuous sheets or tubes that cover external skin, line internal cavities/organs, and form glands). The treatment recommendation was to cleanse with soap and water, pat dry, apply Zinc Oxide Paste and Collagen Particles to base of the wound, and leave open to air. Change every shift and prn (as needed) A Physician's Order, dated 2/26/26, indicated cleanse inner buttocks with soap and water, pat dry, and apply Zinc Oxide every shift and leave open to air until resolved.A Wound NP Note, dated 3/3/26, indicated the Stage 2 pressure ulcer was smaller in size and measured 4.5 cm in length by 2.5 cm in width, by 0.1 cm in width and the wound base was 100% epithelial tissue. The treatment recommendation remained the same as above.A Wound NP Note, dated 3/12/26, indicated the Stage 2 pressure ulcer was improving and measured 1 cm in length, by 1.5 cm in width, by 0.1 cm in depth and the wound base was 100% epithelial tissue. The treatment recommendations remained the same as above. A Wound NP Note, dated 3/19/26, indicated the Stage 2 pressure ulcer had worsened and measured 9.00 cm in length, 3.00 cm in width, and 0.10 cm in depth. The wound was now described as a Kennedy terminal ulcer and 70% epithelial tissue and 30% granulation tissue. The treatment was changed to a dry collagen silicone bordered suprabsorb foam bandage and change three times a week. The Treatment Administration Record (TAR) for 2/2026 and 3/2026 indicated the treatment of cleaning with soap and water and the application of Zinc Oxide cream was completed every day shift and not every shift as ordered by the physician. During an interview on 3/19/26 at 11:55 a.m., the Wound Nurse indicated the resident had the open area to his buttocks and it had worsened. He had been seen by the Wound NP and a treatment was in place. She had thought the treatment was being done every shift. During an interview on 3/19/26 at 4:20 p.m., the Director of Nursing was provided the information and had no additional information to provide. 2. During a wound treatment observation on 3/20/26 at 2:45 p.m., the Wound Nurse removed the bandage from Resident E's buttocks area. There was one pressure ulcer to the right buttock and one pressure ulcer to the left buttock. Both ulcers were clean and pink in color with minimal drainage.The record for Resident E was reviewed on 3/19/26 at 11:55 a.m. Diagnoses included but were not limited to, stroke, dysphagia (difficulty swallowing) and peg tube.The 1/28/26 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had no pressure ulcers.A Care Plan, dated 10/30/25, indicated the resident had impaired skin integrity of skin tears noted to buttocks. A Wound NP Note, dated 2/16/26, indicated the resident had a new Stage 2 pressure ulcer to the right buttock that measured 1.0 centimeter (cm) in length, by 0.5 cm in width, by 0.1 cm in depth and was 100% epithelial tissue. The wound treatment was to cleanse the right buttocks with soap and water, apply Zinc Oxide to the wound base every shift and leave open to air. A Physician's Order, dated 2/16/26, indicated cleanse the right buttock with soap and water, pat dry, apply Zinc Oxide paste and leave open to air every shift. The 2/2026 Treatment Administration Record (TAR) indicated the treatment was left blank and not signed out as being completed for the day shift on 2/17 and 2/21/26 and the for the evening shift on 2/17/26. A Wound NP Note, dated 2/23/26, indicated the Stage 2 pressure ulcer was stable and measured 3.5 cm in length by 1.0 cm in width, by 0.1 cm in depth and had 100% epithelial tissue. The treatment remained the same as above. A Physician's Order, dated 2/23/26, indicated to cleanse both buttocks with soap and water, apply Zinc Oxide paste, and leave open to air every day shift. The TAR for the month of 3/2026, indicated the treatment for the buttocks was blank and not completed on the day shift on 3/3, evening shift 3/1, 3/3, and 3/6/26, and on the midnight shit on 3/3/26. A Wound NP Note, dated 3/16/26, indicated the Stage 2 pressure ulcer to the right buttocks now measured 2.7 cm in length, by 1 cm in width, by 0.1 cm depth. A new open area had developed and was identified as an abrasion to the left inner buttock. The treatment for the right buttocks was changed to apply skin prep to the outer edges, collagen with silver to the base of the wound and cover with a silicone bordered gauze. During an interview on 3/20/26 at 2:45 p.m., the Wound Nurse indicated treatments were supposed to be completed as ordered by the physician. During an interview on 3/23/26 at 9:00 a.m., the Director of Nursing had no additional information to provide. 3. During a wound treatment observation on 3/20/26 at 1:53 p.m., Resident B was observed lying in bed. At that time, his right leg was severely contracted and he had a wound vac observed to his right hip. The wound nurse removed the wound vac and the resident's pressure ulcer was red and pink in color with bloody drainage. The record for Resident B was reviewed on 3/19/26 at 1:30 p.m. The resident was admitted to the facility on [DATE], discharged to hospital on 3/3/26 and returned on 3/10/26. Diagnoses included, but were not limited to, type 2 diabetes, severe protein malnutrition, stroke, pressure ulcer and contracture of right lower leg.The Modification of the Significant Change Minimum Data Set (MDS) assessment, dated 3/3/26, indicated the resident was not cognitively intact for daily decision making and was dependent on staff for activities of daily living. The had 1 unstageable pressure ulcer.The Care Plan, dated 12/31/25, indicated the resident was at risk for pressure ulcers related to contractures to the right leg and arm. The resident had an actual altered skin integrity to the right hip. The approaches were to administer treatments as ordered by the physician. A Wound NP Note, dated 1/6/26, indicated the resident developed an abrasion to the right hip, that measured 7 centimeters (cm) by 5.5 cm in width by 0.1 cm.in depth. The treatment was to cleanse with wound cleanser, apply Xeroform to base of the wound, and secure with ordered gauze three times a week. The Wound NP saw and assessed the resident's right hip every week.A Wound NP Note, dated 2/2/26, indicated the wound was worsening and was now full thickness with slough (necrotic tissue) to wound bed. The wound measured 3.5 cm in length by 2 cm in width, by 0.1 cm in depth with 100% slough. The treatment was changed to cleanse with wound cleanser, apply Honey Hydrogel Sheet Dressing to base of the wound, and secure with bordered gauze change every day. A Wound NP Note, dated 2/9/26, indicated the wound now appeared as an unstageable pressure injury with greater depth and slough to the wound bed. The wound measured 3.5 cm in length by 3 cm in width by 0.5 cm in depth and had 100% slough. The treatment was changed to cleanse with wound cleanser, apply Collagen to base of the wound, and secure with a bordered gauze and change daily and prn. The Treatment Administration Record (TAR) for the month of 2/2026, had the order of cleanse the right hip with wound cleanser, pat dry with gauze, apply collagen, cover with bordered gauze every day shift. The treatment was blank and not completed on 2/15 and 2/21/23.A Wound NP Note, dated 2/23/26, indicated the wound to right hip was now noted with undermining and was malodorous after cleaning. The wound measured 4.5 cm in length, by 1.5 cm in width, and by 1.2 cm in depth with undermining from undefined o'clock to 3 o'clock of 1.6 cm. The wound was 100% granulation tissue. The treatment was changed at that time to cleanse with 0.25% Dakins solution, apply Collagen with silver to base of the wound, and secure with Bordered gauze every day and prn. A Physician's Order, dated 2/24/26, indicated to clean the right hip with Dakins 0.25% solution, pat dry with gauze, apply collagen with silver, cover with bordered gauze every day shift.The TAR for 2/2026 and 3/2026, indicated the treatment was blank and not completed on 2/26 and 3/2/26.During an interview 3/20/26 at 1:41 p.m., the Wound Nurse indicated the resident favored his right side and his right leg was contracted. He developed an abrasion to the right hip which turned into a pressure ulcer, however, the resident refused to stay off of the right hip and would refuse care from staff. The pressure ulcer was healing but then became infected so he was sent to the hospital and it was debrided. He returned with a wound vac and it was healing and doing better. The treatments were to be completed as ordered by the physician. This citation relates to Intake 2794393 410 IAC (Indiana Administrative Code) 16.2-3.1-40(a)(1)

Based on observation, record review, and interview, the facility failed to ensure a resident who was admitted with a limited range of motion received the necessary treatment and services to prevent decline related to application of an orthotic device by the Physical Therapy (PT) for 1 of 3 residents reviewed for range of motion. (Resident B)Finding includes: During a random observation on 3/17/26 at 8:40 a.m., CNA 1 was asked to remove the bed linens from the resident so his lower extremities could be observed. At that time, the resident was observed with a serve contracture to his right leg. His leg was completely bent and he was unable to fully extend it.The record for Resident B was reviewed on 3/19/26 at 1:30 p.m. The resident was admitted to the facility on [DATE], discharged to hospital on 3/3/26 and returned on 3/10/26. Diagnoses included, but were not limited to, severe protein malnutrition, stroke, pressure ulcer, contracture of right lower leg, and seizures.The admission Minimum Data Set (MDS) assessment, dated 10/9/25, indicated the resident had a limited range of motion to both of his lower extremities.The Modification of the Significant Change (MDS) assessment, dated 3/3/26, indicated the resident was not cognitively intact for daily decision making and was dependent on staff for activities of daily living. The resident had a limited range of motion to both of his lower extremities. A Care Plan, dated 3/16/26, indicated the resident had an alteration in musculoskeletal status related to right leg contracture related to a stroke.A Physician's Order, dated 10/5/26, indicated physical therapy (PT) five times a week for four weeks. A PT evaluation and treatment note, dated 10/5/25, indicated the patient presented with a decline in functional mobility with decreased strength, impaired balance, reduced activity tolerance and decreased safety awareness. The patient would benefit from skilled PT services to address functional limitations. The reason for skilled services was the patient required skilled PT services to evaluate the need for an assistive device to facilitate with functional mobility and increase lower extremity strength. A new goal on the evaluation indicated the patient will safely wear least restrictive splinting/orthotic device one hour on and one hour off without skin irritation in order to inhibit abnormal positions (target 10/11/25).There was no documentation on the initial evaluation of the lower extremity strength, the degree of any contracture, and what the functional limitations of the lower extremities were on 10/5/25.The resident received PT five times a week with documentation of assist active range of motion to the lower extremities, however, the resident could not return the demonstration by himself. A PT Progress Note, dated 10/13/26, indicated active assist range of motion was performed to bilateral lower extremities to focus on strengthening and improve functional mobility. The resident could not return demonstration with the range of motion. A PT Progress Note, dated 10/14/26 and 10/16/26 indicated active assist range of motion was performed on bilateral lower extremities to improve overall functional mobility.A PT Progress Note, dated 10/21/26, indicated the resident's family was getting concerned the right lower extremity was becoming contracted. The therapist reviewed the goals and advised that wearing an orthotic device within the resident's toleration was part of the plan of care. A PT Progress Note, dated 10/28/26 indicated gentle manual stretch to the right lower extremity was completed with fair toleration due to increased pain with movement. A PT Progress Note, dated 11/3/26, indicated gentle manual stretch on the right lower extremity hamstrings was completed within the resident's toleration to increase range of motionA PT Progress Note, dated 11/5/26, indicated active assist range of motion was performed on bilateral lower extremities to improve overall functional mobility.A PT Progress Note, dated 11/12/26, indicated the orthotic device was introduced to the resident's right knee. The orthotic device was placed on the resident's right knee on 11/13, 11/15, 11/16, and 11/19/25, The resident was only able to tolerate 15 minutes of the right knee brace and the therapist had to remove it because of pain. There was no documentation the right knee brace/orthotic device was ever placed back on the resident's right knee after 11/19/25. A Physical Therapy Recertification and Updated Plan of Treatment, dated 10/30/25 through 11/26/25, indicated therapeutic exercises for lower extremities to facilitate independence in mobility tasks, gentle manual stretch to right lower extremity as tolerated and continued treatment to prevent further decline may include orthotic management and training.A Physical Therapy Recertification and Updated Plan of Treatment, dated 11/25/25 through 12/22/25, indicated therapeutic exercises for lower extremities to facilitate independence in mobility tasks, gentle manual stretch to right lower extremity as tolerated and continued treatment to prevent further decline may include orthotic management and training. The resident decreased static balances and limitations in range of motion and strength impairments. Physician therapy was reduced from five times a week to three times a week at that time. A PT Discharge summary, dated [DATE], indicated a restorative nursing program was recommended to facilitate and maintain the resident's current level of performance and prevent further decline. Active range of motion to the left lower extremity and passive (gentle) range of motion to the right knee.A Physician's Order, dated 2/13/26, indicated gentle passive range of motion to the right knee, 10 times for one rep up to seven days a week. Restorative Nursing Notes indicated the resident received passive range of motion to the right knee 12 times from 2/14 through 3/3/26. During an interview on 3/23/26 at 9:30 a.m. PT 1 indicated he saw the resident some of the days for therapy but the therapist who did the initial evaluation was another therapist and only worked prn (as needed). He indicated the resident was confused and could not tolerate some of the exercises. He was unaware when the orthotic device was ordered or when it was available. He was also unaware why the orthotic device was not placed back on the resident after only 7 days of use. He only saw the resident when the other PT was not here in the building. During an interview at the above time, the Director of Rehabilitation (DOR) did not know the answers to any of the questions because she was not available and on leave during that time period. She had instructed the therapists to write down in their progress notes when orthotic devices were ordered and when they came in. She would look into the questions and try to contact the PT who saw the resident most of the time. During an interview on 3/23/26 at 1:37 a.m., Physical Therapist Assistant, (PTA) 1 indicated she treated the resident when he was in therapy. On the initial evaluation, the need for an orthotic device indicated there was some type of contracture or physical limitation. She indicated the right lower extremity was already partially contracted when he was admitted to the facility. She was unable to indicate the degree of limitations because that was not in her scope of practice. There was no documentation of what the lower extremity strength or the degree of the lower extremity limitations on the initial evaluation. She had an interview with the resident's sister on 10/21/26 and explained to the family there was a need for an orthotic device, however, there was a process to get the patient to that point for the device. She indicated the resident needed an increase in range of motion and stretching before the orthotic device would be put in place and thereapy needed to do more exercises for the knee to fit in the brace. The therapists can choose what goals they would want to work on, therefore range of motion may not have been completed every day and/or the orthotic device being fitted. She indicated the resident could only tolerate 15 minutes of the orthotic device to the knee because of pain, and the resident would refuse to even allow staff to touch his right leg during therapy. During an interview on 3/23/26 at 2:15 p.m., the DOR indicated she reviewed the PT's notes and there was no documentation of the resident's initial lower extremity strength or functional range of motion. She also indicated she read where the continuation of the orthotic device was to be utilized for the recertification for the continued physical therapy and it was not. There was no documentation by the physical therapist on why the device was not trialed anymore after 11/21/26. The Physical Therapist who completed the initial evaluation and treated the resident most of the time was unavailable to interview. During an interview on 3/23/26 at 3:55 p.m., the Restorative Nurse indicated his contracture to the right knee was the same today as it was when he was discharged from therapy on 2/12/26. She received the referral from therapy at that time for restorative therapy with the hopes of some improvement, so he was on the restorative case load, however sometimes he would not allow the staff to work with the right leg due to pain. He was discharged from restorative on 3/3/26 because he was admitted to the hospital and when he came back, she received another referral from therapy for functional maintenance program because there was no chance of improvement of the right leg. This citation relates to Intake 2794393.410 IAC (Indiana Administrative Code) 16.2-3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident with a physician's order for intravenous (IV) fluids received the correct amount over a 24 hour period for 1 of 1 resident reviewed for hydration. (Resident F)Finding includes:During a random observation on 3/16/26 at 10:49 a.m., Resident F was observed in bed with an IV infusing into a port located in his right chest. The IV fluid was a one liter bag of 0.9% Normal Saline and the date on the bag was 3/16/26. The IV fluid was flowing to gravity rather than via an infusion pump. During a random observation on 3/17/26 at 11:13 a.m., the resident was observed in bed with the same IV bag of 0.9% Normal Saline, dated 3/16/26, hanging and infusing per gravity into the resident's port. At 2:57 p.m., the same IV of 0.9 Normal Saline, dated 3/16/26 was still infusing per gravity into the resident's port. During a random observation on 3/18/26 at 8:05 a.m., the resident's IV of 0.9% Normal Saline, dated 3/16/26, was still infusing per gravity into the resident's port. At 9:00 a.m., the IV bag, dated 3/16/26 was almost empty and still infusing to gravity. During a random observation on 3/18/26 at 1:15 p.m., the resident's IV of 0.9% Normal Saline, dated 3/18/26, was infusing per gravity into the port. The record for Resident F was reviewed on 3/18/26 at 9:10 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, colon, liver, rectal and large intestine cancer, severe protein malnutrition, adult failure to thrive, obstruction of bile duct, dysphagia, pressure ulcer of sacral region, and electrolyte and fluid balance disorder. The Modification of the admission Minimum Data Set (MDS) assessment, dated 3/3/26, indicated the resident was moderately impaired for daily decision making. The resident had coughing or choking while swallowing and complaints of difficulty or pain when swallowing, and weighed 72 pounds. He received parental/Intravenous fluids and a mechanical diet. A Care Plan, revised on 3/16/26, indicated the resident was at risk for dehydration or potential fluid deficit related to malnutrition and metastatic colon and liver cancer. The resident has dehydration as evidenced by laboratory results and was receiving IV fluids for hydration of 0.9% Normal Saline times three days. A Physician's Order, dated 3/14/26, indicated Sodium Chloride 0.9%, use 50 milliliters (ml) per hour intravenously every shift for dehydration for three days.A Nurses' Note, dated 3/11/26 at 6:50 p.m. indicated the resident has been receiving an IV of 0.9% Normal Saline related to a dietary issue ordered by Nurse Practitioner. Nurses' Notes, dated 3/14, 3/16 and 3/17/26 indicated the resident refused to eat after several attempts. The resident did not receive the required IV fluids from 3/16-3/18/26 as the same IV bag was hanging from 3/16/26. During an interview on 3/18/26 at 9:10 a.m., the East Unit Manager was informed the resident's IV was still the same one hanging from 3/16/26. She indicated she was aware the resident had an IV but was unaware it the same bag from two days prior. During an interview on 3/19/26 at 4:20 p.m., the Director of Nursing had no additional information to provide. 410 IAC (Indiana Administrative Code) 16.2-3.1-46(b)

Based on record review and interview, the facility failed to ensure a dependent resident received the alternate meal choice they requested for 1 of 1 resident reviewed for choices. (Resident L)Finding includes:During an interview on 3/16/26 at 11:25 a.m., Resident L indicated she did not get to choose what she ate. Her meal trays were brought to her room by the aide, and if she did not want what was brought, she would request the alternate meal. She indicated more than half of the time, the aides would not bring the alternate meal, and she would not eat. The resident's record was reviewed on 3/18/26 at 2:50 p.m. Diagnoses included, but were not limited to, diabetes, and need for assistance with personal care. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact for daily decision making, and required maximal assistance with activities of daily living (ADLs). During an interview on 3/20/26 at 10:21 a.m., the Kitchen Manager indicated alternate meals were always available. If a resident wanted the alternate meal, they would tell the aide and they would tell him. During a Resident Council meeting on 3/19/26 at 1:14 p.m., Resident 86 indicated if he wanted the alternate meal, he would have to notify the kitchen himself because the aides would not bring it to him. During an interview on 3/24/26 at 10:10 a.m., the Regional Director of Clinical Operations was informed of the findings and had no additional information to provide. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(u)

Based on record review and interview, the facility failed to ensure residents with a urinary catheter received the necessary treatment and services related to not assessing urinary output as ordered for 2 of 3 residents reviewed for urinary catheters. (Residents D and 53)Findings include:1. Record review for Resident D was completed on 3/18/26 at 1:42 p.m. Diagnoses included, but were not limited to atrial fibrillation, hypertension, and hypotension.The admission Minimum Data Set (MDS) assessment, dated 2/1/26, indicated the resident was cognitively intact. The resident was dependent on staff for bed mobility, transfers, and toileting hygiene. The resident had an indwelling urinary catheter.A Physician's Order, dated 1/28/26, indicated to measure and record output every shift from the indwelling urinary catheter.The February and March 2026 Treatment Administration Records (TARs) indicated the urinary output was not recorded on the following days and shifts: - Days: 2/1, 2/2, 2/7, 2/12, 2/16, 2/17, 2/20, 2/23, 2/26, 2/27, 3/3, 3/7, 3/13, 3/14 and 3/17/26- Evenings: 2/3, 2/19, 3/3, 3/6, and 3/8/26 - Night: 2/13, 2/19, 2/25, 2/26, 2/28, 3/1, 3/3, and 3/11/26The record lacked any documentation the resident's urinary output amount was recorded on the above dates and shifts. During an interview on 3/19/26 at 2:11 p.m., the Divisional Director of Clinical Services indicated she was unable to provide any documentation the urinary output was recorded on the above dates and shifts. 2. Record review for Resident 53 was completed on 3/19/26 at 3:39 p.m. Diagnoses included, but were not limited to, end stage renal disease and obstructive uropathy.The admission MDS assessment, dated 1/18/26, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance from staff for assistance in toileting hygiene. The resident had an indwelling urinary catheter.The March 2026 Physician's Order Summary (POS) indicated an order to measure and record output every shift from the indwelling urinary catheter.The February and March 2026 TARs indicated the urinary output was not recorded on the following days and shifts: - Days: 2/12, 2/13, 2/16, 2/17, 2/20, 2/23, 2/25, 3/13, and 3/17/26- Evenings: 2/24, 3/15, and 3/16/26- Nights: 2/13 and 3/16/26The record lacked any documentation the resident's urinary output amount was recorded on the above dates and shifts. During an interview on 3/23/26 at 2:00 p.m., the Regional Director of Clinical Operations indicated she was unable to provide any documentation the urinary output was recorded on the above dates and shifts. A policy was provided but did not pertain to recording urinary output.410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure acceptable parameters of nutrition were maintained related to not following the Registered Dietitian's (RD) recommendations timely which resulted in a significant weight loss for a resident who was NPO and only receiving an enteral feeding. The facility also failed to ensure food consumption was documented for residents with a history of weight loss for 5 of 7 residents reviewed for nutrition. (Residents 89, 24, N, 5, and 8) Findings include: 1. On 12/12/22 at 9:37 a.m., Resident 89 was observed sitting in a wheelchair in her room. At that time, there was an enteral tube feeding of Jevity infusing at 45 cubic centimeters (cc) per hour. On 12/16/22 at 5:30 a.m., the resident was observed in bed. The tube feeding had been disconnected. At 8:03 a.m., LPN 1 was observed to hang a new bottle of the enteral feeding. The record for Resident 89 was reviewed on 12/15/22 at 3:00 p.m. Diagnoses, included but were not limited to, multiple sclerosis, dysphagia, dementia with behaviors, schizophrenia, peg tube, and depressive disorder. The Annual Minimum Data Set (MDS) assessment, dated 12/7/22, indicated the resident was moderately impaired for decision making. The resident weighed 105 pounds and had significant weight loss. She received greater than 51% of fluid intake and calories every day through the peg tube. The Care Plan, revised on 12/14/22, indicated the resident required a tube feeding. The resident's weights were as follows: 7/7/22 - 129 pounds 8/16/22 - 129 pounds 9/2/22 - 108 pounds 10/2/22 - 112 pounds 10/17/22 - 112 pounds 11/13/22 - 105 pounds 12/19/22 - 101 pounds An RD Progress Note, dated 10/19/22 at 3:06 p.m. and 10/20/22 at 12:47 p.m., indicated the resident was NPO and received all nutrition via peg tube. The current tube feeding order of Jevity 1.2 at 35 cc per hour provided 42 grams of protein, 924 Kcal, and 1521 of water. RD recommended to discontinue current enteral nutrition order and current tube feed flush order. RD recommended Fibersource HN at 45 cc per hour times 22 hours. This would provide 990 milliliters (ml) of total volume, 1188 kcal, 53 grams of protein. RD recommended to flush with 125 ml of water every 4 hours. A RD Progress Note, dated 11/17/22 at 2:54 p.m., indicated the resident was NPO and received all nutrition via peg tube. The current tube feeding order of Jevity 1.2 at 35 cc per hour provided 42 grams of protein, 924 Kcal, and 1521 of water. The resident presented with a with a significant weight loss of 6.3% times 30 days. RD recommended Fibersource HN at 45 cc per hour times 22 hours. This would provide 990 milliliters (ml) of total volume, 1188 kcal, 53 grams of protein. RD recommended to flush with 125 ml of water every 4 hours. Physician's Orders, dated 3/25/22 and discontinued 10/8/22, indicated Enteral feed of Jevity 1.2 at 50 cc per hour times 22 hours. Physician's Orders, dated 10/9/22 and discontinued 11/17/22, indicated Enteral feed Jevity 1.2 at 35 cc per hour times 22 hours. Off at 6:00 a.m., and on at 8:00 a.m. Physician's Orders, dated 11/18/22 and discontinued 12/5/22, indicated Enteral feed Fibersource HN at 45 cc per hour times 22 hours. Off at 6 a.m., and on at 8 a.m. Physician's Orders, dated 10/20/22, indicated Fibersource HN - may substitute if Jevity 1.2 & Jevity 1.5 unavailable. Infuse at same rate per order. Physician's Orders, dated 12/6/22, indicated Enteral feed of Jevity 1.2 at 45 cc per hour times 22 hours. Off at 6:00 a.m., and on at 8:00 a.m. The Medication Administration Record (MAR) for the months of 10/2022 and 11/2022 indicated the Jevity 1.2 at 35 cc per hour was signed out as being administered 10/9-10/31/22 and 11/1-11/17/22. The tube feeding was flushed every 4 hours with 150 cc of water from 10/1-10/31/22 and 11/1-11/17/22. Jevity at 35 cc per hour was signed out as being substituted for the Fibersource HN on 10/20, 10/21, 10/24, 10/27-10/30/22 and on 11/2-11/4, 11/7, 11/10-11/13, and 11/16-11/17/22. Interview with the RD on 12/19/22 at 3:35 p.m., indicated she had made the recommendation for the tube feeding increase and for a different formula. The recommendation was not acted upon for 1 month. She documented her recommendations on a paper and it was up to the nursing staff to follow through with the orders. Interview with the Nurse Consultant on 12/21/22 at 8:15 p.m., indicated there were no other weights obtained during the months of November or December 2022 and the RD's recommendation was not acted upon in a timely manner. 2. On 12/13/22 at 3:00 p.m., Resident 24 was observed in bed. At that time, the enteral feeding was turned off and not infusing. On 12/14/22 at 9:30 a.m., the resident was observed in bed and enteral feeding was infusing at 55 cubic centimeters (cc) per hour. On 12/16/22 at 5:30 a.m., the resident was observed in bed. The tube feeding had been disconnected. At 8:05 a.m., LPN 1 was observed to hang a new bottle of the enteral feeding. The record for Resident 24 was reviewed on 12/16/22 at 5:00 a.m. Diagnoses included but were not limited to, encephalopathy, quadriplegia, epilepsy, anxiety, and peg tube. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 9/30/22, indicated the resident was not cognitively intact. The resident weighed 148 pounds and had a significant weight loss. A Care Plan, revised on 11/28/22, indicated the resident was NPO and required tube feeding. The approaches were to provide enteral feeding per physician diet orders and the RD will evaluate quarterly and as needed and make recommendations for changes to tube feeding as needed. The resident's weights were as follows: 8/16/22 199 pounds 9/2/22 148 pounds 10/2/22 146 pounds 10/3/22 146 pounds 10/4/22 146 pounds 11/13/22 142 pounds 12/14/22 145 pounds A RD Quarterly Assessment, dated 11/28/22, indicated the resident presented with a significant weight loss of 28.5% times 90 days (8/16-11/13/22). The resident was NPO and had an open wound on the right second toe. Recommendations were to discontinue current tube feed order and start Fibersource HN at 65 cc times 22 hrs. Interview with the Registered Dietitian on 12/19/22 at 3:35 p.m., indicated she made the recommendation for the tube feeding increase and it had not been acted upon as of yet. She documented her recommendations on a paper and it was up to the nursing staff to follow through with the orders. Physician's Orders, dated 11/17/22, indicated Fibersource HN at 55 cc per hour times 22 hours. Off at 6:00 a.m., and on at 8:00 a.m. Water flush of 125 cc every 4 hours per peg tube. Interview with the Nurse Consultant on 12/20/22 at 3:18 p.m., indicated the RD was going to reassess the resident's nutritional status. 3. The record for Resident N was reviewed on 12/16/22 at 6:50 a.m. Diagnoses included, but were not limited to, stroke, type 2 diabetes, chronic kidney disease, heart failure, depressive disorder, atrial fibrillation, altered mental status, and high blood pressure. The Quarterly, 10/23/22 Minimum Data Set (MDS) assessment, indicated the resident was not alert and oriented and was severely impaired for decision making. The resident was an extensive assist with a 1 person assist for personal hygiene and totally dependent on staff for bathing. The resident weighed a 126 pounds and had significant weight loss. A Care Plan, revised on 10/12/22, indicated the resident had a nutritional problem. The approaches were to monitor meal intake. The resident's weights were as follows: 8/1/22 178 pounds 9/4/22 177 pounds 10/10/22 126 pounds 10/18/22 126 pounds 10/20/22 127 pounds 10/24/22 128 pounds 10/27/22 128 pounds 11/3/22 128 pounds 12/14/22 128 pounds An Admission RD Assessment, dated 10/12/22, indicated the resident presented with a significant weight loss of 28.8% x 30 days (10/10/22 vs 9/4/22). The resident received a regular diet. Recommendations to continue weekly weights. The meal consumption for the last 30 days indicated no meals were documented on 11/18-11/20, 11/23, 11/24, 11/26, 11/27, 11/30, 12/4, 12/6-12/10, 12/14, and 12/15/22. Breakfast was not documented on 11/17, 11/21, 11/22, 11/25, 12/5, and 12/11/22. Lunch was not documented on 11/17, 11/21, 11/22, 11/25, 12/5, and 12/11/22. Dinner was not documented on 12/3 and 12/12/22. Interview with the Nurse Consultant on 12/20/22 at 3:18 p.m., indicated the meal consumption intakes were incomplete. 10326 4. The record for Resident 5 was reviewed on 12/19/22 at 9:48 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), urinary tract infection, and schizoaffective disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 9/17/22, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. She required extensive assistance with eating and received a mechanically altered diet. A Physician's Order, dated 12/8/22, indicated the resident was to receive a pureed diet with nectar thick liquids. A revision on 12/14/22, indicated the resident could have soft foods with supervision. Dietary Progress Notes, dated 12/1/22 at 4:44 p.m., indicated the resident was being followed in Nutrition at Risk (NAR) for readmission on 11/15/22. The resident was currently NPO (nothing by mouth) and was receiving a tube feed bolus. The resident presented with a significant weight loss of 38.9% times 60 days. Her current weight was stable with a gradual weight gain of 4.5% times 45 days. Continue with current nutritional plan. Dietary Progress Notes, dated 12/9/22 at 12:49 p.m., indicated the resident was being followed in Nutrition at Risk (NAR) for readmission on 11/15/22. Her current diet order was a regular diet with puree texture and continue with tube feed order of Jevity 1.5 bolus four times a day. The resident presented with a weight gain of 4.3% in 7 days. The weight gain was desired related to a history of weight loss. Continue to follow in NAR. The food consumption logs, dated 12/8-12/18/22, indicated there was no meal consumption documented on 12/13, 12/17, and 12/18/22. No breakfast was documented on 12/15/22 and no dinner was documented on 12/11 and 12/14/22. Interview with the Director of Nursing on 12/19/22 at 1:30 p.m., indicated the food consumption logs should have been completed based on the resident's history of weight loss. 5. The record for Resident 8 was reviewed on 12/15/22 at 3:13 p.m. Diagnoses included, but were not limited to, acquired absence of the left leg below the knee, type 2 diabetes, and dementia without behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 11/16/22, indicated the resident had short and long term memory problems and was severely impaired for daily decision making. She required extensive assistance with eating and received a mechanically altered diet. A Care Plan, dated 10/12/22, indicated the resident was at nutritional risk related to a history of diabetes, hypertension, cognitive status, weight loss, and impaired skin integrity. Interventions included, but were not limited to, monitor daily intakes. The 12/2022 Physician's Order Summary (POS), indicated the resident was to receive a pureed diet. The food consumption log, dated 11/16 - 12/16/22, indicated no meal consumption was documented on 11/25, 11/28, 12/3, 12/4, 12/5, 12/6, 12/8, and 12/9/22. No breakfast or lunch was documented on 11/24, 11/26, 12/11, and 12/12/22. No dinner was documented on 11/17, 11/19, 11/20, 11/21, 11/29, 12/1, and 12/15/22. Interview with the Director of Nursing on 12/19/22 at 1:30 p.m., indicated the food consumption logs should have been completed based on the resident's history of weight loss. 3.1-46(a)(1)

Based on record review and interview, the facility failed to provide supervision to prevent an elopement of a cognitively and mentally impaired resident, who had a court appointed Guardianship, from signing himself out of the facility. The resident was out of the building for 5.5 hours before he was identified as missing. The Police were notified and a Silver Alert was issued. The whereabouts were unknown to the facility and the resident was found in a neighboring state at a hotel close to an airport 4.5 days later. The Hotel where the resident was found was 30-31 miles from the facility. The Guardianship papers were not at the facility at the time of the elopement, though the facility was aware of the Guardianships, for 1 of 3 residents reviewed for supervision. (Resident Q) The immediate jeopardy began on 7/14/21 when the facility allowed the resident to sign himself out of the facility and the facility was unaware of the resident's whereabouts. The resident, who walks with a walker, walked to a local gas station and was transported to a hotel in neighboring state by strangers and was found after a Silver Alert was issued on 7/14/17on 7/17/21 at the hotel. The Director of Nursing (DON) and the Regional Clinical Director were notified of the immediate jeopardy at 1:26 p.m. on 7/26/21. The immediate jeopardy was removed, and the deficient practice corrected, on 7/23/21, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: An Indiana Department of Health (IDOH) Reportable Incident Form, dated 7/15/21, indicated the incident occurred on 7/14/21 at 4:01 p.m. Resident Q had signed himself out of the facility to eat breakfast with his brother. The resident had not returned to the facility and the brother was notified. The brother had indicated the resident had not been with him. The Police were then notified. Resident Q's record was reviewed on 7/25/21 at 2:47 p.m. The diagnoses included, but were not limited to, [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. The admission into the facility occurred on 7/9/21. A Preadmission Screening and Resident Review, dated 9/23/19, from a past admission and remained in the electronic record, indicated the mother had been appointed as his legal guardian. A confidential fax from the discharging Hospital to the facility, dated 6/22/21, indicated a Patient Information Form was faxed to the facility and the brother was identified as the Guardian. The Hospital History and Physical, dated 6/10/21, indicated the brother and the mother were both Court Appointed Guardians. Court appointed Guardianship papers, dated 4/7/16, scanned into the record on 7/21/21, indicated the mother and brother were appointed as Guardian. The Admission Packet forms, dated, 2/12/20 and signed on 7/9/21, were all signed by the brother. During an interview on 7/26/21 at 8:57 a.m., the Admission's Coordinator, indicated the brother had signed all the admission paperwork. She indicated the date on the Admission Agreement was 2/12/20 due to a past admission and he was still in the system. The admission paperwork was signed on 7/9/21. The brother had informed her at the time of the paperwork he was either the Power of Attorney or the Guardian. She had asked the brother for this paperwork prior to the admission and at the time of the admission. He had indicated the the paperwork was not with him. He was asked again a few days later. The validation of the Power of Attorney and/or Guardianship could not be completed without the paperwork. It was the responsibility of the Admission's Team, to obtain all paperwork. A, Care Plan Recommendation and Minimum Data Set Components form, dated 7/12/21, indicated there was mild-moderate cognitive impairment and modified independence with daily decision making skills. A Care Plan, dated 7/12/21, indicated the cognitive function of the resident was impaired. The interventions included changes in cognitive function, specifically in decision making ability, memory, and recall were to be documented and reported to the Medical Provider. The Care Management Team Meeting note, dated 7/12/21 at 9:48 a.m., indicated the Executive Director (ED), Director of Nursing (DON), Resident Assessment Coordinator, Social Service, and direct care staff were in attendance. The resident had been living at home and barricaded himself in the bedroom, was not eating, had weight loss, refused showers, and would not allow the family to help. The resident's mother was a Court Appointed Guardian. During an interview on 7/26/21 at 12:50 p.m., the DON indicated she had not been at the Care Management Team Meeting and was unaware the resident had a Guardian until the incident occurred. The Physician's Orders indicated there was no order obtained for the resident to leave the facility with or without supervision. A Nurse's Progress Note, dated 7/14/21 at 9:30 a.m. (documented on 7/14/21 at 4:20 p.m.) indicated he had signed himself out of the facility in the morning. The Physician had been notified. The facility was waiting on him to return to the facility. Information was passed on to the Evening Nurse. A facility Sign Out form, indicated the resident had signed himself out on 7/14/21 at 9:30 a.m. and had not signed self back into the facility. A Nurse's Note, dated 7/14/21 at 3:45 p.m. (late entry on 7/14/21 at 9:34 p.m.) indicated he had not yet returned to the facility. The family, Supervisor, and DON had been notified. There were no further Nurses' Progress Notes which indicated the resident was still missing from the facility. A Nurse's Progress Note, dated 7/17/21 at 7:29 p.m., indicated the resident was readmitted from the Hospital. A time line for the incident, provided by the DON on 7/26/21 at 9:09 a.m., indicated on 7/14/21 at 9:30 a.m. the resident was in the front of the building in a wheelchair and had informed the Receptionist he was leaving for breakfast with his brother. The Receptionist notified LPN 1 and the Medical Records Nurse came to the front of the building with the Sign Out Form and he signed himself out of the facility. He then used a walker and walked outside of the facility. On 7/14/21 at 2 p.m., LPN 1 had noticed he had not returned to the building and notified the brother who indicated the resident had not been with him. The mother was then notified and stated she had not seen the resident. At 4 p.m., the Unit Manager was notified and notified the DON. At 4:15 p.m. the building was searched. On 7/14/21 at 4:30 p.m., the DON had notified the brother, who indicated he does not know where the resident was and had not heard from him nor seen him. He stated he was the Court Appointed Guardian and had not brought the papers in to the facility yet. He stated he was going to go to the local Police Department and would bring the Guardian papers to the facility. On 7/14/21 at 4:15 P.M., the facility notified the local Police Department. The Local Police Department Incident Report, indicated the facility notified them on 7/14/21 at 5:59 p.m. and an officer was dispatched. The DON had advised the Officer the resident had signed himself out at 10 a.m. on 7/14/21 and had not returned to the building. The DON indicated he had a Power of Attorney and should not have been able to sign himself out. The Power of Attorney had requested the resident be reported missing. During an interview on 7/26/21 at 11:10 a.m., the DON indicated he was brought back to the facility on [DATE]. The Police had said he was found in a neighboring State at a hotel near the airport. He had been at the gas station and informed a [NAME] at the station he had been abandoned and needed to get to the airport so he could go to California. The [NAME] at the gas station gave him a ride to the hotel. Once he was found, the brother picked him up and transported him to the Hospital to evalutated for medical clearance for him to return to the facility. During an interview on 7/26/21 at 4:50 p.m., a Detective at the Local Police Department indicated the resident was found in a hotel near an airport in a neighboring state. They had received a call from the facility at 5:59 p.m. on 7/14/21 and a Patrolman was sent to he facility. A Silver Alert was issued. A [NAME] at the gas station had given him a ride after he had told him he needed to get to California. The resident had been found on 7/17/21 between 12 and 2 p.m. A camera timeline, dated 7/14/21, indicated at 9:07 a.m. the resident walked down the sidewalk with the walker and sat in the wheelchair in the shade at the front entrance in the parking lot. At 9:14 a.m., the Medical Records Nurse approached him and he signed himself out, 9:15 a.m., the Medical Records Nurse walks back into the building. At 9:21 a.m., he walks in the mulch, standing by the tree and had not used his walker. At 10:07 a.m., he gets up from the wheelchair, used his walker and walked to the northeast side of the parking lot. At 10:08 a.m. he was at the exit of the parking lot and the walker was being used. Signed statements from staff indicated: On 7/14/21, the Receptionist indicated around 9:30 a.m. he stated he was going to breakfast with his brother and asked if he could wait for him in front of the building. He was asked if he checked out at the Nurses' Station and he said yes. His yes was not very convincing. He was let out the front door and the Nurses' Station was notified. The resident had not signed out at the Nurses' Station. They were informed the resident was at the end of the sidewalk, sitting in the wheelchair, and waiting on his brother to go to breakfast. On 7/14/21, LPN 1 indicated she had received a phone call from the Receptionist, stating the resident was outside in the wheelchair at the corner of the sidewalk around 9:30 a.m. The Medical Records Nurse was asked to to take the Sign Out Form to him so he could sign himself out. Rounds were completed at 3 p.m. and the resident had not returned to the facility. His cell phone, mother, and brother was called. A voicemail was left on the cell phone to return to the facility. The Unit Manager was also notified. On 7/14/21, the Unit Manager indicated she arrived at the building at 8:30 a.m. and was informed later by the Floor Nurse, the resident had went out on pass at 9:30 a.m. The Resident Information Form (facesheet) indicated he was responsible for himself, his mother and brother were emergency contacts. A signed statement from the Admissions Director, dated 7/15/21, indicated the admissions process was completed with the brother on 7/9/21. The resident was present during the process. During the conversation the brother indicated he was Power of Attorney and would provide the paperwork. The resident was informed he could go out on pass with his brother though he needed to be signed out prior to leaving and could only leave facility property when accompanied by his brother. During an interview on 7/26/21 at 9:31 a.m., the Corporate Regional Clinical Director indicated through their investigation, this was determined to be a leave of absence. There had been no Guardian limitations in place and the brother had not brought the Guardianship papers into the facility. During an interview on 7/26/21 at 9:38 a.m., the Unit Manager indicated LPN 1 had notified her around 3 p.m. on 7/14/21 and she had notified the DON around 3:30 - 4 p.m. She had looked at the face sheet when he went out and it had indicated he was responsible for himself. There was nothing that indicated he had a Power of Attorney. At 9:53 a.m. on 7/26/21, the DON presented the facesheet at the time of the incident, which indicated the resident was his own financial agent. Emergency contact number one was his brother and number 2 was his mother. During an interview on 7/26/21 at 11:01 a.m., RN 2 indicated she was told by LPN 1 he was missing when she came into work that later evening. The admission documentation indicated he had severe [CONDITION(S)] and was not able to make safe judgements or decisions. She questioned why he was able to sign himself out of the building. During an interview on 7/26/21 at 12:47 p.m., the Resident's Guardian indicated when the admission paperwork was completed, he had informed the facility he was the Guardian. He was never asked for the paperwork and had assumed they still had the paperwork from the past admissions. He was never asked about the paperwork until 7/13/21, when the facility called him and he informed them he would bring the paperwork in to the facility on [DATE]. A facility policy, dated 7/1/16, titled, Resident Leave of Absence (LOA), received from the DON as current, indicated, .a resident/patient who is cognitively intact with independent decision making with a physician's order may sign themselves out for a LOA .For residents/patients that sign out for a LOA the resident/patient/family/responsible party will indicate the anticipated time of return at the time they sign out .Obtain a physician's order for the resident/patient to leave the facility with or without supervision .Notify the Executive Director (ED) if unable to contact the resident/patient or family/responsible party, or if they refuse to return. The past noncompliance immediate jeopardy began on 7/14/21. The immediate jeopardy was removed and the deficient practice corrected by 7/23/21 after the facility implemented a systemic plan that included the following actions: the resident was assessed for elopement and a Wanderguard bracelet had been applied to the right ankle, all staff were inserviced on the Leave of Absence, Elopement Management, and Elopement Prevention policies. The Admission's Director had training for clinical review, requesting all Power of Attorney/Guardianship paperwork from the Hospital prior to admission or from the family/Guardian prior to admission or on admission, and ensuring all have been updated in the medical record. Elopement/Wandering assessment will be completed on all residents on admission and with significant changes. Photographs and resident information will for residents at risk for elopement will be kept at the Nurses' Station and Reception Desk. Staff were interviewed and able to explain the policies and procedures. Binders were located at the Nurses' Desk and Receptionist Desk, which included the other residents who were at risk for elopement. All charts were reviewed for accurate information on the Facesheet for status of Power of Attorney/Guardianships. This Federal tag relates to Complaint IN 517. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing of pressure ulcers, related to treatments not completed as ordered by the Physician for 5 of 6 residents reviewed for pressure ulcers. One pressure wound had deteriorated due to increased drainage, redness, and inflammation for Resident C. (Residents C, E, G, J & K) Findings Include: 1) During an observation of Resident C, on 7/25/21 at 10:23 a.m. with RN 2 present, there were two foam dressings on the resident's inner left and right knees. The dressings were marked with the date of 7/22/21. Both dressings were saturated with dark colored drainage. RN 2 indicated the dates on the dressings were 7/22/21 and the dressings were saturated. During an observation with the Wound Nurse and RN 2 on 7/25/21 at 11:42 a.m., the wound nurse indicated the dressings were dated 7/22/21 and were saturated with drainage. She indicated the dressings were to be changed twice a day. The nurses were responsible for all treatments to be completed. The Wound Nurse measured the wounds weekly and followed up to make sure the dressings were intact. The resident was to have a dry dressing on the pressure wounds, not the foam dressing. RN 2 indicated there were foam dressings on the pressure areas on the bilateral inner knees. During an observation with the Wound Nurse and RN 2 on 7/25/21 at 11:52 a.m., RN 2 removed the dressing from the right inner knee and identified the drainage as purulent. The areas had been debrided by the Wound Physician and the resident was on an antibiotic. The Wound Nurse identified the peri wound as pink. RN 2 indicated the wound looked better. She then applied a new dressing to the right inner knee. RN 2 then removed the dressing from the left inner knee, which was still affixed to the skin and had slid off the pressure wound. She indicated there was a large amount of purulent drainage on the old dressing. The Wound Nurse indicated the drainage had increased and the peri wound was more red and inflamed since the last time she had observed the area. Resident C's record was reviewed on 7/26/21 at 1:05 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set (MDS) assessment, dated 7/1/21, indicated a severely impaired cognition, required extensive assistance with activities of daily living (ADL's), frequently incontinent of bowel and bladder, had two unstageable pressure ulcers (covered with slough or necrotic tissue) on admission, non-surgical dressings and ointments were applied, and had seven days of antibiotic therapy. A Care Plan, dated 6/28/21, indicated wound management was required. The interventions included the treatment per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Dakins Solution (solution to prevent and treat skin and tissue infections) was to be applied and dry dressings were to be used to cover the pressure ulcers twice a day and as needed. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound cultures of the right and left inner knee pressure ulcers, dated 7/16/21, indicated many Proteus miribilis (growth of the organism). The Wound Specialist's Progress Notes, dated 7/14/21, indicated the right inner knee measured 4 centimeters (cm) by 5 cm, was unstageable with moderate amount of serous (blood) drainage, and was covered with 80% of necrotic tissue. A surgical excision debridement was completed with 1.5 cm depth and healthy bleeding tissue observed. The left knee measured 3.5 cm by 3.5 cm, unstageable with 80% necrotic tissue. A surgical excisional debridement was completed with 1.5 cm depth and health bleeding tissue was observed. The Wound Nurse Progress Notes, dated 7/21/21, indicated the right inner knee area was 4 cm by 5 cm. The depth was not measured and the area was unstageable. The left inner knee area measured 3.5 cm by 3.5 cm. The depth was not measured and the area was unstageable. The Treatment Administration Records (TARs), dated 7/2021, indicated the left inner knee pressure ulcer dressing change was scheduled for 8 a.m. and 5 p.m. There were initials, which indicated the dressing had been changed on 7/22/21 at 8 a.m. and 5 p.m., 7/23/21 at 8 a.m. and 5 p.m., refused at 8 a.m. on 7/24/21, and completed at 5 p.m. on 7/24/21. The TARs indicated the right inner knee pressure ulcer change was scheduled for 10 a.m. and 2 p.m. There were initials, which indicated the dressing had been changed on 7/22/21 and 7/23/21 at 10 a.m. and 2 p.m. The initials on 7/24/21 at 10 a.m. and 2 p.m. indicated the resident refused the dressing change. 2) During an observation on 7/25/21 at 11:36 a.m. with the Wound Nurse present, Resident E was lying in bed. There was an open area on the left hip with no drainage, there was no dressing on the left hip, and the brief and sheets were saturated with urine. The Wound Nurse indicated the left hip should have had a dressing covering the pressure area and acknowledged the resident was saturated with urine. Resident E's record was reviewed on 7/27/21 at 12:47 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 6/13/21, indicated a severely impaired cognitive status, extensive assistance with bed mobility, dependent on staff for transfers, dressing, toileting, hygiene, and bathing, was always incontinent of bowel and bladder, and had had no pressure ulcers. A Care Plan, dated 6/24/21, indicated a stage 2 (partial thickness of skin loss) pressure ulcer on the left hip. The interventions included wound care would be provided as ordered by the Physician. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing change was to be completed on evening shift on Monday, Wednesdays and Fridays. The TAR, dated 7/2021, indicated the treatment to the left hip had been completed on Friday, 7/23/21. The Wound Physician's measurements of the pressure ulcer on 7/7/21 indicated a healing wound caused from neurotic excoriation, which measured 6 cm by 6 cm by 0.2 cm on the left hip. A Wound Progress Note, dated 7/14/21, indicated the left hip measured 0.5 x 4.5 x 0.2, with no drainage. 3) During an observation with the Wound Nurse on 7/25/21 at 12:09 p.m., Resident G was lying in bed. The Wound Nurse indicated the resident had a stage 4 (full thickness skin loss) pressure area on the coccyx. The resident was observed and there was no dressing on the stage 4 area on the coccyx. The area was clean without drainage. CNA 3 was also in the room and indicated he had not checked the resident for incontinence since he started work at 6 a.m. The resident had not been incontinent. Resident G's record was reviewed on 7/27/21 at 1:43 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 4/8/21, indicated a severely impaired cognitive status, extensive assistance of two staff for bed mobility and toileting, dependent on two staff for transfers, extensive assistance of one staff for hygiene, and dependent on one staff for bathing, was always incontinent of urine, had an ostomy, had one stage 4 pressure ulcer, and received pressure ulcer care. A Care Plan, dated 10/7/20, indicated a pressure ulcer was present. The interventions included, wound care was to be completed as ordered by the Physician. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Iodosorb (gel dressing) was to be applied and covered with a dry protective dressing every evening shift. The TAR, dated 7/2021, indicated the treatment to the coccyx had been completed on the evening shift on 7/24/21. 4) During an observation with the Wound Nurse, on 7/25/21 at 12:18 p.m., Resident J was lying on a low air loss bed. The Wound Nurse indicated there was a stage 2 pressure area on the right buttock and stage 2 areas on the right hip. The areas were observed, there was an open area on the right buttock with no dressing covering the area. There was no drainage from the the area. The right hip had a dressing over three stage 2 areas, which was dated 7/21/21. There was a [MEDICATION(S)] dressing on the left buttock. The Wound Nurse indicated the left buttock was healed and the [MEDICATION(S)] dressing had been discontinued. There was no dressing on the sacrum area. Resident J's record was reviewed on 7/27/21 at 3:21 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change MDS assessment, dated 6/29/21, indicated a moderately impaired cognitive status, no behaviors, required extensive assistance of two staff for bed mobility, transfers, and toileting, required extensive assistance of one staff for hygiene, dependent on staff for bathing, was always incontinent of bowel and bladder, had one stage 2 pressure area, 1 stage 3 pressure area, and received pressure ulcer care. A Care Plan, revised on 7/8/21, indicated there were pressure ulcers present and the left buttock pressure area was resolved on 7/7/21. The interventions included, the wounds would be treated as ordered by the Physician. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/9/20, the right buttock was to be cleansed with normal saline, patted dry and a hydrocollloid dressing was to be applied on Monday, Wednesday, and Fridays on day shift. On 7/18/21, the right hip was to be cleansed with normal saline, patted dry, [MEDICATION(S)] cream was to be applied, and covered with a dry dressing every evening shift. On 3/8/21, the sacrum area was to be cleansed with wound cleanser, patted dry, skin prep was to be applied, and then covered by a foam dressing every Saturday. The TAR, dated 7/2021, indicated the [MEDICATION(S)] dressing treatment to the left buttock had been discontinued on 7/8/21, the right buttock treatment had been completed on Friday 7/23/21, the right hip treatment had been completed on July 22 and 23, 2021, and not completed on 7/24/21 due to the resident was sleeping. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 5) During an observation, with the Wound Nurse, on 7/25/21 at 12:30 p.m., Resident K was lying in bed. There was a dressing on the left heel dated 7/21/21. There was bloody/purulent drainage on the dressing. The right heel was scabbed with no dressing on the heel. The Wound Nurse indicated the right heel was to be left open to air. Resident K's record was reviewed on 7/27/21 at 4:14 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS assessment, dated 7/10/21, indicated a moderately impaired cognitive status, required extensive assistance of one staff for bed mobility, transfers, toilet use, dressing, and hygiene, was frequently incontinent of bowel and bladder, had two stage three (full thickness skin loss involving subcutaneous tissue damage) pressure ulcers, and received pressure ulcer care. A Care Plan, dated 12/15/20, indicated pressure ulcers were present. The interventions included, treatments would be administered as ordered by the Physician. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The right heel was to be cleansed with [MEDICATION(S)], patted dry, [MEDICATION(S)] to be applied, and leave open to air. The TAR, dated 7/2021, indicated the left heel treatment had been completed on Wednesday, 7/21/21 and not completed on Friday, 7/23/21. The right heel treatment had not been completed on 7/23/21 and 7/24/21. This Federal Tag relates to Complaint IN 517. 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a newly admitted resident with non-pressure wounds with multiple drains, history of weight loss, underweight status according to the Body Mass Index (BMI), and multiple antibiotics and vitamin supplements was assessed by a Registered Dietitian (RD) in a timely manner which resulted in a significant weight loss and hospitalization . The facility also failed to follow the RD recommendations for a resident with a history of weight loss for 2 of 3 residents reviewed for weight loss. (Residents E and L) Findings include: The record for Resident E was reviewed on 12/20/18 at 11:20 a.m. The resident was admitted to the facility on [DATE] from an acute care hospital. [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment, dated 11/5/18, indicated the resident was alert and oriented and weighed 105 pounds, with no history of weight loss or weight gain. The resident received a therapeutic diet and needed supervision with one person physical assist for eating. The nursing admission assessment, dated 10/29/18, indicated the resident had a large surgical abdominal wound that was open. The resident had a right flank drain and an axiom drain noted to the right flank area. The resident was also admitted with a [MEDICAL CONDITION] and [MEDICAL CONDITION] drainage systems. There was no current plan of care regarding weight loss for review. physician's orders [REDACTED]. Another physician's orders [REDACTED]. physician's orders [REDACTED]. physician's orders [REDACTED]. Another physician's orders [REDACTED]. The weight record indicated the resident weighed 105 pounds with a height of 64 inches on 10/30/18. This was the first and last documented weight in the clinical record. The resident's BMI was calculated at 18, which was underweight status. There was no RD (Registered Dietitian) assessment available for review. The meal consumption log for 10/2018 and 11/2018 indicated the resident had refused 3 meals since admission. The resident had a food consumption of 51%-75% 22 times and had a consumption of 76%-100% 13 times. The lab results were reviewed. On 11/2/18 the resident's [MEDICATION NAME] level (used to evaluate nutritional status) was 1.8, a low value (Normal values: 3.2-5.0). On 11/8/18, the [MEDICATION NAME] level was 1.7. Nursing notes, dated 11/13/18, indicated the resident left for a Physician appointment in Indianapolis, where he was then sent to the hospital and admitted . Interview with the current RD on 12/20/18 at 1:10 p.m., indicated she had started consulting at the facility on 11/15/18. She was unaware of the resident's situation, as she was not in the building at that time. Interview with the East Unit Manager on 12/20/18 at 1:45 p.m., indicated the resident was only weighed one time while he was a resident and weekly weights were not completed as ordered. There was also no RD admission assessment or progress notes for the resident. Telephone interview on 12/20/18 at 2:00 pm with the Indianapolis hospital Social Worker, indicated Resident E was discharged to the facility on [DATE]. She had spoken with the RD who had been following the resident during his previous admission and also currently since the resident was readmitted on [DATE]. The resident's weight on the 10/2018 discharge was 52.7 kg. The resident's weight on the 11/13/18 readmission from the facility was 40.2 kg. Interview with the Director of Nursing (DON) on 12/20/18 at 2:30 p.m., indicated there were no RD admission assessments for the resident. She indicated she would have expected an assessment to be completed due to the resident's condition and open surgical wounds. Interview with the DON on 12/20/18 at 2:50 p.m., indicated the old RD's last day was on 11/9/18 and the new RD, currently in the building, started on 11/15/18. 2. The record for Resident L was reviewed on 12/20/18 at 9:57 a.m. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, dated 10/25/18, indicated the resident was alert and oriented and required limited 1 person assist with eating and had no weight loss. A Nutritional Care Plan, dated 7/2/18, indicated the resident was at risk related to a body mass index less than 25. The interventions included, but were not limited to, monitor and evaluate weight and changes and to notify the Registered Dietitian (RD) and Physician of significant changes. Weights: 10/08/18 139 Lbs (pounds) 11/07/18 140 Lbs 12/10/18 124 Lbs An RD progress note, dated 12/12/18 at 3:32 p.m., indicated the resident presented with an 11.4% weight loss over the past month. The recommendation was to increase Ensure plus (chocolate) to twice a day and weekly weights for 4 weeks. There was no documentation to indicate the recommendations were followed. Interview with the RD on 12/20/18 at 12:35 p.m., indicated her process for communicating recommendations to the staff was to track them on a communication form and provide the Department Heads with copies at the end of her shift. Observation and interview with the resident on 12/20/18 at 1:05 p.m., indicated there was no Ensure plus on the resident's lunch meal tray and she had not been receiving the drinks but would like to be. Interview with the Director of Nursing on 12/2018 at 2:16 p.m., indicated the resident had a weight loss over the past month and the RD's recommendations should have been followed. This Federal tag relates to Complaint IN 350. 3.1-46(a)(1)

Based on observation, record review, and interview, the facility failed to ensure residents with Percutaneous Endoscopic Gastrostomy (PEG) tubes received the necessary care and treatment related to checking for proper placement and residual, starting and stopping tube feedings per Physician's Orders, proper labeling of tube feeding formula bags, proper hand washing, and incorrect infusion rates for 4 of 5 residents with PE[DEVICE]s, one of whom required hospitalization , in a sample of 6. (Residents B, C, E, and G) Findings include: 1. The closed record for Resident B was reviewed on 12/16/16 at 2:00 p.m. [DIAGNOSES REDACTED]. A Physician's Order on admitted d 12/12/16 indicated [MEDICATION NAME] 1.2 (a PE[DEVICE] feeding formula) 65 ml (milliliters) per hours continuous with 30 ml water flush every 4 hours. On 12/13/16 at 2:51 p.m., the computer Physician's Orders indicated Diabeticsource AC (a PE[DEVICE] formula) 75 cc (cubic centimeter) per (/) hour for (x) 20 hours or until 1500 cc infused, with 40 cc per hour water flush x 20 hours while the tube feeding infused. There were no Physician's Orders related to the time frame in which the tube feeding was to start and stop infusing. There were no orders related to PE[DEVICE] site care every shift, checking the resident's PE[DEVICE] for proper placement and/or residual every shift. The Admission Medical Nutrition Therapy assessment dated [DATE] at 1:53 P.M., completed by the Registered Dietician (RD) indicated a diet/nutrition recommendation based on the nutritional assessment Diabeticsource AC at 75 cc/hour x 20 hours including 40 cc/hour water x 20 hours, NPO (nothing by mouth), ice chips only. The Admission History and Physical note dated 12/14/16, completed by Nurse Practitioner (NP) #1 indicated, awaiting dietician recommendations. Will continue [MEDICATION NAME] 1.2 at 65 ml/hr continuous with 30 ml water flush every 12 hours. A care plan dated 12/13/16 indicated the resident required gastric tube feedings. The interventions included, but were not limited to, administer formula by pump as ordered. Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold if greater than 100 cc aspirate. Monitor absence or presence of drainage and/or signs or symptoms of infection at the tube site. Monitor, document, and report to Physician as needed nausea, vomiting, aspiration, fever, and shortness of breath. The 12/2016 Medication Administration Record [REDACTED]. There was no documentation related to monitoring, assessing, and providing care related to the resident's PE[DEVICE] every shift. There was no documentation related to the start and stop time of the resident's tube feeding. Nursing Notes dated 12/12/16 through 12/15/16 indicated no documentation related to monitoring and/or assessing the resident's PEG site for signs and symptoms of infection, proper placement or residual. There was no documentation in the record of the resident's fluid intake via his PE[DEVICE] feeding and flush. The 12/14/16 Prompt Medical Transportation Patient Care Report indicated, upon arrival the resident was short of breath, he was found laying supine (on his back) in facility bed with labored breathing. Per staff the resident vomited and became short of breath. The resident had been short of breath for 15 minutes and was suctioned. He had rales (coarse sounds) noted in all lung fields and was on nasal cannula at 5 liters. He was sat upright and transferred from the bed to the crews cot. Per the facility staff the resident's mental status was normal, he was alert to verbal stimuli and answered yes and no, he was able to follow commands. His skin parameters were normal and pupils were equal and reactive. He was disconnected from the tube feeding by facility staff and transported to the ambulance. The hospital admitting [DIAGNOSES REDACTED]. Interview with CNA #1 on 12/16/16 at 5:06 p.m., indicated she cared for the resident on 12/13/16 on the evening shift from 2:00 p.m., until 10:00 p.m. Her nurse was LPN #2. At some time during her shift the resident had vomited. She changed his clothes and notified her nurse. Interview with CNA #2 on 12/19/16 at 10:05 a.m., indicated she cared for the resident on 12/14/16 on the evening shift from 2:00 p.m., until 10:00 p.m. Her nurse was LPN #2. During the end of her shift the resident had vomited. She and her nurse changed the resident before he was transferred to the hospital. Interview with LPN #1 on 12/19/16 at 10:59 a.m., indicated she cared for the resident on 12/13/16 and 12/14/16 from 6:00 a.m., until 2:30 p.m. The resident was alert and verbalized no pain. She was unsure if she assessed the resident's vitals, intake or output. There was no abdominal distension, and no reports of nausea and vomiting. She checked for proper placement and there was no residual. She did not document the assessments. The nurse did not at any time during her shifts turn off the resident's tube feeding other than to pause it during ADL care. Interview with LPN #2 on 12/16/16 at 4:12 p.m., indicated she cared for the resident on 12/13/16 from 2:00 p.m., until 6:30 a.m.,, on 12/14/16. She then returned to work on 12/14/16 at 2:00 p.m., she cared for the resident until he was transferred out to the hospital at 9:37 p.m. The resident was alert with no changes in condition on 12/13/16. She did not document any assessments of the resident on that date. On 12/14/16 she completed visual rounds of her residents when she arrived, He seemed ok. During her medication pass that evening she indicated the resident was not in any distress. However, at that time, she did not assess the resident's vitals, intake or output. She did not assess for the placement of the resident's PEG nor did she assess for residual during either shift. On or about 9:00 p.m., CNA #2 informed her the resident had vomited. She entered the resident's room when she was finished with what she was doing. Upon entering the room, she found the resident in distress. He had vomit on his gown. She then assessed the resident and turned off his tube feeding. The resident was suctioned and 911 was called. While waiting for EMS, the resident was cleaned up by the nurse and the CNA. When EMS arrived the resident was laying flat and still hooked up to his tube feeding. The nurse did not at any time during her shifts turn off the resident's tube feeding or monitor intake prior to when she turned it off after she noted his vomiting on or about 9:00 p.m. on 12/14/16. Interview with the RD (Registered Dietician) on 12/19/16 at 10:22 a.m., indicated she completed an admission assessment for Resident B on 12/13/16. During her interview the resident indicated he had no issues. Her rationale for increasing the resident's intake was related to skin breakdown, previous weight loss, and to meet his daily allotted hydration. She entered the new tube feeding order in the computer as pending and forwarded her recommendations to the Medical Director's NP (NP #2) for approval as per her usual process. She thought approval had been given to one of the nurse managers, as the order had been activated & staff had changed the tube feeding to her recommendations. Interview with NP #2 on 12/19/16 at 10:30 a.m., indicated the facilities current practices related to approving RD recommendations included the following: the RD assessed the residents, she then typed her recommendations onto the MNT Recommendation Flowsheet and input an order as pending into the electronic ordering system, awaiting approval. If the NP was not available she then placed the flowsheet into her mailbox. Once the recommendation was reviewed by the NP and approved, the order was then active. Review of the 12/13/16 MNT Recommendation Flowsheet, at that time, indicated her signature along the bottom of the page. The NP stated her signature only indicated she received the recommendations, she did not approve the recommendation, she did not assess the resident, NP #1 assessed the resident, therefore, she should have reviewed the pending order and approved it. Interview with NP #1 on 12/19/16 at 9:22 a.m., indicated she assessed the resident on 12/14/16 before noon. He was alert and confused. His lungs were clear, the PEG site showed no signs and symptoms of infection. There was no abdominal distention and bowel sounds were heard in all four quadrants. The resident's tube feeding was running at the time, however, she did not verify the feeding type infusing nor did she verify the rate. Staff did not report to her the resident had any nausea or vomiting. The NP was not aware the resident's tube feeding and water intake had been increased. The resident had been tolerating the [MEDICATION NAME] 1.2 at 65 ml/hr with 30 ml water flushes every 4 hours and in her professional opinion that was appropriate. In her nursing practice, to verify if a resident was tolerating tube feeding was by checking residual and if there was too much residual it would cause vomiting and residents become higher risk for aspiration. Interview with the Director of Nursing on 12/19/16 at 3:27 p.m., indicated residents should be assessed and monitored for 72 hours after admission. The resident should have had documented assessments of his vitals, intake and output, catheter care and PE[DEVICE] care every shift. The resident's tube feeding orders should have been properly verified by the NP who assessed the resident on 12/14/16. The tube feeding should have had stop and start parameters. 2. On 12/19/16 at 1:20 p.m., LPN #5 was observed administering medications for Resident G. Upon entering the resident's room, the tube feeding was observed to be infusing. The LPN washed her hands, donned clean gloves and proceeded to flush the resident's tubing with a water flush, she then stopped and turned of the feeding. She was observed checking for proper placement and residual before administering the medication. The tube feeding was then restarted before the LPN left the room. The record for Resident G was reviewed on 12/19/16 at 2:10 p.m. [DIAGNOSES REDACTED]. A Physician's Order dated 12/18/16 indicated [MEDICATION NAME] 1.2 (a PE[DEVICE] formula) 75 cc/hr for 20 hours (on at 4 p.m./off at 12 p.m.). A current and updated care plan dated 10/5/16 indicated the resident required tube feeding. The interventions included, but were not limited to, hold tube feeding based on Physician's Orders for resident. Interview with LPN #5 on 12/19/16 at 1:40 p.m., indicated the resident's tube feeding orders were, on at 4:00 p.m., and off at 12:00 p.m. The resident's tube feeding should have been turned off per the Physician's Orders. Interview with the Director of Nursing on 12/19/19 at 3:27 p.m., indicated the LPN should have followed the Physician's Orders. The tube feeding should have been turned off at 12:00 p.m. 3. During an initial tour on 12/16/16 at 2:22 p.m. with RN #1, Resident C was observed sleeping with the head of bed (HOB) elevated 30 degrees. At that time, the enteral nutrition (tube feeding - delivery of nutrients through a feeding tube directly into the stomach) bag was not infusing and was hanging on the pole with about 175 cubic centimeters (cc) of liquid still in the bag. The bag was dated 12/15/16, but did not have a start time. On 12/16/16 at 4:50 p.m., LPN #3 was observed preparing medications for Resident C. She dispensed the medication from her medication cart and poured the contents into a plastic cup then entered the resident's room. She went into the bathroom washed her hands and obtained water from the sink. She then donned gloves, placed a new bag (dated 12/16/16 - timed 4:00 p.m.) of tube feeding on hold, uncovered the resident, and disconnected the tube feed from the Percutaneous Endoscopic Gastrostomy (PEG) tube. She then placed a plastic syringe into the residents PE[DEVICE], and indicated she was going to flush the PE[DEVICE] with 10 milliliters (ml) of water, she then poured the medication into the syringe, and flushed the PE[DEVICE] again with 10 ml of water. The LPN was not observed listening for bowel sounds with the stethoscope she had around her neck. She also was not observed checking for proper tube placement or checking the PE[DEVICE] for residual. During the above process the resident's door and curtain were also left open. Interview at the time with the LPN, indicated she forgot to close the curtain and/or door, she did not check for proper placement of the PE[DEVICE], nor did she check for residual prior to administering the resident's medications. The record for Resident C was reviewed on 12/19/16 at 10:30 a.m. [DIAGNOSES REDACTED]. The current care plan indicated the resident required tube feeding. The interventions included, but were not limited to, resident is dependent with tube feeding and water flushes, see MD orders for current feeding orders. Interview with the Director of Nursing (DON) on 12/16/16 at 6:50 p.m., indicated the LPN should have closed either the curtain or the door for privacy, and also checked for proper placement and residual of the resident's PE[DEVICE] prior to administering the medications. 4. During an initial tour on 12/16/16 at 2:55 p.m., an observation was made of Resident E watching television. At that time the tube feeding bag was hanging on the pole with about 150 cc still in the bag. The bag was dated 12/15/16, but did not have a start time. At 4:35 p.m. the resident was observed watching television and his tube feeding was not infusing. LPN #4 was observed looking up the next time of medication for the resident. He entered the room from the hallway and donned gloves. An observation of the setting on the pump was 70 cc/hour of tube feeding with a 25 cc/hour water flush. After being asked about the rate, he went to the medication cart and looked the rate up on the computer. He then re-entered the room and changed the pump settings. He assessed bowel sounds, checked for placement, and residual and turned on the tube feeding bag hanging there from earlier. Interview at that time with LPN #4 indicated he should have washed his hands before starting the tube feeding, and it should have been started on time. He was not sure what the setting should have been, and after looking the setting up in the computer indicated the settings were wrong on the pump. He indicated that the tube feeding and water flush should have been changed because it did not have a start time on the bag. The record for Resident E was reviewed on 12/19/16 at 11:40 a.m. [DIAGNOSES REDACTED]. The current care plan indicated the resident required tube feeding. The interventions included, but were not limited to, administer formula by pump as ordered. The Physician order dated 11/29/16, indicated tube feeding to run at 85 cc per hour for 18 hrs. Up at 3:00 p.m., and down at 9:00 a.m. The Physician order dated 11/14/16, indicated water flush to run at 45 cc per hour for 18 hrs with enteral feeds every shift. Interview with the Director of Nursing (DON) on 12/16/16 at 6:50 p.m., indicated the LPN should have washed his hands prior to assessing the resident. Nursing staff should always know the settings prior to starting the tube feeding. All the tube feeding bags should be labeled with the date and time that the tube feeding was started. If there was not a time on the bag, the entire bag needed to be thrown away and a new bag started. The nursing staff have a one hour window to administer medications, one hour before and one hour after their due time according to the medication administration record. Review of the current Administration of Medication through an Enteral Feeding Tube policy dated 5/2015, provided by the DON on 12/19/16 at 1:27 p.m., indicated to perform hand hygiene, and check the tube for placement and patency. Review of the current Enteral Nutrition policy dated 9/2016, provided by the DON on 12/19/16 at 1:27 p.m., indicated when the patient is fed by tube the nursing staff is assigned to specific enteral feeding responsibilities, such as administration of the feeding, formula, amount, feeding flow rate, and flushing with fresh tap water at appropriate intervals. Feeding complications are monitored, and corrective actions are implemented to alleviate complications. Review of the current General Dose Preparation and Medication Administration policy dated 1/2013, provided by the DON on 12/19/16 at 1:27 p.m., indicated administer medications within timeframe's specified by facility policy. This Federal Tag relates to Complaint IN 463. 3.1-44(a)(2)

Based on record review and interview, the facility failed to ensure each resident received the necessary care and treatment related to lack of assessments, monitoring intake and output, urinary catheter care, and PE[DEVICE] (Percutaneous Endoscopic Gastrostomy) care including tube feeding which resulted in a hospitalization for 1 of 6 residents with a urinary catheter and PE[DEVICE] in a sample of 6. (Resident B) Finding includes: The closed record for Resident B was reviewed on 12/16/16 at 2:00 p.m. [DIAGNOSES REDACTED]. A Physician's Order dated 12/13/16 indicated Foley (urinary) catheter 16 french (size). There were no Physician's Orders related to urinary catheter care. A Physician's Order on admitted d 12/12/16 indicated [MEDICATION NAME] 1.2 (a PE[DEVICE] formula) 65 ml (milliliters) per hours continuous with 30 ml water flush every 4 hours. A Physician's Order on 12/13/16 at 2:51 p.m., indicated Diabeticsource AC (a PE[DEVICE] formula) 75 cc (cubic centimeter) per (/) hour for (x) 20 hours or until 1500 cc infused, with 40 cc per hour water flush x 20 hours while the tube feeding infused. There were no Physician's Orders related to the time frame in which the tube feeding was to start and stop infusing. There were no orders related to PE[DEVICE] site care every shift, checking the resident's PE[DEVICE] for proper placement and/or residual every shift. The Admission Medical Nutrition Therapy assessment dated [DATE] at 1:53 P.M., completed by the Registered Dietician (RD) indicated a diet/nutrition recommendation based on the nutritional assessment Diabeticsource AC at 75 cc/hour including 40 cc/hour water x 20 hours, NPO (nothing by mouth), ice chips only. The Admission History and Physical note dated 12/14/16 completed by Nurse Practitioner (NP) #1 indicated, awaiting dietician recommendations. Will continue [MEDICATION NAME] 1.2 at 65 ml/hr continuous with 30 ml water flush every 12 hours. A care plan dated 12/13/16 indicated the resident had an indwelling Foley catheter. The interventions included, but were not limited to, catheter care every shift and as needed. A care plan dated 12/13/16 indicated the resident required gastric tube feedings. The interventions included, but were not limited to, administer formula by pump as ordered. Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold if greater than 100 cc aspirate. Monitor absence or presence of drainage and/or signs or symptoms of infection at the tube site. Monitor, document, and report to Physician as needed nausea, vomiting, aspiration, fever, and shortness of breath. The 12/2016 Medication Administration Record [REDACTED]. There was no documentation related to monitoring, assessing, and providing care related to the resident's indwelling Foley catheter and PE[DEVICE] every shift. There was no documentation related to monitoring or assessing the resident's vitals (heart rate, temperature, respirations, blood pressure), fluid intake or urinary output. Nursing Notes dated 12/12/16 through 12/15/16 indicated no documentation related to monitoring and/or assessing the resident, the PEG tube or Foley catheter for the first 72 hours of admission. There was no documentation in the record of the resident's fluid intake via his PE[DEVICE] feeding or output from his Foley catheter. The 12/14/16 Prompt Medical Transportation Patient Care Report indicated, upon arrival the resident was short of breath, he was found laying supine (on his back) in facility bed with labored breathing. Per staff the resident vomited and became short of breath. The resident had been short of breath for 15 minutes and was suctioned. He had rales (coarse sounds) noted in all lung fields and was on nasal cannula at 5 liters. He was sat upright and transferred from the bed to the crews cot. Per the facility staff the resident's mental status was normal, he was alert to verbal stimuli and answered yes and no, he was able to follow commands. His skin parameters were normal and pupils were equal and reactive. He was disconnected from the tube feeding by facility staff and transported to the ambulance. The hospital admitting [DIAGNOSES REDACTED]. Interview with CNA #1 on 12/16/16 at 5:06 p.m., indicated she cared for the resident on 12/13/16 on the evening shift from 2:00 p.m., until 10:00 p.m. Her nurse was LPN #2. At some time during her shift the resident had vomited. She changed his clothes and notified her nurse. Interview with CNA #2 on 12/19/16 at 10:05 a.m., indicated she cared for the resident on 12/14/16 on the evening shift from 2:00 p.m., until 10:00 p.m. Her nurse was LPN #2. During the end of her shift the resident had vomited. She and her nurse changed the resident before he was transferred to the hospital. Interview with LPN #1 on 12/19/16 at 10:59 a.m., indicated she cared for the resident on 12/13/16 and 12/14/16 from 6:00 a.m., until 2:30 p.m. The resident was alert and verbalized no pain. She was unsure if she assessed the resident's vitals, however, she assessed his Foley catheter and it was draining amber urine. She did not indicate she provided catheter care. There was no abdominal distension, no reports of nausea and vomiting. She checked for placement and there was no residual. She did not document the assessments. The nurse did not at any time during her shifts turn off the resident's tube feeding other than to pause it during ADL care. Interview with LPN #2 on 12/16/16 at 4:12 p.m., indicated she cared for the resident on 12/13/16 from 2:00 p.m. until 6:30 a.m. on 12/14/16. She then returned to work on 12/14/16 at 2:00 p.m., she cared for the resident until he was transferred out to the hospital at 9:37 p.m. The resident was alert with no changes in condition at all on 12/13/16. She did not document any assessments of the resident on that date. On 12/14/16 she completed visual rounds of her residents when she arrived, He seemed ok. During her medication pass that evening she indicated the resident was not in any distress. However, at that time, she did not assess the resident's vitals, intake or output. She did not assess for the placement of the resident's PEG nor did she assess for residual during either shift. On or about 9:00 p.m., CNA #2 informed her the resident had vomited. She did not enter the resident's room until she was finished with what she was doing. Upon entering the room she found the resident in distress. He had vomit on his gown, she then assessed the resident and turned off his tube feeding. The resident was then suctioned and 911 was called. While waiting for Emergency Medical Services (EMS) the resident was cleaned up by the nurse and the CNA. When EMS arrived the resident was laying flat and still hooked up to his tube feeding. The nurse did not at any time during her shifts turn off the resident's tube feeding prior to when she turned it off after she noted he vomited on or about 9:00 p.m., on 12/14/16. Interview with the RD (Registered Dietician) on 12/19/16 at 10:22 a.m., indicated she completed an admission assessment for Resident B on 12/13/16. During her interview the resident indicated he had no issues. Her rationale for increasing the resident's intake was related to skin breakdown, previous weight loss, and to meet his daily allotted hydration. She entered the new tube feeding order in the computer as pending and forwarded her recommendations to the Medical Director's NP (NP #2) for approval as per her usual process. She thought approval had been given, as the order had been activated & staff had changed the tube feeding to her recommendations. Interview with NP #2 on 12/19/16 at 10:30 a.m., indicated the facilities current practices related to approving RD recommendations included the following: the RD assessed the residents, she then typed her recommendations onto the MNT Recommendation Flowsheet and input an order as pending into the electronic ordering system, awaiting approval. If the NP was not available she then placed the flowsheet into her mailbox. Once the recommendation was reviewed by the NP and approved, the order was then active. Review of the 12/13/16 MNT Recommendation Flowsheet, at that time, indicated her signature along the bottom of the page. The NP stated her signature only indicated she received the recommendations, she did not approve the recommendation, she did not assess the resident, NP #1 assessed the resident, therefore, she should have reviewed the pending order and approved it. Interview with NP #1 on 12/19/16 at 9:22 a.m., indicated she assessed the resident on 12/14/16 before noon. He was alert and confused. His lungs were clear, the PEG site showed no signs and symptoms of infection. There was no abdominal distention and bowel sounds were heard in all four quadrants. The resident's tube feeding was running at the time, however, she did not verify the feeding nor did she verify the rate. Staff did not report to her the resident had any nausea or vomiting. The NP was not aware the resident's tube feeding and water intake had been increased by the RD. She indicated the resident had been tolerating the [MEDICATION NAME] 1.2 at 65 ml/hr x 20 hours with 30 ml water flushes every 4 hours and in her professional opinion that was appropriate. In her nursing practice, to verify if a resident was tolerating tube feeding was by checking residual and if there was too much residual it would cause vomiting and residents become higher risk for aspiration. Interview with the Director of Nursing on 12/19/16 at 3:27 p.m., indicated residents should be assessed and monitored for 72 hours after admission. The resident should have had documented assessments of his vitals, intake and output, catheter care and PEG care every shift. This Federal Tag relates to Complaint IN 463. 3.1-37(a)

Based on observation, record review, and interview the facility failed to ensure Physician ordered treatments were provided as ordered for 2 of 3 residents reviewed for Pressure Ulcers in the sample of 5. (Residents #D and #E) (LPN #1 and LPN #2). The facility also failed to ensure excoriated and red areas were monitored and treatments rendered as ordered resulting in the development of an Unstageable Pressure Ulcer and a Deep Tissue Injury to the areas. (Resident #E) (LPN #1 and LPN #2) Findings include: 1. On 7/20/14 at 9:45 a.m. Resident #E was observed in bed. The resident was awake. LPN #2 was present at this time and the resident's wound dressings were checked by the LPN. The resident had dressings in place to the left hip and left upper posterior thigh areas. The date of 7/18 was written on both of the dressings. LPN #2 confirmed the dates on the dressings were 7/18. On 7/20/14 at 1:30 p.m., LPN #2 was observed completing wound care for Resident #E. The resident was in bed. The LPN removed the dressing to resident's left buttock area. There was around open area to the outer left buttock area. The LPN measured the area and indicated the area measured 5.9 cm (centimeters) x 4.9 cm . There was also an irregular shaped open area to the side of the above open area. This open area was measured by the LPN also. The area measured 1.8 cm x 2.4 cm. The LPN proceeded to cleanse the round wound with wound wash and applied Santyl ointment to the area. The LPN then cleansed the irregular shaped area and also applied Santyl ointment to the area. The record for Resident #E was reviewed on 7/20/14 at 11:20 a.m. The resident's [DIAGNOSES REDACTED]. The resident was sent to the hospital on [DATE] and was re-admitted to the facility on [DATE]. Review of the 5/16/14 Minimum Data Set Quarterly assessment indicated the resident required extensive assistance of two staff members for bed mobility, transfers, and dressing. The assessment also indicated the resident was at risk for the development of pressure ulcers and did not have any Stage I or greater pressure ulcers at this time. A 4/30/14 Braden Scale for pressure ulcer risk indicated the resident's score was (17). A score of (17) indicated the resident was at risk for pressure ulcer development. A Care Plan initiated on 10/8/12 indicated the resident had the potential for skin and tissue alterations related to the need for assistance with ADL's (Activities of Daily Living) , a history of pressure ulcers, and a Braden scale score indicating the resident was at high risk. The Care Plan was last updated with a goal date of 8/4/14. Care Plan interventions included for staff to turn and reposition the resident every two hours, assess skin weekly, and provide treatments as ordered by the Physician. A Care Plan initiated on 7/7/14 indicated the resident had an actual alteration in skin integrity related to an Unstageable ulcer to the left buttock and a Suspected Deep Tissue Injury wound to the left posterior thigh related to decreased mobility. The 7/2014 Medication Record indicated there was a Physician's order to cleanse the left buttock with normal saline, apply Santyl ointment and Kallostat and cover with Meplex every day. This order was initiated on 6/16/14. No Physician orders for any new treatments were written on 7/20/14. There was a Physician order written [REDACTED]. The order indicated the family was notified of the new order at this time. The 7/20/14 Nursing Progress Notes were reviewed. There was no documentation of the Physician or the resident's family being notified of the new area on 7/20/14. Review of the 7/1/14 physician progress notes [REDACTED]. The note indicated the residents buttock/coccyx area was "red", "raw", and "flaky". The progress note indicated the plan was to discontinue [MEDICATION NAME] and to change the treatment to apply Nystantin/Zinc 1:1 to the area every shift. The plan also indicated staff were to turn the resident side to side and to monitor. The 7/2014 Physician orders were reviewed. An order was written on 7/1/14 to discontinue [MEDICATION NAME] to the buttock and to start Nystantin 1:1 zinc oxide to the coccyx every shift. Another order was written on 7/5/14 to apply Santyl (a [MEDICATION NAME] ointment) on the red area on the coccyx and Nystantin 1:1 zinc oxide to the necrotic area (SIC). Two orders were written on 7/7/14. The first order was to cleanse the left buttock with wound cleanser, apply Santyl/[MEDICATION NAME] 1;1 and cover with a foam dressing every day. The second order was to cleanse the left posterior thigh area with wound wash and cover with a foam dressing every three days. The 7/2014 Treatment Record was reviewed. The treatment for [REDACTED]. The treatment ordered on [DATE] was not signed out as completed on 7/5/14 or 7/6/14. The 6/2014 Weekly Skin Check sheets were reviewed. A Skin Check Sheet was completed on 6/13/14. There were no further Weekly Skin Sheets for June 2014. The 6/13/14 Weekly Skin Check Sheet indicated there were no skin conditions or changes, ulcers, or injuries The 7/2014 Weekly Skin Check Sheets were reviewed. The first sheet completed in July was dated 7/4/2014. This sheet indicated " no" was marked for any skin conditions or changes, ulcers, or injuries. The Comments section indicates no new areas were noted at this time and redness continued to the coccyx. There were no Non Pressure sheets available for the dates of 7/1/14 thru 7/10/14. The 6/2014 Nursing Progress Notes were reviewed. The last June entry made was entered on 6/22/14 at 11:09 a.m. This entry indicated the resident was alert and verbally responsive and his skin was warm and dry to touch. The 7/2014 Nursing Progress Notes were reviewed. The first entry was titled as a "late entry" 7/1/2014 at 8:50 a.m. The entry noted the [MEDICATION NAME] to the coccyx was discontinued and Nystantin Zinc Oxide 1:1 to the coccyx every shift was to be applied. There was no assessment of the coccyx area in this entry. The next entry was titled as a "late entry" at 6:50 p.m. The entry indicated there was a new order from the Nurse Practitioner for the area on the residents "left buttock" and "left posterior thigh." The entry also indicated on 7/1/14 the Nurse Practitioner assessed the area on the residents left buttock and left posterior thigh and wrote a treatment order for that area. On 7/5/14 while doing personal care a CNA called the writer into the room to look at the area. The area was red with dark areas . The writer called the Nurse Practitioner on call and treatment orders were changed to include Santyl on the" dark areas" with zinc oxide on the "red areas"noted with dark red areas. One entry was made on 7/6/14. This entry was made at 4:44 a.m. The entry indicated the resident was in bed and the dressing to the buttock was clean, dry, and intact. The next entry was made on 7/7/14 at 1:28 a.m. This entry indicated the resident was repositioned side to side every two hours and the dressing was intact to the wound. The next entry in the Nursing Progress Notes was entered by the Wound Nurse. The entry was made on 7/7/14 at 11:08 a.m. This entry indicated the resident was assessed and an Unstageable pressure ulcer was noted to the left buttock area with 90% slough and 10% DTI (deep tissue injury) and another DTI was noted to the left posterior thigh. The Nurse Practitioner was called and appropriate treatment orders were obtained for both areas. The July Weekly Pressure Ulcer Report were reviewed. There were two reports initiated on 7/7/14. The first report indicated the resident had an Unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough or eschar) pressure ulcer to the left buttock. The ulcer measured 10.0 cm x 5.5 cm. the report indicated 7/5/14 was the initial observation of the area. The second 7/7/14 Weekly Pressure Ulcer Report was reviewed. The report indicated a Suspected Deep Tissue Injury area was noted on the resident's rear left thigh area. The area measured 6.0 x 6.0 cm. The report indicated 7/5/14 was the initial observation of the area. The 7/2014 Weekly Pressure Ulcer reports were reviewed. A Weekly Skin Pressure Ulcer report was initiated on 7/21/14 for an area to the left medial buttock. The report indicated this was a new onset pressure ulcer. The area was identified as a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed). The report indicated the pressure ulcer measured 2.0 cm x 1.0 cm. The 7/2014 Laboratory test results were reviewed. A culture of the left buttock wound was obtained on 7/8/14. The results were reported on 7/11/14. The report indicated the wound culture was positive for a moderate amount [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus) indicating an infection in the wound. A Resident Event Report Worksheet form was initiated on 7/21/14 at 10:00 a.m. The form was initiated by the Wound Nurse. The form indicated the resident developed a Stage II pressure ulcer to the left medial buttock. A Pressure Ulcer Investigation- In House Acquired form attached to the Event Report indicated the ulcer measured 2.0 cm x 1.0 cm with no tunneling. The form indicated the section titled " Area Avoidable" was checked. A Resident Event Report Worksheet form was initiated on 7/5/14 at 5:00 p.m. The report indicated the resident developed a pressure area to the buttock. The attached Pressure Ulcer Investigation - In House Acquired form attached to the Event Report indicated pressure areas on the resident's left buttock measured 10 cm x 5 cm and an are to the left posterior thigh measured 6 cm x 6 cm. The form indicated the section titled " Area Avoidable" was checked. Review of the 7/2104 Daily Monitoring/Pressure Ulcers logs for Resident #E was reviewed. There was one log for the left hip pressure ulcer and one log for the left buttock pressure ulcer. The first entries on both of these logs were entered on 7/7/14. When interviewed on 7/20/14 at 1:51 p.m., LPN #2 indicated she worked on 7/19/14 and was assigned to care for Resident #E. The LPN indicated she did not complete the treatment to the resident's left buttock area on 7/19/14. The LPN indicated the resident did not refuse the treatment yesterday. LPN #2 indicated another Nurse was going to do the treatment for [REDACTED]. The LPN indicated she applied the Santyl ointment to both the open areas on the left buttock area When interviewed on 7/21/14 at 8:55 a.m., the Wound Nurse indicated she completed the residents's treatment to the left buttock and left posterior thigh wounds on 7/18/14. The Wound Nurse indicated the resident had two open areas on 7/18/14 when she completed the treatments. The Wound Nurse indicated there was only one open area on the resident's left buttock area when she completed the resident's treatments on 7/18/14. The Wound Nurse indicated second area to the left buttock was not present on 7/18/14. The Wound Nurse indicated an Unstageable pressure ulcer was noted to the resident's left buttock area on 7/7/14 and a Suspected Deep Tissue injury was noted to the resident's left rear thigh on 7/7/14 and new treatment areas were obtained. When interviewed on 7/22/14 the Director of Nursing indicated no non-pressure skin sheets, pressure wound sheets, or any skin/wound assessments were initiated when Physician orders were obtained to start a new treatment to the coccyx area on 7/1/14 . The Director of Nursing indicated the treatment ordered was first signed out as completed on 7/3/14. Continued interview with the Director of Nursing indicated a new order was obtained on 7/5/14 to treat the necrotic and red areas to the left buttock with Santyl and [MEDICATION NAME]/Zinc. The Director of Nursing indicated the above ordered treatment was not signed out as completed on 7/5/14 and 7/6/14. The Director of Nursing indicated the treatments should have been completed as ordered. The Director of Nursing indicated the Wound Nurse assessed the left buttock and let posterior thigh areas on 7/7/14, initiated Pressure Ulcer Reports for wounds and the new treatment orders were obtained. The policy titled "Documentation and Charting Frequency Guidelines" was reviewed on 7/22/14 at 9:22 a.m. the policy was dated 8/31/12. The Director of Nursing provided the policy and indicated the policy was current. The policy indicated Licensed Nurses were to document weekly progress notes for non-pressure skin conditions. The policy also indicated the documentation was to be completed on a Weekly Non Pressure Skin Conditions Report. 2. On 7/20/14 at 9:25 a.m., Resident #D was observed in bed. LPN #1 was present in the room. The resident had a dressing in place to the left right buttock area. The date of 7/18 was written on the dressing. The resident had a dressing in place to the right heel area. The date of 7/18 was written on the dressing. There were initials written on the dressing. There was dried dark red drainage on the heel dressing. On 7/201/4 at 11:05 a.m., LPN #1 was observed providing wound care for the resident. The resident was sitting in a wheel chair in her room LPN#1 removed the kerlix wrap dressing from around the resident's right ankle area. The LPN then removed a small dressing from the wound area. There was dried yellow/tan colored drainage on the dressing. The resident had an open wound to the right heel. The open area was approximately 4 cm (centimeters) x 3 cm. the wound was dark in color. The resident stated "I was wondering why they don't change this every day" when the LPN was completing the treatment. The record for Resident #D was reviewed on 7/20/14 at 10:25 a.m. The resident's [DIAGNOSES REDACTED]. The July 2014 Treatment Record was reviewed. There was a Physician's order to cleanse the right heel with wound cleanser, apply [MEDICATION NAME] (an antibiotic ointment/Santyl (a [MEDICATION NAME] ointment) 1:1 and wrap with Kerlix one a day. The Treatment Record indicated the treatment was to be completed on the 6:00 a.m.- 2:00 p.m. shift daily. The right heel treatment was circled as not completed on 7/19/14. An entry on the back page of the Treatment Record indicated the resident was up in the wheel chair at 10:00 a.m. and she refused the right heel treatment at this time. The 4/15/14 Minimum Data Set Significant Change assessment indicated the resident BIMS (Brief Interview for Mental Status) score was 15. A score of 15 indicated the resident's cognitive patterns were intact. The assessment also indicated the resident required extensive assistance of 2 or more staff members for bed mobility, transfers, and personal hygiene. The assessment also indicated the resident had one Stage III (full thickness tissue loss with no visible bone or tendon exposed) Pressure ulcer. The 7/14/14 Weekly Pressure Ulcer report indicated the resident had an Unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound) to the right heel. The pressure ulcer measured 2.9 cm x 4.1 cm with no depth. The 7/21/14 Weekly Pressure Ulcer report indicated the right heel pressure ulcer was Unstageable and measured 4.0 cm x 4.2 cm with no depth. A 6/19/14 Physician's Progress Note indicated the resident had an infected wound to the right foot. The Progress Note also indicated the wound culture was positive for Proteus Mirablis (an infection). The Progress Note also indicated the resident was to be treated to IV (intra-venous) antibiotics. The 6/21/14 results of a wound culture obtained on 6/16/14 was positive for Proteus Mirablis [MEDICAL CONDITION] (an infection). When interviewed on 7/20/14 at 10:20 a.m., LPN #1 indicated she had worked on 7/19/14 and was assigned to care for Resident #D. The LPN indicated she did not complete the dressing change to the the resident's right heel on 7/19/14. The LPN indicated the resident had been gotten out of bed by 10:00 a.m. on 7/19/14 and she had not completed the resident's treatments on 7/19/14. When interviewed on 7/21/14 at 3:00 p.m., the Director of Nursing indicated the treatments should have been completed as ordered. This Federal tag relates to Complaints IN 386, IN 377, and IN 823. 3.1-40(a)(2)

Based on observation, record review and interview, the facility failed to ensure fall prevention devices were in place for 1 of 3 residents reviewed for accidents of the 11 residents who met the criteria for accidents. This deficient practice resulted in an injury requiring the resident to receive sutures. (Resident #62) The facility also failed to initiate a fall intervention timely for 1 of 3 residents reviewed for accidents of the 11 residents who met the criteria for accidents. (Resident #155) Findings include: 1. Resident #62 was observed on 10/17/12 at 8:34 a.m. She was seated in a Broda chair. The resident had a self releasing seat belt around her waist with the buckle in the front of her. There was no pull tab alarm attached to the resident. The resident was observed on 10/17/12 at 10:30 a.m., she was seated in a Broda chair in the West Unit dining room. She had a self release belt on, there was no pull tab alarm attached to the resident. On 10/17/12 at 12:40 p.m., the resident was in the Broda chair in the dining room. There was no pull tab alarm attached to the resident. There was a self release seat belt in place. The resident was observed on 10/17/12 at 3:20 p.m., she was seated in the Broda chair in front of the Nurses' Station. There was a self release seat belt in place, there was no pull tab alarm attached to the resident. On 10/18/12 at 8:15 a.m., the resident was up in the Broda chair with a self release seat belt in place, there was no pull tab alarm in place. On 10/18/12 at 1:55 p.m., the resident was observed being transferred from the Broda chair to the bed by CNA #1 and CNA #2. The self release seat belt was on the resident. There was no Dycem (a material used to prevent sliding) in the chair under the resident and there was no pull tab on the chair attached to the resident. Interview with CNA #1 on 10/18/12 at 1:55 p.m., indicated there was no Dycem and no pull tab alarm on the resident. Continued interview with CNA #1, indicated she had not applied the pull tab alarm since the seat belt was applied. CNA #1 had the West Unit CNA Assignment Sheet in her pocket. On 10/18/12 at 1:55 p.m., the CNA assignment sheet was reviewed. It indicated the resident was to have a low bed with a mat at bedside, a self release belt, a pressure alarm to the bed, a pull tab to chair, a cushion with Dycem, and a foot buddy to the Broda chair. The record for Resident #62 was reviewed on 10/18/12 at 2:08 p.m. The resident had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment with an assessment reference date of 9/26/12, indicated the resident had long and short term memory problems and required extensive assistance of 2 staff members with transfers. It also indicated the resident's balance was not steady when moving from a seated to a standing position and during transfers. A fall risk assessment was completed on 9/11/12 and 9/21/12. Both assessments indicated the resident had a score of 75, which indicated a high risk for falls. Review of the resident's record, indicated the resident had falls on 6/19/12, 7/6/12, 7/15/12, 7/20/12, 7/25/12, 8/4/12, 9/6/12 and 10/5/12. Review of the form titled "Post Fall Evaluation Part 2 IDT (Interdisciplinary Team) Review" that was dated 9/18/12, indicated the resident had a fall on 9/6/12. The "Interventions After Fall" section of the form indicated the intervention implemented after the fall was a seat belt. There was a physician's orders [REDACTED]. There was a Falls Care Plan with a revision date of 9/20/12, that indicated the resident was at risk for falls due to unsteady gait, psychoactive drug use, poor communication/comprehension, disease process condition, and dementia. The interventions to be used to prevent falls were: -Broda chair for proper positioning -concave mattress to bed -Dycem to Broda chair -low bed with mat next to bed -pressure alarm to bed -pull tab alarm to wheelchair -self release wheelchair belt to Broda chair The October 2012 Physician order [REDACTED]. The resident had a fall on 10/5/12 at 11:00 a.m. Review of the form titled, "Post Fall Evaluation Part 1," dated 10/5/12, indicated the resident had a witnessed fall with injury. She was transferred to the hospital. The resident kneeled forward from her Broda chair and hit her face on a table in the dining room. The staff member assisted the resident to the floor. There was no evidence that the fall interventions were in place prior to the fall. The form titled "Post Fall Evaluation Part 2 IDT Review" dated 10/8/12 was reviewed. It indicated the resident received sutures above her right eye brow while in the emergency room . The interventions at the time of the fall included, Broda chair, under direct supervision of staff, in the west assisted dining room during an activity, attending a group activity listening to music, "nurse was on seen (sic) immediately and first aide was initiated resident was sent to ER for evaluation, updated doctor on blood pressures and meds (medications) for review due to low blood pressure, will re-educate CNA's on restraint use." There was a progress note dated 10/5/12 at 4:00 p.m. "Res.(resident) returned from ER. Noted with 3 sutures to rt.(right) eyebrow. No active bleeding noted, No signs of pain/discomfort. POA (Power of Attorney) notified of res . return and is on her way to facility. Report called from hospital stating all CT scans were negative..." Review of the Emergency Department notes, dated 10/5/12, indicated, "Pt. (patient) arrives BLS (Basic Life Support) via (Name if Ambulance company) to Room 3B c/o (complaint) facial lacerations r/t (related to) witnessed fall at nursing home. Pt. is awake and alert only to self per baseline, stated EMS (Emergency Medical Staff). Pt. is longboarded with cervical stabilization with rolled towels. Writer notes small laceration to Right orbit, bleeding controlled with gauze at this time. Dentition cracks noted, but unsure if this is new to today's injury. Pt. non-verbal with staff. EMS states that this is her norm. 1 cm (centimeter) laceration beneath right eyebrow, to right of eyebrow, skin tear note, V shaped, 1 cm by 1 skin closure: 5-0 nylon, Number of sutures 3. technique: simple dressing 4 x 4 sterile gauze." Interview with the West Unit Manager on 10/18/12 at 2:15 p.m., indicated the resident did not have a self release belt on, as ordered by the Physician, at the time of the fall on 10/5/12. She indicated the resident was gotten up by a Hospice CNA who did not place the seat belt on the resident. She also indicated facility staff did not apply the seat belt after Hospice staff left. The form titled (Name of Hospice Company) Hospice "Incident Report Tracking Form," dated 10/5/12, was reviewed. It indicated, "Staff at (Facility's Name) Nursing facility stated that patient fell from Broda chair striking her head, resulting in need for emergency hospital visit. Our HHA (Home Health Aide) had gotten patient up at 7:15 a.m., did care, and when she left facility patient was fully reclined in Broda and next to the Nurses' station. The fall occurred at approximately 11:00 a.m. The seat belt was not fastened/secured and was underneath patient." Interview with the West Unit Manager on 10/18/12 at 2:30 p.m., indicated the resident had physician's orders [REDACTED]. She indicated the fall devices were not in place as ordered during observations on 10/17/12 and 10/18/12. She indicated the devices should have been in place. 2. On 10/17/12 at 8:22 a.m., Resident #155 was observed sitting in a wheelchair eating breakfast in the dining room on the West Unit. The resident was observed with a clip chair alarm attached to her and the wheelchair. The record for Resident #155 was reviewed on 10/17/12 at 8:47 a.m. The resident was admitted to the facility on [DATE] from the hospital. The resident's [DIAGNOSES REDACTED]. Review of Physician Orders, dated 9/4/12, indicated to place the bed against the wall. A Physician Order, dated 9/10/12, indicated pull tab alarm to wheelchair, place bed against the wall and pull tab alarm to be used in bed also. Review of the Patient Evaluation, dated 8/27/12, indicated the resident was a medium risk for falls. Review of the Minimum Data Set (MDS) admission assessment, dated 9/3/12, indicated the resident was alert and oriented times three, she needed extensive assist with one person physical assist for bed mobility, transfers, dressing, and personal hygiene. The resident had no limitations to her upper or lower extremities, and the resident had a history of [REDACTED]. Review of the post fall evaluation #1, dated 9/28/12, indicated the resident was found on the floor at 12:45 a.m. Review of post fall #2 evaluation, dated 10/1/12, indicated the IDT team met and reviewed the fall. The decision was made to consult the Physician about Ativan (an anti-anxiety medication) being given at night. Review of Physician Orders, dated 10/1-10/14/12, indicated there was no order for the Ativan to be given routinely at night to the resident. Review of the post fall #1, dated 10/14/12 at 2:00 a.m., indicated the resident was found on the floor matt next to her bed. The resident sustained [REDACTED]. Review of the post fall #2, dated 10/17/12, indicated IDT summary review which indicated the resident had insomnia and was not sleeping at night. Review of the current plan of care that was updated on 9/4/12, indicated the resident had an actual fall with minor injury related to unsteady gait. The Nursing approaches were to continue interventions on the at risk plan, pull tab alarm to wheelchair and bed. Review of Physician Orders, dated 10/23/12, indicated Ambien (a medication used for sleep) was ordered for the resident for insomnia. Interview with the Regional Interim Director of Nursing #1 on 10/23/12 at 11:17 a.m., indicated the resident's Physician was not notified of the resident's restlessness and insomnia at night time until 10/23/12. She indicated the IDT interventions should have been completed in a more timely manner. She further indicated the Ambien was just ordered on [DATE] after the resident had another fall on 10/14/12. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure CPR (Cardio [MEDICAL CONDITION] Resuscitation) was performed correctly by licensed staff, when during CPR efforts, an LPN intervened and removed the Ambu resuscitation device from the resident's [MEDICAL CONDITION] (a cannula inserted into the a surgical opening in the throat as an alternate airway) tube and placed the Ambu over the resident's mouth and face, for 1 of 2 residents reviewed for CPR. This deficient practice affected 1 of 3 residents with with [MEDICAL CONDITION] in place in a sample of 6. (Resident #B) The facility also failed to ensure emergency equipment was in place in the resident's room and on Crash Carts for CPR supplies on 3 of 3 units and in the rooms of residents with [MEDICAL CONDITION], for 2 of 3 residents reviewed for tracheostomies in the sample of 6. (Residents #D and #E) (The East, West, and South units) The Immediate Jeopardy began on [DATE] when licensed facility staff failed to ventilate Resident #B through the [MEDICAL CONDITION] during cardio [MEDICAL CONDITION] resuscitation efforts when the resident was found with a faint pulse and no respirations. The facility Administrator, Director of Nursing, and Corporate Nurse were informed of the Immediate Jeopardy on [DATE] at 10:05 a.m. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The closed record for Resident #B was reviewed on [DATE] at 6:55 a.m. The resident was originally admitted to the facility on [DATE]. The resident was re-admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the ,[DATE] physician's orders [REDACTED]. A care plan initiated on [DATE] indicated the resident was a Full Code. The ,[DATE] Nursing Progress Notes were reviewed. An entry made by LPN #1 on [DATE] at 4:30 a.m. indicated the CNA reported to the LPN that the resident was non responsive, and the writer went to the room. The resident "had faint weak pulse, respirations were not noted, eyes were closed and would not respond to verbal or tactile, code blue called, 911 called, C.P.R. initiated and continued until paramedics came to relieve nurses." An entry made by LPN #4 (the LPN who was assigned to care for Resident #B) on [DATE] at 6:52 a.m., indicated the resident was resting in bed, and her breathing was even and unlabored at about 11:15 p.m. when first rounds were done. The same entry indicated at 4:00 a.m. the resident's feeding was replaced, placement checked, and the peg (percutaneous endoscopic gastrostomy tube) was in place. The entry also indicated a nurse from the East unit was covering when writer left to take a break at about 4:00 a.m. Upon returning from break, the resident was unresponsive, had no pulse and no respirations, 911 was called and the resident was transported to the hospital in an ambulance. Another entry was made by LPN #4 on [DATE] at 7:22 a.m. This entry indicated upon returning from a lunch break at about 4:15 a.m. the resident was received unresponsive, had no pulse and no respirations and LPN "joined in performing CPR, 911 called, family aware, NP (nurse practitioner) notify. Res (resident) transported in ambulance to (hospital name)." A "Patient Care Report" form, completed by the ambulance service that responded to the above 911 call on [DATE], was reviewed after a request was made for the facility to obtain the report from the 911 provider. The report was provided by the West Unit Manager on [DATE] at 4:50 p.m. The report indicated the 911 call was received on [DATE] at 4:17 a.m., the 911 team arrived at the facility at 4:20 a.m., and the resident was transported at 4:51 a.m. The resident's pulse and respirations were absent and the ECG (monitor placed on the resident to register heartbeats) read "asystole" (absence of heart beats). The narrative section of the report indicated the 911 team was sent to the facility related to a resident in [MEDICAL CONDITION], and upon arrival to the facility, they were informed by staff that staff thought they felt a weak pulse on the resident and then the resident went into [MEDICAL CONDITION], 911 was called, and CPR started. The report indicated the facility was ventilating the resident via mask with the device on the resident's nose and mouth, and the resident had a [MEDICAL CONDITION] in place. The report also read "When asked if pt (patient) normally breathes [MEDICAL CONDITION] or nose and mouth, they replied through [MEDICAL CONDITION] they were instructed to bag the pt through [MEDICAL CONDITION] not the nose and mouth. CPR is continued...pt remains in asystole...." The hospital Emergency Department records were reviewed. The records indicated the resident arrived via ambulance on [DATE] at 4:39 a.m. and expired on [DATE] at 6:59 a.m. The Physical Exam indicated a [MEDICAL CONDITION] was present and no pulse was present. When interviewed on [DATE] at 6:10 a.m., the West Unit Manager indicated she spoke to LPN #4, who reported the resident was fine until she went on her break, and when she returned, the resident had coded. The Unit Manager also indicated LPN #1 was covering the floor while LPN #4 was on break. The Unit Manager indicated CNA #2 complained that she had told LPN #4 that the resident was not breathing right. The Unit Manager indicated she pulled LPN #4 into the Medication Room to ask her what happened that night, and LPN #4 told her the resident was fine before she went on break. The Unit Manager indicated CNA #2 had said "I told her she wasn't breathing right" as she passed by the nurses' station. The Unit Manager indicated the CNA never told this to her directly. When interviewed again on [DATE] at 9:50 a.m., the West Unit Manager indicated Resident #B had already been gone from the facility when she arrived on [DATE] at 5:30 a.m. The Unit Manager indicated LPN #4 had informed her of the event that occurred for Resident #B. She also indicated LPN #4 had gone off of the unit. She also indicated she heard CNA #2 saying "I told her she wasn't breathing right," and then she (the Unit Manager) pulled LPN #4 into the Medication Room and talked to her. The Unit Manager indicated she did not follow up with CNA #2. The Unit Manager also indicated she spoke with LPN #3, who was working on the South unit on the night shift, and LPN #3 indicated LPN #4 had called her over to the unit to look at Resident #B because she was making a noise. She came over to the unit, the resident was snoring, and this was normal for her. The Unit Manager also indicated LPN #1 came from the East Unit to cover for LPN #4's break, and that is when the Code Blue was called. When interviewed on [DATE] at 3:45 p.m., LPN #1 indicated she started working at the facility approximately 1 ,[DATE] months ago. The LPN indicated she worked the night when Resident #B coded on [DATE]. She indicated she was the nurse who did CPR on the resident that shift. She also indicated another nurse had come over to the East Unit where she was working and and told her to come over to the West unit to cover while LPN #4 went on her break. LPN #1 indicated when she got on the West unit, LPN #2 and LPN #4 were on the unit and then they left without giving her report. She indicated LPN #2 was "not on the clock" that shift. LPN indicated CNA #2 came out of Resident #B's room, looking for LPN #4 and stated the resident was unresponsive. She then started checking the chart for the resident's code status and getting the crash cart as the QMA came and said she would look at the chart for her. LPN #1 indicated CNA #2 was on the floor and making statements that she had been telling LPN #4 that the resident had been like that. LPN #1 then went to the resident's room and felt a faint pulse on the resident, and the resident had no respirations. The LPN indicated at first she didn't see an Ambu bag in the room, and then saw it behind a cabinet in the room and then started ventilating the resident with the Ambu bag on the resident's trach. The LPN indicated there was no Ambu bag on the crash cart when it was brought into the resident's room. The LPN indicated LPN #2 and LPN #4 then came into the room while CPR was being given, and LPN #2 then removed the Ambu from the [MEDICAL CONDITION] and placed it over the resident's mouth. LPN #1 indicated the Paramedics arrived after that, and they told LPN #2 several times to take the bag off the resident's mouth and place it on her trach. The Paramedics then took over the situation. The LPN indicated the resident left the facility with the Paramedics around 4:25 a.m. or 4:30 a.m. LPN #1 indicated she informed the West Unit Manager in the morning after the code, about what CNA #2 had been saying and about the LPN removing the Ambu from the [MEDICAL CONDITION] and placing it on the resident's mouth. LPN #1 indicated she did not inform the DON of the concerns she had with LPN #2 removing the Ambu device, as she had already reported the events to the Unit Manager. LPN #1 indicated she was never contacted by any other facility staff or management related to the above events. When interviewed on [DATE] at 7:57 a.m., the facility Administrator indicated a Respiratory Therapist had been employed at the facility until [DATE]. The Administrator indicated a new Respiratory Therapist was to start on [DATE]. When interviewed on [DATE] at 9:20 a.m., the District Director of Respiratory Therapy indicated in a code situation on a resident with a [MEDICAL CONDITION] in place, the protocol would be to proceed with ventilation attached to the [MEDICAL CONDITION], if the [MEDICAL CONDITION] was patent. When interviewed on [DATE] at 8:15 a.m., the facility Administrator indicated she first was aware of the concerns with the Ambu techniques upon reviewing the 911 report obtained by the facility on [DATE]. The Administrator indicated staff members present during the Code Blue were interviewed this morning. The Administrator also indicated upon interviewing staff this morning, some statements did indicate LPN #2 was not on duty when she performed CPR on the resident. The Administrator indicated LPN #1 was interviewed this morning, and LPN #1 indicated she was asked to go the West Unit to cover for a nurse on that unit and when she went to the unit, a CNA informed her Resident #B was in distress and she went to the resident's room. The LPN indicated the resident was unresponsive with a faint pulse and CPR was started. LPN #1 indicated LPN #3 then came from the South Unit to assist, and LPN #3 assisted LPN #1 with attaching the Ambu to the resident's [MEDICAL CONDITION]. LPN #1 indicated LPNs #2 and #4 then came into the resident's room, and LPN #2 took over and put the Ambu over the resident's mouth and then the EMTs entered the room. The Administrator also stated that LPN #1 indicated she had attached the Ambu to the resident's [MEDICAL CONDITION]. The Administrator indicated she had not been aware that LPN #2 had not been scheduled to work or clocked in as working that shift until this morning. During the same interview, the Administrator also indicated she interviewed CNA #2 this morning, and the CNA indicated she alerted LPN #1 the resident was in distress, and the LPN came to the room and started CPR. When interviewed on [DATE] at 8:15 a.m., the interim DON (Director of Nursing) indicated LPN #3 was interviewed, and this LPN indicated she responded to the Code Blue call and LPN #4 was not in the room when she first responded, and then LPN #2 and LPN #4 came into the room during the code, and LPN #2 then said to put the Ambu on the resident's mouth. LPN #3 then indicated that there were three nurses in the room, so she returned to her unit. The interim DON indicated he was first informed this morning, that LPN #2 was not clocked into work the shift when CPR was performed. When interviewed on [DATE] at 8:15 a.m., the West Unit Manager indicated the staff LPNs involved in the CPR for Resident #B were LPN's #1, #2, and #3. The manager indicated she believed LPN #4 came into the room near the end of the code and did not perform any CPR to her knowledge. The Unit Manager indicated LPN #1 told her that LPNs #2 and #4 entered the room, and LPN #2 removed the Ambu from [MEDICAL CONDITION] put it over the resident's mouth. The Unit Manager indicated LPN #1 told her the above this morning, and she does not recall the LPN telling her before today. The Unit Manager stated she spoke briefly with LPN #1 that morning. The Unit Manager indicated she did not interview LPN #2 on [DATE], because the LPN had already left the facility when she arrived to the facility that morning. 2. On [DATE] at 9:25 a.m. and 10:10 a.m., Resident #D was observed in her room. The resident had a [MEDICAL CONDITION] in place. No Ambu resuscitation bag was observed in the resident's room at the above times. The East Unit Manager was interviewed at this time. The Unit Manager indicated suction equipment, and an Ambu bag were to be in place in the room of every resident with a [MEDICAL CONDITION] in place. On [DATE] at 10:15 a.m. the Crash Cart in the East Unit Medication Room was observed. There was no suction machine on the cart. When interviewed at this time, the Unit Manager indicated the suction machine had been taken off the cart to use for a resident and should have been replaced at that time. On [DATE] at 11:00 a.m., the Crash Cart in the South Unit Nurses' Station was observed with the Unit Manager. There was no Ambu bag on the cart. When interviewed on [DATE] at 11:10 a.m., the Unit Manager indicated the crash cart was being checked by the Respiratory Therapist when he was working here and he no longer is employed at the facility at this time. The Unit Manager indicated the midnight nurses should be responsible to check the cart and make sure supplies are in place, as they checked it before in the past before the Respiratory Therapist was employed at the facility. On [DATE] at 11:05 a.m., the Crash Cart in the West Unit Nurses' Station was observed with the Unit Manager. There was no Ambu bag on the cart. When interviewed at this time, the Unit Manager indicated there should be an Ambu bag on the cart. The Unit Manager indicated she was not sure what the protocol was for checking the cart, but thought is was for the midnight shift to check the cart. When interviewed on [DATE] at 9:00 a.m., the Administrator indicated there are currently two residents in the facility with tracheostomies (Residents #D and E). The Administrator indicated all staff should be trained to provide CPR correctly to residents with tracheostomies. The Staff Development Nurse provided a list of staff members with confirmed CPR training on [DATE] at 2:50 p.m. A total of 20 nurses were listed as having current CPR certification. LPN's #2 and #3 were listed as having valid CPR certification cards. The Staff Development Nurse indicated she is still waiting for other staff members to bring in their CPR cards to verify they are current. On [DATE] at 2:30 p.m., the Staff Development Nurse indicated the following staff Nurses had expired CPR certification as of [DATE]. LPN #14-hired on [DATE] LPN #15- hired on [DATE] LPN #6- hired on [DATE] LPN #16- hired on [DATE] There facility had a total of 35 LPNs and 7 RNs employed. When interviewed on [DATE] at 2:30 p.m., the Staff Development Nurse indicated all Licensed Nurses working at the facility are required to have current CPR certification. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility inserviced staff on the CPR policy and the procedure of providing ventilation to a resident with a [MEDICAL CONDITION] during emergency resuscitation efforts, inserviced all staff on the proper techniques for [MEDICAL CONDITION] ventilation with staff providing a return demonstration, inserviced all scheduled staff on the procedure to be followed when an employee who is not on duty is present during an emergency situation, a Respiratory Therapist completed assessments of the two residents in the facility with [MEDICAL CONDITION] in place, daily staff schedules were reviewed to ensure at least one nurse with current CPR certification will be on each shift, emergency equipment was placed in each of the two resident's rooms with a listing of the required equipment and a checklist to verify the equipment is in place. But, the 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, because inservicing needed to be provided to all nursing staff prior to working, and CPR certification needed to be completed for all nurses. This federal tag relates to Complaint IN 424. 3XXX,[DATE](a)

Based on observation, record review and interview, the facility failed to ensure a restorative ambulation program was implemented for 1 of 1 resident discharged from physical therapy in the sample of 6. The failure to implement the ambulation program for the resident resulted in a decline in the distance he was able to ambulate. (Resident #C) Findings include: On 10/19/11 at 11:20 a.m., Resident #C was observed in his room seated in a wheelchair. There was no rolling walker in the resident's room. The record for Resident #C was reviewed on 10/19/11 at 12:40 p.m. The resident's [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] with orders for physical and occupational therapy evaluations. The resident received physical therapy from 7/19-9/16/11. The physical therapy discharge summary dated 9/22/11, indicated the resident's physical therapy was discontinued on 9/16/11 due to the resident reaching his maximum potential. The discharge summary indicated the resident had made significant progress in the past week and the resident was able to ambulate 10-15 steps with a rolling walker with maximum assist of 1 or moderate assist of 2. The discharge recommendations indicated the resident was to have a functional maintenance program/restorative aide for active range of motion and ambulation. The physical therapy functional maintenance program dated 9/20/11, indicated the resident's current status was able to walk up to 10 steps with maximum assist with rolling walker. The goal was to continue current level of functioning and prevent decline. Interview with the resident on 10/20/11 at 1:45 p.m., indicated nobody had walked with him since therapy was discontinued in September. Interview with CNA #1 on 10/20/11 at 1:55 p.m., indicated that he had not walked the resident since he had been employed at the facility. Interview with the Staff Development Coordinator, who used to oversee the Restorative Nursing Program, on 10/20/11 at 1:15 p.m., indicated the facility currently did not have a formal restorative nursing program. She indicated the aides were to complete range of motion with care and assist residents with ambulation when they could. There was no documentation to ensure range of motion and ambulation was being completed. The Staff Development Coordinator further indicated that she was not aware if the resident had ambulated since being discharged from therapy in September. An entry in the physician progress notes [REDACTED]. A letter was faxed to the facility from the Wound Clinic on 10/13/11. The letter indicated the physician from the Wound Clinic would like the resident to be re-evaluated for physical and occupational therapy. A plan of care dated 10/18/11, indicated the resident continued to make repetitive statements about therapy. One of the approaches indicated the resident would be re-evaluated by therapy. A physician's orders [REDACTED]. The physical therapy evaluation form dated 10/19/11, indicated the resident would be seen in therapy five times a week for 4 weeks for gait training, therapeutic exercise, therapeutic activities, wheelchair management, and neuromuscular re-education. The resident was referred to therapy by nursing for ambulation and general conditioning. The justification for skilled services was to improve strength, ambulation, and balance. The baseline evaluation indicated the resident was able to ambulate approximately 5 steps with a rolling walker and maximum assistance. Interview with Physical Therapist #1 on 10/20/11 at 1:40 p.m., indicated when the resident was evaluated on 10/19/11 that he was able to walk approximately 4-5 steps with the rolling walker and maximum assistance. Continued interview at the time, indicated the resident did have a decline in the distance he was able to walk since last being seen in September. This federal tag relates to complaint IN 323. 3.1-38(a)(2)(B)

2. The record for Resident #198 was reviewed on 9/1/11 at 8:41 a.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] from the hospital. Review of Physician orders [REDACTED]. Further review of Physician orders [REDACTED]. Review of Nursing Progress Notes dated 5/26-6/3/11 indicated there was no documentation of the resident having anxiety or exhibiting signs and symptoms of anxiety. Review of physician progress notes [REDACTED]. Review of Social Service Progress Notes from 6/3-8/31/11 indicated there was no documentation regarding the resident receiving routine [MEDICATION NAME]. Interview with the South Unit Social Service Director on 9/1/11 at 10:17 a.m., indicated she was unaware the resident was taking routine [MEDICATION NAME]. She further indicated she does not have any progress notes regarding the resident being on routine [MEDICATION NAME]. The South Unit Social Service Director also indicated at the time, there was no documentation in physician progress notes [REDACTED]. 3. The record for Resident #131 was reviewed on 8/30/11 at 3:11 p.m. The resident admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the 3/25/11 quarterly Minimum Data Set (MDS) assessment indicated the resident was not interviewable and had no behaviors noted. The resident's active [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the back side of MAR indicated [REDACTED]. There was no other documentation on the back of MAR indicated [REDACTED]. Review of Nursing Progress Notes indicated there was no documentation on 8/16, 8/17, 8/20, 8/21, and 8/27/11 of why the resident received the prn [MEDICATION NAME]. Interview with LPN #1 on 9/1/11 1:50 p.m., indicated nurses were required to document in Nursing Progress Notes any interventions tried first before giving the prn medication as well as why the medication was being given. Interview with East Unit Manager on 9/1/11 at 2:04 p.m., indicated the nurses were to document in Nursing Progress Notes interventions tried first before giving a prn medication as well as the reason. 3.1-48(a)(3) 3.1-48(a)(4) Based on observation, record review, and interview, the facility failed to monitor the continued use of an anticoagulant medication related to the lack of obtaining laboratory results during the use of anticoagulant medications for 1 of 1 resident reviewed for [MEDICAL TREATMENT] in the stage 2 sample of 53 which resulted in the need to hospitalize the resident for [MEDICAL CONDITION] and the need for plasma infusions. (Resident #174) The facility also failed to ensure each resident was free from unnecessary medications related adequate indications for the use of [MEDICATION NAME] and [MEDICATION NAME] (both antianxiety medications) for 2 of 10 residents reviewed for unnecessary medications. (Residents #131 and #198) Findings include: 1. The record for Resident #174 was reviewed on 9/1/11 at 2:12 p.m. The resident was admitted to the facility on [DATE] and was sent to the hospital on [DATE]. The resident was readmitted to the facility from the hospital on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the 8/3/11 Physician orders [REDACTED]. Review of the 6/29/11 admission Physician orders [REDACTED]. There were no other orders for any further or ongoing INR laboratory tests to be completed. A care plan initiated on 6/29/11 indicated the resident was receiving long term anticoagulant therapy. Care plan approaches were for staff to administer the medication as ordered, monitor PT/INR levels as ordered, monitor the resident for symptoms of bleeding, and to report all lab results to the MD or Nurse Practitioner. Review of 6/30/11 laboratory results indicated the INR level was 2.20. The results were signed as reviewed by the Physician. The results did not indicate the date the Physician signed the results. Review of the 7/2011 laboratory results indicated there was no documentation of any further INR test results. physician progress notes [REDACTED]. The 7/2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of a hospital History and Physical report dictated on 8/4/11 indicated the resident was admitted to the hospital on [DATE]. The report indicated the residents INR results were greater than 10 upon admission to the hospital. The impression and plan on the report indicated hemorrhagic and hypovolemic shock and coagulopathy secondary to [MEDICATION NAME] (Jantoven) toxicity. The resident was transfused with 2 units of fresh frozen plasma on 8/3/11 and was to receive another unit on 8/4/11. A physician consult completed in the hospital dated 8/11/11 indicated the resident was receiving anticoagulation therapy secondary to a history of a mitral valve (a heart valve) replacement and now presented with an INR of 10 leading to a [MEDICAL CONDITION]. The facility policy titled "[MEDICATION NAME] Dosing" was presented by the Director of Nursing on 9/2/11 at 11:05 a.m. The Director of Nursing identified the policy as current. The policy was dated 10/31/06. The policy indicated a [MEDICATION NAME] Anticoagulation Record was to be completed. The dose of the [MEDICATION NAME] and results of any INR tests were to be recorded on the form. When interviewed on 9/2/11 at 1:20 p.m., the South Unit Nursing Manager indicated the Anticoagulation Record for Resident #174 could not be located. When interviewed on 9/2/11 at 9:59 a.m., the Director of Nursing indicated there were no further INR laboratory tests completed between 6/30/11 and 8/3/11 while the resident was receiving Jantoven ([MEDICATION NAME]) doses daily.

Based on record review and interview the facility failed to ensure fall interventions were in place, assessments completed after a fall for 2 of 3 residents review for falls in a sample of 8 related to an alarm not being in place and the resident not assessed after a fall, resulting in the resident going to the hospital with a fractured right hip (Resident #H) and a resident being transferred by one staff member using the hoyer (mechanical) lift. (Resident #E) Findings include: 1. The record for Resident #H was reviewed on 7/27/11 at 11:30 a.m. The resident's [DIAGNOSES REDACTED]. A nursing note dated 7/11/11 at 12:28 a.m., indicated the nurse was called to the resident's room by the CNA. The resident was observed lying on the floor next to the bathroom door. The resident indicated she was going to the bathroom. The resident was assessed while on the floor. There were no deformities or discoloration noted. The resident complained of slight pain to the right femur (upper leg). On a scale of 1 to 10 her pain was 4. The resident was assisted to the wheelchair and then to bed where she was further assessed. The resident had no leg deformities or discoloration and was able to bear slight weight. The resident complained of pain at a level of 6 on a scale of 1-10. An order was received for an x-ray of the right leg to rule out a fracture and the resident was to be on bed rest until the x-ray results were obtained. The resident will continue to be monitored for pain. Pain medication was given. A nursing note dated 7/11/11 at 6:30 a.m., indicated the resident was reassessed and noted to have a rotated right hip. The resident's pain was 7 on a scale of 1-10. The nurse practitioner was called and made aware of the right leg being externally rotated out and the right leg being shorter than the other leg. An order was received for the resident to be sent to the hospital for evaluation and treatment. A nursing note dated 7/11/11 at 3:35 p.m., indicated late entry for 7/11/11 at 6:30 a.m.. The nurse arrived and received report from the night nurse that the resident fell during the night and had slight pain and received Tylenol (pain medication); The nurse did rounds and noticed resident in pain and right leg rotated outwards and painful to touch or bend. The nurse called the nurse practitioner and explained what the nurse had assessed. An order was received to send the resident to the emergency room for evaluation and treatment. A hospital History and Physical dated 7/14/11, indicated the resident was admitted on [DATE]. The History of Present Illness: The patient "was admitted to the hospital through the emergency room after undergoing a fall on the evening of admission while she went to turn around and had subsequently lost her balance. The patient subsequently fell and at this time did develop a comminuted intertrochanteric fracture of the right hip (right hip fracture). A physician order [REDACTED]. A care plan initiated on 7/9/11 indicated a problem of risk for falls related to requiring assistance with mobility. The approaches included, but were not limited to, a personal alarm to her bed and wheelchair. A fall assessment was completed on 6/9/11 with a score of 18 which indicated the resident was at high risk for falls. An assessment completed on 7/15/11 with a score of 15 which indicated the resident was at high risk for falls. A post fall evaluation indicated the date of the fall was 7/11/11 at 12:30 a.m. and completed by Nurse #1. The fall was unwitnessed. There was no injury noted at the time of the fall. An x-ray was ordered to rule out a fracture. The resident was rechecked and discoloration was noted to the resident's right hip. An order was received to send the resident to the hospital. The section "Intervention In Place At Time Of Fall: there was no mark in the box for alarm. The section "Footwear/Assistive Devices At Time of Fall": there was a check in the box for shoes. The section "Location of Resident Prior to the Fall": a check was in the box for wheelchair. The immediate interventions were to toilet the resident every two hours. The Summary of Interdisciplinary Team: "to add bed alarm when back from hospital." The investigation of the fall was provided by the Administrator on 7/27/11 and reviewed at 3:00 p.m. A typed interview dated 7/13/11 with CNA #1 regarding the events of 7/11/11 and fall of Resident #H, indicated, "I had the assignment that included (Resident #H's name). At about 12:20-12:30 a.m., I noticed the door to her room was closed. When I tried to enter, I discovered the resident sitting on the floor with her back against the closed bathroom door. I called to the nurse to help. When (Nurse #1's name) came into the room, he tried to get the resident to stand up and walk to her bed, but she said, "no, "I can't stand, my leg is broken." He argued with her and said that it wasn't broken. Then we both got her into the wheelchair. I then got her to bed by standing her from the w/c (wheelchair) and quickly pivoting her on her (unaffected) leg. I remember that she was just a one-person, minimal assist on South unit-she was able to stand and walk and was almost independent with it, so I knew she had changed. She wasn't crying, but said that it hurt really bad. I think (Nurse #1's name) gave her some medication. I went back in to check on her at (sic) at between 2:30 and 3:00, and changed her brief. She said it still hurt her, so I didn't turn her very far, but was able to get it changed. I don't remember seeing (Nurse #1's name) go back into the room during my shift." A performance Improvement Form dated 7/11/11 for Nurse #1 indicated the reason for the counseling/corrective action was the neglect to monitor resident with significant injury from fall despite giving Tylenol shortly after the fall. The documentation was inconsistent on Neuro check relative to injury sustained. The documentation was incomplete related to pain and non sequential negligence is evident. An Environmental Factors form dated 7/11/11 completed by Nurse #1, indicated the alarm was sounding, the resident's shoes were off, and both of the yes and no boxes were marked for alarm intact/battery. Interview with the Administrator on 7/28/11 at 12:30 p.m., indicated she did not know if the alarm was on when the Resident #H fell . She also indicated due to the interview with CNA #1 there was concern the resident had not been assessed prior to being moved. She further indicated CNA #2 had told management the resident had informed Nurse #1 he leg was broken prior to the resident being moved. She also indicated due to the discrepancy in the nurse's documentation it was felt the resident had not been assessed properly after the resident's fall. The nurse was terminated for this and other issues. 2. The record of Resident #E was reviewed on 7/27/11 at 2:20 p.m. The resident's [DIAGNOSES REDACTED]. A nursing note dated 7/5/11 at 6:45 a.m., indicated the CNA notified the nurse the resident was having pain in her right leg when attempting to dress her. When the resident was assessed the resident's thigh was swollen and internally rotated. At 7:45 a.m. an order was received to the resident's right hip x-rayed. At 8:00 a.m. the resident was further evaluated and sent to the hospital for evaluation and treatment. A nursing note dated 7/5/11 at 3:45 p.m., indicated staff called the hospital to check of the resident and was informed the resident was admitted with a hip fracture. A nursing note dated 7/5/11 at 6:00 p.m., indicated late entry for 7/5/11 at 8:30 a.m. The nurse was called to the resident's room to assess the resident. The resident was in bed, in no distress. Her right leg was swollen to the right thigh and internally rotated with some distortion in appearance. When her leg was moved the resident complained of severe pain. The resident was unable to move her leg unassisted and could not bend her knee. When questioned, the resident denied any recent falls or injuries. The resident indicated nothing unusual had happened to cause her to have pain in her leg. The resident's speech was clear and appropriate. She was alert and oriented times two. The nurse explained to the resident that x-rays needed to be done and she may need to be transferred to the emergency room . The resident verbalized understanding and agreed. A nursing noted dated 7/5/11 late entry, indicated at approximately 8:00 a.m. the nurse spoke with the resident regarding her injury. The resident was asked if she had fallen and if she had been transferred without the use of the hoyer lift. The resident state, "no". The resident indicated she had no pain when she was changed during the night but had pain this morning. When the resident was questions about what could have happened to cause this pain the resident stated, "I don't know, I'm so clumsy, I could have done this to myself." The resident was reassured she could talk to the nurse about any abnormal occurrences with her care without fear of retaliation and she again stated that nothing abnormal happened that she could recall. A quarterly Minimum Data Set assessment dated [DATE], indicated the resident was understood and understands. She scored a 9 on the Brief Interview for Mental Status which indicated the resident was moderately impaired cognitively. A hospital History and Physical, indicated the resident was admitted on [DATE]. The Chief Complaint: "status [REDACTED]." History of Present Illness: She fell and was "brought to the hospital, was found to have a right hip fracture, which is hurting when she moves." A care plan initiated on 3/1/11, indicated a problem of resident being at risk for fall. The approaches included, but were not limited to, use hoyer/sling lift for transfers. A reportable incident with investigation was provided by the Administrator and was reviewed on 7/27/11 at 3:00 p.m., indicated "Yesterday when getting resident dressed, CNA reported that resident was complaining of pain to her right leg. Nurse assessment noted that resident's thigh was red and swollen. Nurse Practitioner ordered resident (sic) to be sent out for evaluation , where she was admitted with a hip fracture. Resident has not had any recent falls and when interviewed could not recall anything specific that happened to cause the fracture. Resident alert and oriented X's (times) 2. Investigation was immediately begun." Follow up: "All staff that cared for (Resident #E's name) 48 hours prior to her starting to complain of pain were interviewed. None reported any unusual occurrence or anything that could have contributed to the injury. When her son was called, he stated that he could see the injury being self-inflicted due to the way she holds that leg. Due to the above information, facility was unable to substantiate that this injury occurred through mistreatment or accident. An Alleged Abuse, Neglect and Exploitation Investigation Worksheet provided with the investigation, indicated CNA #4's description of incidence was at approximately 2:30 p.m. the resident was up in her wheelchair. She did not want to take a nap. After dinner at approximately 6:20 p.m. the CNA started to lay her resident's down. Resident #E was in front of the nurse's station at 7:30 p.m. The CNA asked her to start toward her room. She assisted her to her room and assisted the resident to bed in the hoyer lift. The CNA cleaned up the resident. The resident did not have swelling and did not complain of pain. Review of the staffing sheet for 7/4/11, indicated CNA #4 worked the evening shift. The Hoyer Lift Policy was provided by the Administrator on 7/27/11 at 2:50 p.m. the procedure included, but was not limited to, "Obtain assistance from another staff member for transfer." Interview with Resident #E on 7/2711 at 10:20 a.m., indicated she hurt her leg due to a fall. She further indicated she must have done it herself. She also indicated staff always use the lift to transfer her but sometime one staff member would transfer her and sometimes two staff members transfer her. Interview with Resident #E on 7/28/11 at 11:30 a.m., indicated she would tell staff if something happened. She had told someone she would not tell because she would not want to get anyone in trouble but she thought about it and now she would tell because if something happened to her it could happen to others. Interview with the Administrator on 7/28/11 at 12:30 p.m., indicated two staff members should be present during a hoyer lift transfer. She further indicated she was aware the hospital information for Resident #E indicated she had fallen. She further indicated multiple staff had spoken to her and she would not say she had fallen or anything unusual had occurred. Interview with the East Unit Manger on 7/28/11 at 1:55 p.m., indicated when the CNA #4 transferred Resident #E she did not use the assistance of another staff member. The East unit manager indicated CNA #4 had been instructed on the proper use of the hoyer lift. Interview with the Administrator on 7/28/11 at 2:00 p.m., indicated she was unaware CNA #4 had transferred Resident #E alone using the hoyer lift. The Federal tag relates to complaint IN 712. 3.1-45(a)(1)

Based on record review and interview the facility failed to ensure residents were free from neglect for 1 of 1 residents reviewed with percutaneous endoscopic gastrostomy tube (peg tube, a tube used for nutritional purposes) in a sample of 14 related to a nurses not flushing the resident's peg tube prior to administering medications resulting in the peg tube become clogged and the resident going to the hospital to have the peg tube replaced. (Resident #G) Findings include: The record for Resident #G was reviewed on 3/3/11 at 7:35 a.m. The resident's [DIAGNOSES REDACTED]. A nursing note dated 2/18/11 at 8:00 a.m., indicated the resident was in bed asleep, unable to flush [DEVICE] (gastrostomy tube, tube used for nutritional purposes). The resident's feeding had clogged the tube. Several attempts were made without success to unclog the tube. Bowel sounds were present in four abdominal quadrants. There was no tenderness noted. No facial grimaces at this time. At 8:30 a.m. the Nurse Practitioner was notified. An order was received to place feeding on hold and to contact the physician who inserted the [DEVICE]. The first available appointment with the physician was 2/21/11. The Nurse Practitioner was notified and an order was received to send the resident to the emergency room to have a new [DEVICE] reinserted. At 10:00 a.m. the resident's daughter was made aware of the resident being transferred to the emergency room for an occluded [DEVICE] and she was also made aware the [DEVICE] was starting to rip. Review of a hospital history and physical with a date of admission of 2/18/11, indicated a chief complaint of malfunctioning [DEVICE]. History of present illness: The resident had a [DEVICE] in place which, on presentation, was malfunctioning and this prompted a transfer to the emergency room by the nursing home. The resident was seen promptly by the physician who took the resident for a endoscope (inspection of body organs or cavities with an endoscope) and replacement of the [DEVICE]. The external bumper of the peg tube was noted to have migrated into the abdominal wall. This was removed and the old peg tube was replaced. Impression and plan: The resident was admitted with a malfunctioning [DEVICE]. The external bumper of the tube was found to have migrated into the abdominal wall and required endoscopic removal and replacement. The resident was seen post-procedure and had been restarted on tube feeds. The resident will receive antibiotic in the short-term to cover for possible infection of the abdominal wall. If she tolerates tube feeds, timely discharge back to the nursing home anticipated. Review of a complaints/grievances form provided by the Administrator on 3/3/11 at 8:00 a.m., indicated on 2/1/8/11 the RN #1 reported the complaint on behalf of Resident #G's daughter. Issue: The resident's daughter was noted in the hallway and began to inform RN #1 that the resident's pe[DEVICE] had not been flushed. She also showed RN#1 pictures of the pe[DEVICE] on her cell phone. The pe[DEVICE] did appear to the nurse to be distended, balloon like. The nurse observed both the night and day nurse attempting to flush the pe[DEVICE] without success. Department response: RN #1 attempted to flush the peg tube and was unable to the flush the tube. RN#1 instructed the staff nurse to call the Nurse Practitioner for update and instructions. The Nurse Practitioner instructed staff to refer to the surgeon who place the pe[DEVICE]. The surgeon was out of town. The Nurse Practitioner was informed and instructed staff to sent the resident to the emergency room . The night nurse was also counseled regarding the incident. Resolution: The nurse was terminated for substandard care and public health was notified. Review of a reportable incident was provided by the administrator on 3/3/10 at 8:00 a.m. The date of the incident was 2/18/11 at 5:00 a.m. It was an unusual occurrence involving Resident #G and LPN #2. Event summary/type of injury: On the 2/18/11 at abut 8:00 a.m., it was brought to a QMA's attention by the resident's daughter, that the resident had a problem with her [DEVICE]. Upon assessing the g- tube the RN noted that the tube was occluded and pouched out unnaturally. The night nurse was still in the facility and the RN took her aside and asked her what had happened during the medications administration this morning. "The night nurse said that she was busy and did not flush the [DEVICE]. She did say that she dissolved the meds in water. Efforts to clear the tube were unsuccessful and the patient went to the ER for [DEVICE] re-placement." The nurse was terminated after careful review of the events surrounding this mornings medication pass. The nurse admitted to knowing the policy on [DEVICE] medication pass and stated she "cut corners" this morning as she was overwhelmed. Review of the "Medication via Feeding Tube" policy provided by the Director of Nursing (DoN) on 3/3/11 at 8:40 a.m. The procedure included, but was not limited to, stop tube feeding and disconnect the administration set, if applicable, inspect tube feeding site for: redness around site, swelling, excoriation around site, drainage, or foul odor, check feeding tube placement (feeding tube placement and residual check, flush feeding tube with at least 30 ml of warm water, unless contraindicated, remove plunger from the syringe, attach the syringe to the feeding tube, and pour the medication into the syringe. Interview with the DoN and the Interim DoN on 3/3/11 at 1:40 p.m., indicated the nurse should have never done what she did, there was no reason for what she did. It was further indicated LPN #2 was terminated and was being reported to the licensing board. This Federal tag relates to Complaint IN 845. 3.1-27(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident's care was not neglected related to leaving a resident lying in incontinent bowel movement for a long period of time, for 1 of 10 residents who require assistance with toileting in a sample of 11. (Resident #E) Findings include: A facility policy, dated 10/09, titled, "Abuse", received as current from the Administrator, indicated, "...neglect...strictly prohibited...Develop a specific resident care plan and/or care card that identify resident care needs to reduce the risk of being abused and neglected..." A facility policy, dated 10/08, titled, Federal Abuse, Neglect and Exploitation Definitions", received as current from the Administrator, indicated, "...Neglect, Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." During an interview on 03/28/11 at 11:42 a.m., Resident #E indicated she had been waiting an hour to have her brief changed. She indicated CNA #1 came in and answered her call light and she told the CNA she had been incontinent. She indicated CNA #1 turned off the call light and told her she was busy with another resident and another CNA had been assigned to the Resident. She indicated she would tell the Nurse. Resident #E indicated LPN #3 came into the room and she informed the LPN she had been incontinent of bowel movement and the LPN told her she would tell the CNA assigned to her. During an interview on 03/28/11 at 11:45 a.m., LPN #3 indicated the resident had told her she had been incontinent of bowel movement. LPN #3 indicated she had not informed the Resident's CNA because the CNA was on break. She indicated she would go tell the CNA now. During an interview on 03/28/11 at 11:50 a.m., CNA #2 indicated she was assigned to Resident #E. She indicated she had returned from a 30 minute lunch break at 11:20 a.m. She indicated she was just informed the resident needed some help. During an observation on 03/28/11 at 11:53 a.m., CNA #2 entered Resident #E's room to provide incontinence care to the resident. The Resident was observed to have been incontinent of soft bowel movement. The bowel movement had dried on the resident's buttocks. Upon interviewing the CNA #2 during the observation, she indicated part of the bowel movement had dried on the resident's skin. CNA #2 then washed the area several times to remove the dried bowel movement. The resident's buttocks was red and excoriated and there was a superficial open area on the posterior left thigh which was approximately the size of a dime, round in shape and the skin around the open area was pink. During an interview at the time of the observation, CNA #2 indicated the skin was red and excoriated on the Resident's buttocks. She indicated the area on the left posterior thigh was opened. During an interview on 03/28/11 after the incontinence care had been completed, the Resident indicated she was uncomfortable laying in the bowel movement. During an interview on 03/28/11 at 12:05 p.m., LPN #3 indicated the Resident had told her about being incontinent of bowel movement around 11:20 a.m. or 11:30 a.m. She indicated the other CNA's on the unit were all busy and she was on the phone with a family member so she could not take care of resident when she requested help. During an interview on 03/28/11 at 12:15 p.m., CNA #1 indicated the resident had told her she had been incontinent of bowel movement. She indicated she was getting ready to give another resident a shower, but answered Resident #E's call light. She indicated she had turned the call light off and left the room and told the nurse the resident had been incontinent and needed help. She indicated she did not remember what time she answered the resident's call light. Resident #E's record was reviewed on 03/28/11 at 12:10 p.m. The Resident's [DIAGNOSES REDACTED]. The Resident's Physician's Recapitulation Orders, dated 03/11, indicated the Resident was capable of making her own health decisions. The Annual Minimum Data Set Assessment, dated 01/18/11, indicated the resident was cognitively intact with a score of 15, required extensive assistance for toileting, bed mobility, and personal hygiene, and was frequently incontinent of bowel (two or more episodes). The most current, "Weekly Skin Check Sheet", 03/15/11, indicated the resident had no new skin conditions. The Resident's, "Weekly Non-pressure Skin Condition Report", dated 03/17/11, indicated the resident had a fungal rash to the bilateral thighs, which was resolved on 03/17/11. The Nurses' Notes, dated 03/13/11 at 8 a.m. through 03/25/11 12 a.m., lacked documentation to indicate the resident had a red and excoriated buttocks. During an interview on 03/28/11 at 1:05 p.m., LPN #3 indicated if the resident had skin concerns, it would be documented in the Nurses' Notes. This deficiency was cited 03/03/11. The Facility failed to implement a systemic plan of correction to prevent recurrence. This Federal tag relates to complaint IN 845. 3.1-27(a)(3) 3.1-28(a)

Based on observation, record review and interview, the facility failed to ensure physician's orders were followed as written related to obtaining a consultation for psychiatric counseling services and having leg rests on the wheelchair as ordered for 2 of 14 sampled residents. (Residents #F and #O) The facility also failed to ensure the plan of care was followed as written related to foley catheter care for 1 of 2 residents who had a foley catheter in the sample of 14 and failed to ensure the resident's peg tube ( percutaneous endoscopic gastrostomy tube, a tube used for nutritional purposes) was flushed prior to the resident receiving medications through the peg tube resulting in the peg tube become clogged and the resident going to the hospital to have the peg tube replaced. (Resident #G) Findings include: 1. The record for Resident #F was reviewed on 3/3/11 at 9:00 a.m. The resident's [DIAGNOSES REDACTED]. A Physician's Order written on 1/24/11, indicated the resident was to be seen by Senior Counseling Services related to grieving loss of husband with behaviors. An entry in the Nursing Progress Notes dated 2/3/11 at 1:20 a.m., indicated orders were found on the chart for the resident to be seen by Senior Counseling Services for evaluation and treatment related to grieving loss of spouse with behaviors. The nurse was going to endorse to the next shift to notify the family at a reasonable hour of the order. There was no documentation in the resident's record from Senior Counseling Services. Interview with Social Service Staff Member #1 on 3/3/11 at 1:25 p.m., indicated when an order for [REDACTED].#1, indicated Senior Counseling Services were not faxed the order until 2/3/11. She further indicated that she had to re-fax the resident's payor status on 3/1/11 due to the payor status not listed on the face sheet that was originally faxed. As of 3/3/11, the Social Service staff member indicated the resident had not been seen by Senior Counseling Services. 2. On 3/2/11 at 12:45 p.m. and at 2:15 p.m., Resident #O was observed sitting in her wheelchair with both of her feet on the floor. There were no leg rests noted on her wheelchair and her legs were observed in the dependent position. On 3/3/11 at 9:30 a.m., Resident #O was observed in bed. At that time, the South Unit Manager removed the resident's anti-embolytic stockings (ted) hose and performed a skin assessment. The resident's legs were [MEDICAL CONDITION] and slightly red in color. Both of the resident's feet were [MEDICAL CONDITION]. The resident was observed with deep tissue injury to her left heel. The area was dark red with no drainage. Interview with the resident at that time, indicated her legs hurt because of the swelling. On 3/3/11 at 10:00 a.m., Resident# O was observed sitting in her wheelchair in the main dining room in a church activity. Both of the resident's legs were in the dependent position and there were no wheelchair leg rests observed on the her chair. The record for Resident #O was reviewed on 3/2/11 at 12:45 p.m. Review of Physician orders dated 2/11/11 indicated "Encourage resident to elevate legs, needs two foot rests that will elevate her legs." Interview with the South Unit Manager on 3/3/11 at 9:45 a.m., indicated the resident did not have leg rests on her wheelchair. 3. On 3/3/11 at 7:10 a.m. Resident #G was observed in bed with her foley bag laying on the mat on the floor by her bed. The foley bag was not contained in a dignity bag (a bag used to hold the foley catheter bag so that it cannot be seen or touch the floor). On 3/3/11 at 7:20 a.m. Resident #G was observed in bed with her foley bag laying on the floor mat beside her bed. The CNA moved the floor mat and the bottom of the foley bag was touching the floor. The foley bag was not contained in a dignity bag. On 3/3/11 at 8:55 a.m. the resident was observed in bed with her foley bag touching the floor mat beside her bed and the floor. The foley bag was not contained in a dignity bag. On 3/3/11 at 9:45 a.m. the resident was observed in bed with her foley bag touching the mat on the floor beside her bed and the floor. The foley bag was not contained in a dignity bag. The resident's record was reviewed on 3/3/11 at 7:35 a.m. The record for Resident #G was reviewed on 3/3/11 at 7:35 a.m. The resident's [DIAGNOSES REDACTED]. A care plan initiated on 6/25/10, indicated a problem of at risk for complications related to foley catheter usage. The approaches included but were not limited to, place catheter bag in a dignity bag for privacy. On 3/3/10 at 1: 40 p.m. interview with the Director on Nursing and Interim Director of Nursing, it was indicated that the foley bag of Resident #G was observed last night. The Director of Nursing indicated she thought to get a dignity bag but had not obtained the dignity bag for the resident. 4. A nursing note dated 2/18/11 at 8:00 a.m., indicated the Resident #G was in bed asleep, unable to flush [DEVICE] (gastrostomy tube, tube used for nutritional purposes). The resident's feeding had clogged the tube. Several attempts were made without success to unclog the tube. Bowel sounds were present in four abdominal quadrants. There was no tenderness noted. No facial grimaces at this time. At 8:30 a.m. the Nurse Practitioner was notified. An order was received to place feeding on hold and to contact the physician who inserted the [DEVICE]. The first available appointment with the physician was 2/21/11. The Nurse Practitioner was notified and an order was received to send the resident to the emergency room to have a new [DEVICE] reinserted. At 10:00 a.m. the resident's daughter was made aware of the resident being transferred to the emergency room for an occluded [DEVICE] and she was also made aware the [DEVICE] was starting to rip. An Admission order record dated 2/21/11, indicated to flush peg tube with 5 ml (milliliters) of water before and after each medications and to flush peg tube with 30 ml of water before and after medication administration. Review of a hospital history and physical with a date of admission of 2/18/11, indicated a chief complaint of malfunctioning [DEVICE]. History of present illness: The resident had a [DEVICE] in place which, on presentation, was malfunctioning and this prompted a transfer to the emergency room by the nursing home. The resident was seen promptly by the physician who took the resident for a endoscope (inspection of body organs or cavities with an endoscope) and replacement of the [DEVICE]. The external bumper of the peg tube was noted to have migrated into the abdominal wall. This was removed and the old peg tube was replaced. Impression and plan: The resident was admitted with a malfunctioning [DEVICE]. The external bumper of the tube was found to have migrated into the abdominal wall and required endoscopic removal and replacement. The resident was seen post-procedure and had been restarted on tube feeds. The resident will receive antibiotic in the short-term to cover for possible infection of the abdominal wall. If she tolerates tube feeds, timely discharge back to the nursing home anticipated. Review of a complaints/grievances form provided by the Administrator on 3/3/11 at 8:00 a.m., indicated on 2/1/8/11 the RN #1 reported the complaint on behalf of Resident #G's daughter. Issue: The resident's daughter was noted in the hallway and began to inform RN #1 that the resident's pe[DEVICE] had not been flushed. She also showed RN#1 pictures of the pe[DEVICE] on her cell phone. The pe[DEVICE] did appear to the nurse to be distended, balloon like. The nurse observed both the night and day nurse attempting to flush the pe[DEVICE] without success. Department response: RN #1 attempted to flush the peg tube and was unable to the flush the tube. RN#1 instructed the staff nurse to call the Nurse Practitioner for update and instructions. The Nurse Practitioner instructed staff to refer to the surgeon who place the pe[DEVICE]. The surgeon was out of town. The Nurse Practitioner was informed and instructed staff to sent the resident to the emergency room . The night nurse was also counseled regarding the incident. Resolution: The nurse was terminated for substandard care and public health was notified. Review of a reportable incident was provided by the administrator on 3/3/10 at 8:00 a.m. The date of the incident was 2/18/11 at 5:00 a.m. It was an unusual occurrence involving Resident #G and LPN #2. Event summary/type of injury: On the 2/18/11 at abut 8:00 a.m., it was brought to a QMA's attention by the resident's daughter, that the resident had a problem with her [DEVICE]. Upon assessing the g- tube the RN noted that the tube was occluded and pouched out unnaturally. The night nurse was still in the facility and the RN took her aside and asked her what had happened during the medications administration this morning. "The night nurse said that she was busy and did not flush the [DEVICE]. She did say that she dissolved the meds in water. Efforts to clear the tube were unsuccessful and the patient went to the ER for [DEVICE] re-placement." The nurse was terminated after careful review of the events surrounding this mornings medication pass. The nurse admitted to knowing the policy on [DEVICE] medication pass and stated she "cut corners" this morning as she was overwhelmed. Review of the "Medication via Feeding Tube" policy provided by the Director of Nursing (DoN) on 3/3/11 at 8:40 a.m. The procedure included, but was not limited to, stop tube feeding and disconnect the administration set, if applicable, inspect tube feeding site for: redness around site, swelling, excoriation around site, drainage, or foul odor, check feeding tube placement (feeding tube placement and residual check, flush feeding tube with at least 30 ml of warm water, unless contraindicated, remove plunger from the syringe, attach the syringe to the feeding tube, and pour the medication into the syringe. Interview with the DoN and the Interim DoN on 3/3/11 at 1:40 p.m., indicated the nurse should have never done what she did, there was no reason for what she did. It was further indicated LPN #2 was terminated and was being reported to the licensing board. 3.1-35(g)(2)

Based on observation, record review, and interview, the facility failed to ensure physician's orders and resident's plans of care were followed, related to incontinence products, incontinence care, medications, and catheter care for 2 of 11 residents reviewed for following physician's orders and plans of care in a sample of 11. (Residents #E and #F) Findings include: 1. Resident #E's record was reviewed on 03/28/11 at 12:10 p.m. The Resident's [DIAGNOSES REDACTED]. A) A care plan, dated 03/24/11, indicated the resident was at risk for impaired skin integrity. The approaches indicated, "1. Keep skin clean & (and) dry..." During an interview on 03/28/11 at 11:42 a.m., Resident #E indicated she had been waiting an hour to have her brief changed. She indicated CNA #1 came in and answered her call light and she told the CNA she had been incontinent. She indicated CNA #1 turned off the call light and told her she was busy with another resident and another CNA had been assigned to the Resident. She indicated she would tell the Nurse. Resident #E indicated LPN #3 came into the room and she informed the LPN she had been incontinent of bowel movement and the LPN told her she would tell the CNA assigned to her. During an interview on 03/28/11 at 11:45 a.m., LPN #3 indicated the resident had told her she had been incontinent of bowel movement. LPN #3 indicated she had not informed the Resident's CNA because the CNA was on break. She indicated she would go tell the CNA now. During an interview on 03/28/11 at 11:50 a.m., CNA #2 indicated she was assigned to Resident #E. She indicated she had returned from a 30 minute lunch break at 11:20 a.m. She indicated she was just informed the resident needed some help. During an observation on 03/28/11 at 11:53 a.m., CNA #2 entered Resident #E's room to provide incontinence care to the resident. The Resident was observed to have been incontinent of soft bowel movement. The bowel movement had dried on the resident's buttocks. Upon interview of CNA #2 during the observation, she indicated part of the bowel movement had dried on the resident's skin. CNA #2 then washed the area several times to remove the dried bowel movement. The resident's buttocks was red and excoriated and there was a superficial open area on the posterior left thigh was approximately the size of a dime, round in shape and the skin around the open area was pink. During an interview at the time of the observation, CNA #2 indicated the skin was red and excoriated on the Resident's buttocks. She indicated the area on the left posterior thigh was opened. During an interview on 03/28/11 at 12:05 p.m., LPN #3 indicated the Resident had told her about being incontinent of bowel movement around 11:20 a.m. or 11:30 a.m. She indicated the other CNA's on the unit were all busy and she was on the phone with a family member so she could not take care of resident when she requested help. During an interview on 03/28/11 at 12:15 p.m., CNA #1 indicated the resident had told her she had been incontinent of bowel movement. She indicated she was getting ready to give another resident a shower, but answered Resident #E's call light. She indicated she had turned the call light off and left the room and told the nurse the resident had been incontinent and needed help. She indicated she did not remember what time she answered the resident's call light. B) The Resident's Physician's Recapitulation Orders, dated 03/11, indicated an order for [REDACTED]. During an observation on 03/28/11 at 11:53 a.m., CNA #2 performed incontinence care on the resident. The CNA removed a disposable, non-cloth brief and replaced the brief with a disposable, non-cloth brief. During an interview on 03/28/11 at 1:15 p.m., LPN #3 indicated the resident did not have cloth brief on. 2. Resident #F's record was reviewed on 3/28/11 at 11:50 a.m. Resident #F's [DIAGNOSES REDACTED]. A) During the initial tour on 3/28/11 at 10:15 a.m., with the SDC (Staff Development Coordinator) present, Resident #F was observed sitting in her wheelchair in her room. The resident's indwelling catheter tubing was on the floor under the wheelchair. The SDC applied gloves and adjusted the catheter tubing so it was not touching the floor. The SDC indicated the resident had a history of [REDACTED]. A care plan, dated 2/16/11, indicated "Urinary elimination, altered pattern r/t (related to) indwelling catheter potential...infection...Approach...Position drainage bag below bladder level. Do not let bag or tubing touch floor..." Resident #F was observed on 3/28/11 at 12:50 p.m., sitting in the East unit dining room. The resident's catheter tubing was observed under the wheelchair touching the floor. Resident #F was observed on 3/28/11 at 12:52 p.m., with the Corporate Nurse Consultant present, with the catheter tubing touching the floor. The Corporate Nurse Consultant adjusted the catheter tubing so it was not touching the floor. B) Resident #F's physician's orders recapitulation, dated 3/11, indicated "[MEDICATION NAME] sulfate...325 mg (milligram) tablet po (orally) give 1 tab (tablet) twice a day. 2/28/11 hold until occult stools collected." Resident #F's MAR (medication administration record), dated 3/11, indicated the stools for the occult blood had been collected and the order was discontinued after the 3/17/11 stool specimen had been obtained. The MAR indicated [REDACTED]. During an interview on 3/28/11 at 3:30 p.m., the Administrator indicated the physician wanted the [MEDICATION NAME] sulfate resumed. This deficiency was cited on 12/28/10 and 03/03/11. The Facility failed to implement a systemic plan of correction to prevent recurrence. This Federal tag relates to complaints IN 771 and IN 845. 3.1-35(g)(2)

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services were provided to 1 of 1 resident with a percutaneous endoscopic gastrostomy tube (peg tube, a tube used for nutritional purposes) in a sample of 14 residents related to the nurse failing flush the resident's peg tube prior to administering medications resulting in the peg tube becoming clogged and the resident being sent to the hospital to have the peg tube replaced and the nurse failing to verify placement and checking residual prior to administering medications. (Resident #G). Findings include: 1. The record for Resident #G was reviewed on 3/3/11 at 7:35 a.m. The resident's [DIAGNOSES REDACTED]. A nursing note dated 2/18/11 at 8:00 a.m., indicated the resident was in bed asleep, unable to flush [DEVICE] (gastrostomy tube, tube used for nutritional purposes). The resident's feeding had clogged the tube. Several attempts were made without success to unclog the tube. Bowel sounds were present in four abdominal quadrants. There was no tenderness noted. No facial grimaces at this time. At 8:30 a.m. the Nurse Practitioner was notified. An order was received to place feeding on hold and to contact the physician who inserted the [DEVICE]. The first available appointment with the physician was 2/21/11. The Nurse Practitioner was notified and an order was received to send the resident to the emergency room to have a new [DEVICE] reinserted. At 10:00 a.m. the resident's daughter was made aware of the resident being transferred to the emergency room for an occluded [DEVICE] and she was also made aware the [DEVICE] was starting to rip. Review of a hospital history and physical with a date of admission of 2/18/11, indicated a chief complaint of malfunctioning [DEVICE]. History of present illness: The resident had a [DEVICE] in place which, on presentation, was malfunctioning and this prompted a transfer to the emergency room by the nursing home. The resident was seen promptly by the physician who took the resident for a endoscope (inspection of body organs or cavities with an endoscope) and replacement of the [DEVICE]. The external bumper of the peg tube was noted to have migrated into the abdominal wall. This was removed and the old peg tube was replaced. Impression and plan: The resident was admitted with a malfunctioning [DEVICE]. The external bumper of the tube was found to have migrated into the abdominal wall and required endoscopic removal and replacement. The resident was seen post-procedure and had been restarted on tube feeds. The resident will receive antibiotic in the short-term to cover for possible infection of the abdominal wall. If she tolerates tube feeds, timely discharge back to the nursing home anticipated. Review of a complaints/grievances form provided by the Administrator on 3/3/11 at 8:00 a.m., indicated on 2/1/8/11 the RN #1 reported the complaint on behalf of Resident #G's daughter. Issue: The resident's daughter was noted in the hallway and began to inform RN #1 that the resident's pe[DEVICE] had not been flushed. She also showed RN#1 pictures of the pe[DEVICE] on her cell phone. The pe[DEVICE] did appear to the nurse to be distended, balloon like. The nurse observed both the night and day nurse attempting to flush the pe[DEVICE] without success. Department response: RN #1 attempted to flush the peg tube and was unable to the flush the tube. RN#1 instructed the staff nurse to call the Nurse Practitioner for update and instructions. The Nurse Practitioner instructed staff to refer to the surgeon who place the pe[DEVICE]. The surgeon was out of town. The Nurse Practitioner was informed and instructed staff to sent the resident to the emergency room . The night nurse was also counseled regarding the incident. Resolution: The nurse was terminated for substandard care and public health was notified. Review of a reportable incident was provided by the administrator on 3/3/10 at 8:00 a.m. The date of the incident was 2/18/11 at 5:00 a.m. It was an unusual occurrence involving Resident #G and LPN #2. Event summary/type of injury: On the 2/18/11 at abut 8:00 a.m., it was brought to a QMA's attention by the resident's daughter, that the resident had a problem with her [DEVICE]. Upon assessing the g- tube the RN noted that the tube was occluded and pouched out unnaturally. The night nurse was still in the facility and the RN took her aside and asked her what had happened during the medications administration this morning. "The night nurse said that she was busy and did not flush the [DEVICE]. She did say that she dissolved the meds in water. Efforts to clear the tube were unsuccessful and the patient went to the ER for [DEVICE] re-placement." The nurse was terminated after careful review of the events surrounding this mornings medication pass. The nurse admitted to knowing the policy on [DEVICE] medication pass and stated she "cut corners" this morning as she was overwhelmed. Review of the "Medication via Feeding Tube" policy provided by the Director of Nursing (DoN) on 3/3/11 at 8:40 a.m. The procedure included, but was not limited to, stop tube feeding and disconnect the administration set, if applicable, inspect tube feeding site for: redness around site, swelling, excoriation around site, drainage, or foul odor, check feeding tube placement (feeding tube placement and residual check, flush feeding tube with at least 30 ml of warm water, unless contraindicated, remove plunger from the syringe, attach the syringe to the feeding tube, and pour the medication into the syringe. Interview with the DoN and the Interim DoN on 3/3/11 at 1:40 p.m., indicated the nurse should have never done what she did, there was no reason for what she did. It was further indicated LPN #2 was terminated and was being reported to the licensing board. 2. On 3/3/11 at 7:20 a.m. LPN #1 was observed entering the room of Resident #G with five medication cups containing medications. The LPN put on gloves raised the head of the bed slightly higher than it was and informed the resident of what she was going to do. The nurse removed her gloves walked back to the medication cart to obtain her stethoscope and returned. She put on gloves and turned off the feeding pump. The LPN indicated she need to listen for the "swish". She disconnected the feeding pump for the peg tube, attached a 60 ml (milliliter) syringe, placed stethoscope on resident abdomen and poured approximately 60 cc of water into the syringe and administered the water by gravity. She then removed her stethoscope and proceeded to administer the five medication. Each medication was followed by 30 to 60 cc of water. Review of the "Medication via Feeding Tube" policy provided by the Director of Nursing (DoN) on 3/3/11 at 8:40 a.m. The procedure included, but was not limited to, stop tube feeding and disconnect the administration set, if applicable, inspect tube feeding site for: redness around site, swelling, excoriation around site, drainage, or foul odor, check feeding tube placement (feeding tube placement and residual check, flush feeding tube with at least 30 ml of warm water, unless contraindicated, remove plunger from the syringe, attach the syringe to the feeding tube, and pour the medication into the syringe. The Feeding Tube Placement and Residual Check policy was provided by the Director of Nursing on 3/3/11 at 9:50 a.m. The rationale: "The placement of the [MEDICAL CONDITION] tube is checked by aspiration to validate that the tube is in the stomach and the [MEDICAL CONDITION] tube is checked by auscultation (listening) to validate that the tube has not migrated or is not misplaced to another location such as the lungs This procedure is appropriate for [DEVICE]s, j-tubes, and n/g tubes." [DEVICE]s were to be checked included, but was not limited to, before each feeding and/or flush and before administering medications via tube. The procedure included, but was not limited to, "for [DEVICE]s and n/g tubes, attach syringe to feeding tube, and gently aspirate stomach contents. Interview with LPN #1 on 3/3/11 at 7:30 a.m., indicated she checked the "swish by putting water in the syringe and listening. Interview with RN #2 (weekend manager), on 3/3/11 at 11:15 a.m., indicated prior to using a peg for a initiating a feeding or giving medications the nurse should auscultate with an air [MEDICATION NAME], check residual, and flush the tube with water.. Interview with the DoN and the Interim DoN on 3/3/11 at 1:40 p.m., indicated she had nothing to add if the LPN did not check placement prior to administering the water to the peg tube for Resident #G. 3.1-44(a)(2)

Based on record review and interview, the facility failed to ensure laboratory tests were obtained as ordered by the physician, related to obtaining a urinalysis and urine culture for 1 of 3 residents with urinary tract infections reviewed for following physician orders [REDACTED]. Findings include: The closed record for Resident # C was reviewed on 12/27/10 at 12:20 p.m. The resident had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]." Review of the laboratory tests indicated the urinalysis and urine culture and sensitivity were not obtained as ordered. Interview with the East Unit Nurse Manager on 12/28/10 at 11:45 a.m. indicated the urinalysis and urine culture that were ordered on [DATE] to be obtained on 10/21/10 were not obtained as ordered. This federal tag relates to complaint number IN 771. 3.1-35(g)(2)

Based on observation, record review and interview, the facility failed to ensure physician's orders were followed as written related to obtaining a consultation for psychiatric counseling services and having leg rests on the wheelchair as ordered for 2 of 14 sampled residents. (Residents #F and #O) The facility also failed to ensure the plan of care was followed as written related to foley catheter care for 1 of 2 residents who had a foley catheter in the sample of 14 and failed to ensure the resident's peg tube ( percutaneous endoscopic gastrostomy tube, a tube used for nutritional purposes) was flushed prior to the resident receiving medications through the peg tube resulting in the peg tube become clogged and the resident going to the hospital to have the peg tube replaced. (Resident #G) Findings include: 1. The record for Resident #F was reviewed on 3/3/11 at 9:00 a.m. The resident's [DIAGNOSES REDACTED]. A Physician's Order written on 1/24/11, indicated the resident was to be seen by Senior Counseling Services related to grieving loss of husband with behaviors. An entry in the Nursing Progress Notes dated 2/3/11 at 1:20 a.m., indicated orders were found on the chart for the resident to be seen by Senior Counseling Services for evaluation and treatment related to grieving loss of spouse with behaviors. The nurse was going to endorse to the next shift to notify the family at a reasonable hour of the order. There was no documentation in the resident's record from Senior Counseling Services. Interview with Social Service Staff Member #1 on 3/3/11 at 1:25 p.m., indicated when an order for [REDACTED].#1, indicated Senior Counseling Services were not faxed the order until 2/3/11. She further indicated that she had to re-fax the resident's payor status on 3/1/11 due to the payor status not listed on the face sheet that was originally faxed. As of 3/3/11, the Social Service staff member indicated the resident had not been seen by Senior Counseling Services. 2. On 3/2/11 at 12:45 p.m. and at 2:15 p.m., Resident #O was observed sitting in her wheelchair with both of her feet on the floor. There were no leg rests noted on her wheelchair and her legs were observed in the dependent position. On 3/3/11 at 9:30 a.m., Resident #O was observed in bed. At that time, the South Unit Manager removed the resident's anti-embolytic stockings (ted) hose and performed a skin assessment. The resident's legs were [MEDICAL CONDITION] and slightly red in color. Both of the resident's feet were [MEDICAL CONDITION]. The resident was observed with deep tissue injury to her left heel. The area was dark red with no drainage. Interview with the resident at that time, indicated her legs hurt because of the swelling. On 3/3/11 at 10:00 a.m., Resident #O was observed sitting in her wheelchair in the main dining room in a church activity. Both of the resident's legs were in the dependent position and there were no wheelchair leg rests observed on the her chair. The record for Resident #O was reviewed on 3/2/11 at 12:45 p.m. Review of Physician orders dated 2/11/11 indicated "Encourage resident to elevate legs, needs two foot rests that will elevate her legs." Interview with the South Unit Manager on 3/3/11 at 9:45 a.m., indicated the resident did not have leg rests on her wheelchair. 3. On 3/3/11 at 7:10 a.m. Resident #G was observed in bed with her foley catheter bag laying on the mat on the floor by her bed. The foley catheter bag was not contained in a dignity bag (a bag used to hold the foley catheter bag so it cannot be seen or come in contact with the floor). On 3/3/11 at 7:20 a.m. Resident #G was observed in bed with her foley catheter bag laying on the floor mat beside her bed. The CNA moved the floor mat and the bottom of the foley catheter bag was touching the floor. The foley catheter bag was not contained in a dignity bag. On 3/3/11 at 8:55 a.m. the resident was observed in bed with her foley catheter bag touching the floor mat beside her bed and the floor. The foley bag was not contained in a dignity bag. On 3/3/11 at 9:45 a.m. the resident was observed in bed with her foley catheter bag touching the mat on the floor beside her bed and the floor. The foley catheter bag was not contained in a dignity bag. The resident's record was reviewed on 3/3/11 at 7:35 a.m. The record for Resident #G was reviewed on 3/3/11 at 7:35 a.m. The resident's [DIAGNOSES REDACTED]. A care plan initiated on 6/25/10, indicated a problem of at risk for complications related to foley catheter usage. The approaches included but were not limited to, place catheter bag in a dignity bag for privacy. On 3/3/10 at 1: 40 p.m. interview with the Director on Nursing and Interim Director of Nursing, it was indicated that the foley catheter bag of Resident #G was observed last night. The Director of Nursing indicated she thought to get a dignity bag but had not obtained the dignity bag for the resident. 4. A nursing note dated 2/18/11 at 8:00 a.m., indicated the Resident #G was in bed asleep, unable to flush [DEVICE] (gastrostomy tube, tube used for nutritional purposes). The resident's feeding had clogged the tube. Several attempts were made without success to unclog the tube. Bowel sounds were present in four abdominal quadrants. There was no tenderness noted. No facial grimaces at this time. At 8:30 a.m. the Nurse Practitioner was notified. An order was received to place feeding on hold and to contact the physician who inserted the [DEVICE]. The first available appointment with the physician was 2/21/11. The Nurse Practitioner was notified and an order was received to send the resident to the emergency room to have a new [DEVICE] reinserted. At 10:00 a.m. the resident's daughter was made aware of the resident being transferred to the emergency room for an occluded [DEVICE] and she was also made aware the [DEVICE] was starting to rip. An Admission order record dated 2/21/11, indicated to flush peg tube with 5 ml (milliliters) of water before and after each medications and to flush peg tube with 30 ml of water before and after medication administration. Review of a hospital history and physical with a date of admission of 2/18/11, indicated a chief complaint of malfunctioning [DEVICE]. History of present illness: The resident had a [DEVICE] in place which, on presentation, was malfunctioning and this prompted a transfer to the emergency room by the nursing home. The resident was seen promptly by the physician who took the resident for a endoscope (inspection of body organs or cavities with an endoscope) and replacement of the [DEVICE]. The external bumper of the peg tube was noted to have migrated into the abdominal wall. This was removed and the old peg tube was replaced. Impression and plan: The resident was admitted with a malfunctioning [DEVICE]. The external bumper of the tube was found to have migrated into the abdominal wall and required endoscopic removal and replacement. The resident was seen post-procedure and had been restarted on tube feeds. The resident will receive antibiotic in the short-term to cover for possible infection of the abdominal wall. If she tolerates tube feeds, timely discharge back to the nursing home anticipated. Review of a complaints/grievances form provided by the Administrator on 3/3/11 at 8:00 a.m., indicated on 2/1/8/11 the RN #1 reported the complaint on behalf of Resident #G's daughter. Issue: The resident's daughter was noted in the hallway and began to inform RN #1 that the resident's pe[DEVICE] had not been flushed. She also showed RN#1 pictures of the pe[DEVICE] on her cell phone. The pe[DEVICE] did appear to the nurse to be distended, balloon like. The nurse observed both the night and day nurse attempting to flush the pe[DEVICE] without success. Department response: RN #1 attempted to flush the peg tube and was unable to the flush the tube. RN#1 instructed the staff nurse to call the Nurse Practitioner for update and instructions. The Nurse Practitioner instructed staff to refer to the surgeon who place the pe[DEVICE]. The surgeon was out of town. The Nurse Practitioner was informed and instructed staff to sent the resident to the emergency room . The night nurse was also counseled regarding the incident. Resolution: The nurse was terminated for substandard care and public health was notified. Review of a reportable incident was provided by the administrator on 3/3/10 at 8:00 a.m. The date of the incident was 2/18/11 at 5:00 a.m. It was an unusual occurrence involving Resident #G and LPN #2. Event summary/type of injury: On the 2/18/11 at abut 8:00 a.m., it was brought to a QMA's attention by the resident's daughter, that the resident had a problem with her [DEVICE]. Upon assessing the g- tube the RN noted that the tube was occluded and pouched out unnaturally. The night nurse was still in the facility and the RN took her aside and asked her what had happened during the medications administration this morning. "The night nurse said that she was busy and did not flush the [DEVICE]. She did say that she dissolved the meds in water. Efforts to clear the tube were unsuccessful and the patient went to the ER for [DEVICE] re-placement." The nurse was terminated after careful review of the events surrounding this mornings medication pass. The nurse admitted to knowing the policy on [DEVICE] medication pass and stated she "cut corners" this morning as she was overwhelmed. Review of the "Medication via Feeding Tube" policy provided by the Director of Nursing (DoN) on 3/3/11 at 8:40 a.m. The procedure included, but was not limited to, stop tube feeding and disconnect the administration set, if applicable, inspect tube feeding site for: redness around site, swelling, excoriation around site, drainage, or foul odor, check feeding tube placement (feeding tube placement and residual check, flush feeding tube with at least 30 ml of warm water, unless contraindicated, remove plunger from the syringe, attach the syringe to the feeding tube, and pour the medication into the syringe. Interview with the DoN and the Interim DoN on 3/3/11 at 1:40 p.m., indicated the nurse should have never done what she did, there was no reason for what she did. It was further indicated LPN #2 was terminated and was being reported to the licensing board. This deficiency was cited on 12/28/10. The facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-35(g)(2)

Based on observation, record review, and interview, the facility failed to ensure physician's orders and resident's plans of care were followed, related to incontinence products, incontinence care, medications, and catheter care for 2 of 11 residents reviewed for following physician's orders and plans of care in a sample of 11. (Residents #E and #F) Findings include: 1. Resident #E's record was reviewed on 03/28/11 at 12:10 p.m. The Resident's [DIAGNOSES REDACTED]. A) A care plan, dated 03/24/11, indicated the resident was at risk for impaired skin integrity. The approaches indicated, "1. Keep skin clean & (and) dry..." During an interview on 03/28/11 at 11:42 a.m., Resident #E indicated she had been waiting an hour to have her brief changed. She indicated CNA #1 came in and answered her call light and she told the CNA she had been incontinent. She indicated CNA #1 turned off the call light and told her she was busy with another resident and another CNA had been assigned to the Resident. She indicated she would tell the Nurse. Resident #E indicated LPN #3 came into the room and she informed the LPN she had been incontinent of bowel movement and the LPN told her she would tell the CNA assigned to her. During an interview on 03/28/11 at 11:45 a.m., LPN #3 indicated the resident had told her she had been incontinent of bowel movement. LPN #3 indicated she had not informed the Resident's CNA because the CNA was on break. She indicated she would go tell the CNA now. During an interview on 03/28/11 at 11:50 a.m., CNA #2 indicated she was assigned to Resident #E. She indicated she had returned from a 30 minute lunch break at 11:20 a.m. She indicated she was just informed the resident needed some help. During an observation on 03/28/11 at 11:53 a.m., CNA #2 entered Resident #E's room to provide incontinence care to the resident. The Resident was observed to have been incontinent of soft bowel movement. The bowel movement had dried on the resident's buttocks. CNA #2, during the observation, indicated part of the bowel movement had dried on the resident's skin. CNA #2 then washed the area several times to remove the dried bowel movement. The resident's buttocks was red and excoriated and there was a superficial open area on the posterior left thigh. During an interview at the time of the observation, CNA #2 indicated the skin was red and excoriated on the Resident's buttocks. She indicated the area on the left posterior thigh was opened. During an interview on 03/28/11 at 12:05 p.m., LPN #3 indicated the Resident had told her about being incontinent of bowel movement around 11:20 a.m. or 11:30 a.m. She indicated the other CNA's on the unit were all busy and she was on the phone with a family member so she could not take care of resident when she requested help. During an interview on 03/28/11 at 12:15 p.m., CNA #1 indicated the resident had told her she had been incontinent of bowel movement. She indicated she was getting ready to give another resident a shower, but answered Resident #E's call light. She indicated she had turned the call light off and left the room and told the nurse the resident had been incontinent and needed help. She indicated she did not remember what time she answered the resident's call light. B) The Resident's Physician's Recapitulation Orders, dated 03/11, indicated an order for [REDACTED]. During an observation on 03/28/11 at 11:53 a.m., CNA #2 performed incontinence care on the resident. The CNA removed a disposable, non-cloth brief and replaced the brief with a disposable, non-cloth brief. During an interview on 03/28/11 at 1:15 p.m., LPN #3 indicated the resident did not have cloth brief on. 2. Resident #F's record was reviewed on 3/28/11 at 11:50 a.m. Resident #F's [DIAGNOSES REDACTED]. A) During the initial tour on 3/28/11 at 10:15 a.m., with the SDC (Staff Development Coordinator) present, Resident #F was observed sitting in her wheelchair in her room. The resident's indwelling catheter tubing was on the floor under the wheelchair. The SDC applied gloves and adjusted the catheter tubing so it was not touching the floor. The SDC indicated the resident had a history of [REDACTED]. A care plan, dated 2/16/11, indicated "Urinary elimination, altered pattern r/t (related to) indwelling catheter potential...infection...Approach...Position drainage bag below bladder level. Do not let bag or tubing touch floor..." Resident #F was observed on 3/28/11 at 12:50 p.m., sitting in the East unit dining room. The resident's catheter tubing was observed under the wheelchair touching the floor. Resident #F was observed on 3/28/11 at 12:52 p.m., with the Corporate Nurse Consultant present, with the catheter tubing touching the floor. The Corporate Nurse Consultant adjusted the catheter tubing so it was not touching the floor. B) Resident F's physician's orders recapitulation, dated 3/11, indicated "[MEDICATION NAME] sulfate...325 mg (milligram) tablet po (orally) give 1 tab (tablet) twice a day. 2/28/11 hold until occult stools collected." Resident #F's MAR (medication administration record), dated 3/11, indicated the stools for the occult blood had been collected and the order was discontinued after the 3/17/11 stool specimen had been obtained. The MAR indicated [REDACTED]. During an interview on 3/28/11 at 3:30 p.m., the Administrator indicated the physician wanted the [MEDICATION NAME] sulfate resumed. This deficiency was cited on 12/28/10 and 03/03/11. The Facility failed to implement a systemic plan of correction to prevent recurrence. This Federal tag relates to complaints IN 771 and IN 845. 3.1-35(g)(2)

BASED ON RECORD REVIEW AND INTERVIEW, THE FACILITY FAILED TO ENSURE SIGNIFICANT MEDIATION ERRORS DID NOT OCCUR, RELATED TO THE LACK OF ADMINISTRATION OF [MEDICATION NAME] FOR 1 OF 9 RESIDENTS REVIEWED FOR MEDICATION ERRORS. (RESIDENT #C) THE DEFICIENT PRACTICE RESULTED IN RESIDENT #C'S BEING TRANSPORTED TO THE HOSPITAL FOR EVALUATION AND treatment of [REDACTED]. HE WAS admitted TO THE INTENSIVE CARE UNIT FOR treatment of [REDACTED]. FINDINGS INCLUDE: THE RECORD FOR RESIDENT #C WAS REVIEWED ON 8/30/10 AT 1:20 P.M. THE RESIDENT'S [DIAGNOSES REDACTED]. THE RESIDENT WAS ORIGINALLY admitted to the facility on [DATE] AND readmitted FROM THE hospital on [DATE]. PHYSICIAN ORDERS [REDACTED]. THE April 14, 2010, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE MAR FOR 5/10 INDICATED THE MEDICATION, [MEDICATION NAME] 40 MG BY MOUTH TWICE A DAY WAS HAND WRITTEN ON THE MAR. THE MAR FOR 6/10 INDICATED THE MEDICATION, [MEDICATION NAME] 40 MG BY MOUTH TWICE A DAY WAS HAND WRITTEN ON THE MAR. THE MAR FOR 7/10 INDICATED THE MEDICATION, [MEDICATION NAME] 40 MG BY MOUTH TWICE A DAY WAS HAND WRITTEN ON THE MAR. THE MAR FOR 8/10, INDICATED [MEDICATION NAME] 40 MG BY MOUTH TWICE A DAY HAD BEEN HAND WRITTEN ON THE MAR indicated [REDACTED]. THE PHYSICIAN ORDER [REDACTED]. THERE WAS NO ORDER TO DISCONTINUE THE [MEDICATION NAME] 40 MG ONE TABLET BY MOUTH TWICE A DAY IN THE PHYSICIAN ORDER [REDACTED]. A NURSING NOTE DATED 8/13/10 AT 1:00 P.M., INDICATED THE NURSE PRACTITIONER WAS ASSESSING RESIDENT, REVIEWED THE MEDICATIONS LIST, AND AN ORDER WAS RECEIVED TO RESTART [MEDICATION NAME] 40 MG BY MOUTH TWICE A DAY, CHEST X-RAY, OXYGEN AT 2 LITERS, STAT (IMMEDIATE) COMPLETE BLOOD COUNT AND BASIC METABOLIC PANEL. AT 1:30 P.M. THE RESIDENT WAS LYING IN BED WITH THE HEAD OF BED ELEVATED, CALL LIGHT IN REACH, OXYGEN SATURATION WAS 87% ON ROOM AIR, RESPIRATIONS WERE 24 AND LABORED, BLOOD PRESSURE 132/101, PULSE 96. THE RESIDENT COMPLAINED OF ABDOMINAL PAIN AND CHEST PAIN. THE NURSE PRACTITIONER WAS INFORMED OF THE RESIDENT'S COMPLAINTS AND AN ORDER WAS RECEIVED TO SEND THE RESIDENT TO THE HOSPITAL. A PHYSICIAN'S PROGRESS NOTE WRITTEN BY THE NURSE PRACTITIONER, DATED 8/13/10 AT 1:00 P.M., INDICATED THE RESIDENT HAD "MULTIPLE COMPLEX MEDICAL CONDITIONS INCLUDING DIABETES, [MEDICAL CONDITION], ASCITES AND [MEDICAL CONDITION]". THE RESIDENT HAD A "WEIGHT GAIN OF NINE POUNDS SINCE 7/21/10 WHEN HE HAD HIS LAST PARACENTESIS" (PUNCTURE OF A CAVITY WITH THE REMOVAL OF FLUID AS IN ASCITES). THE RESIDENT WAS ON A 1800 ML (MILLILITER) FLUID RESTRICTION A DAY. THE RESIDENT'S "RIGHT EYE WAS [MEDICAL CONDITION] MORE THAN THE LEFT" WITH PERIORBITAL (AROUND THE EYES) [MEDICAL CONDITION]. HE HAD "INFORMED STAFF EARLIER HE HAD ABDOMINAL PAIN BUT THEN DENIED" THE PAIN. THE RESIDENT'S MEDICATIONS WERE REVIEWED AND THE RESIDENT WAS "admitted on [MEDICATION NAME] 40 MG TWICE A DAY" WITH KCL (POTASSIUM CHLORIDE). "NOTED PATIENT RECEIVED THE [MEDICATION NAME] LAST MONTH BUT NOT THIS MONTH, WILL RESTART [MEDICATION NAME] TODAY AND CHECK STAT LABS". THE RESIDENT WAS NOT FEELING WELL TODAY. THE RESIDENT WILL BE EVALUATED Monday AND IF NO IMPROVEMENT WILL SEND FOR PARACENTESIS. IMPRESSION: ASCITES, DIABETES, [MEDICAL CONDITION] FIBRILLATION, [MEDICAL CONDITION], AND RIGHT [MEDICAL CONDITION]. VITAL SIGNS WERE BLOOD PRESSURE 132/110, PULSE 72, RESPIRATIONS 16, TEMPERATURE 96, AND OXYGEN SATURATION 87%. AT 1:30 "PATIENT STATES HE WANTS TO GO TO THE HOSPITAL. OXYGEN SATURATION 87% WILL SEND TO" THE HOSPITAL FOR EVALUATION. THE HOSPITAL RECORDS WERE REVIEWED ON 8/31/10 AT 11:40 A.M. AN EMERGENCY NURSING RECORD/RESPIRATORY COMPLAINTS FORM DATED 8/13/10 AT 2:20, INDICATED A CHIEF COMPLAINT OF SHORTNESS OF BREATH. THE RESIDENT WAS TRANSFERRED FROM THE NURSING HOME, MEDICATION [MEDICATION NAME] WAS NOT GIVEN FOR OVER ONE WEEK. THE PATIENT COMPLAINS OF CHEST PAIN AND SHORTNESS OF BREATH. AN EMERGENCY PHYSICIAN RECORD DATED 8:13/10 AT 2:30 P.M., INDICATED CHIEF COMPLAINT "SHORTNESS OF BREATH AND CHEST PAIN". OXYGEN SATURATION WAS 87% AT NURSING HOME AT 1:30 P.M. TODAY. "INITIATING EVENT: [MEDICATION NAME] WITHHELD FOR 1 MONTH FOR UNKNOWN REASONS, POSSIBLY FROM TRANSFER" TO NURSING HOME FROM PRIOR FACILITY. THE PATIENT WAS TRANSFERRED FROM NURSING HOME TO THE HOSPITAL. HE WAS A NEW PATIENT AT THE NURSING HOME. HE WENT AUGUST 1ST WEEKS, TRANSFER NOTES FROM PREVIOUS FACILITY MISSED [MEDICATION NAME]. "SUPPOSEDLY 40 MG [MEDICATION NAME] TWICE A DAY MISSED FOR 1-2 WEEKS". HIS POTASSIUM WAS 5.6 (NORMAL WAS 3.4 TO 5.1). THE CLINICAL IMPRESSION WAS NON-ST [MEDICAL CONDITION] INFARCTION (TYPE OF [MEDICAL CONDITION]), PNEUMONIA, [MEDICAL CONDITION], AND [MEDICAL CONDITION] FIBRILLATION. REVIEW OF THE INCIDENT WITH INVESTIGATION PROVIDED BY THE DIRECTOR OF NURSING SERVICES (DNS) ON 8/30/10 AT 11:00 A.M., INDICATED THE DNS WAS MADE AWARE OF THE MEDICATION VARIANCE NOTED ON 8/13/10. THE RESIDENT DID NOT RECEIVE HIS DOSE OF [MEDICATION NAME] FOR THE MONTH OF AUGUST. INITIAL INVESTIGATION SHOWED THAT THE DOSE WAS NOT TRANSCRIBED ONTO THE AUGUST 2010 MAR FROM THE July MAR. PATIENT had a history of [REDACTED]. HE HAS BEEN WEIGHED THREE TIMES WEEKLY AND HAD BEEN GAINING WEIGHT STEADILY, WHICH WAS HIS PATTERN. HE HAD BEEN VERY NON-COMPLIANT WITH HIS FLUID RESTRICTION AND THE NURSES ATTRIBUTED HIS [MEDICAL CONDITION] TO THIS HISTORY. DNS WAS NOTIFIED ON THE A.M. OF 8/16/10 THAT THE RESIDENT WAS admitted to the hospital with [REDACTED]. FURTHER INVESTIGATION NOTED THAT [MEDICATION NAME] WAS NOT ON THE TYPED PHYSICIAN ORDER [REDACTED].[REDACTED] THE INVESTIGATION OF THE INCIDENT: AUGUST 13TH, AT ABOUT 2:30 P.M. THE DNS WAS MADE AWARE THAT RESIDENT #C WAS GOING TO THE HOSPITAL. THE NURSE PRACTITIONER "HAD ASSESSED HIM AND NOTED HIS CURRENT MAR indicated [REDACTED]." ON AUGUST 16TH, AT 8:30 A.M. "DNS OBTAINED RECORDS FROM THE HOSPITAL WHICH INDICATED THE PATIENT HAD AN MI" ([MEDICAL CONDITION] INFARCTION) "AND WAS diagnosed with [REDACTED]." RESEARCH INDICATED THE "[MEDICATION NAME] ORDER HAD BEEN HANDWRITTEN ON THE MAR'S SINCE MAY, BUT THEN MISSED ON THE TRANSCRIPTION FOR THE July TO AUGUST (2010)" MAR. "DNS DISCOVERED THE PATIENT'S ADMISSION to the facility on [DATE] DID INDEED HAVE an order for [REDACTED]. THE NURSE MANGERS CONTINUED TO WRITE IT ON THE MAR FOR THOSE MONTHS BUT FAILED TO COMMUNICATE THIS TO MR" (MEDICAL RECORDS) "TO FIX THE POS." INTERVIEW WITH THE NURSE PRACTITIONER ON 8/31/10 AT 8:45 A.M., INDICATED SHE DID SEE THE RESIDENT ON 8/13/10. HE WAS NOT VERY WELL KNOWN TO HER, HE WAS NOT fell ING WELL AND WOULD NOT SAY MUCH TO HER. SHE FURTHER INDICATED THAT WAS A TYPICAL BEHAVIOR BUT IT WAS APPARENT HE DID NOT FEEL WELL. THE RESIDENT ASKED TO SPEAK TO A RELATIVE, A NURSE IN THE FACILITY. THE NURSE PRACTITIONER GOT THE FAMILY MEMBER AND BEGAN TO WRITE ORDERS. THE NURSE CAME TO THE NURSE PRACTITIONER AND INDICATED THE RESIDENT WANTED TO GO THE THE HOSPITAL. SHE THEN INDICATED SHE INFORMED STAFF TO GET A SET OF VITALS BEFORE THE RESIDENT WAS SENT OUT. SHE COULD NOT SAY IF THE LACK OF RECEIVING THE [MEDICATION NAME] WAS THE CAUSE OR A CONTRIBUTING FACTOR OF THE [MEDICAL CONDITION] INFARCTION. SHE INDICATED A PHYSICIAN COULD BETTER ANSWER THAT QUESTION. INTERVIEW WITH THE DIRECTOR OF NURSING SERVICES ON 9/1/10 AT 8:30 A.M. INDICATED THE ORDER FOR [MEDICATION NAME] ON THE AUGUST 2010 MAR indicated [REDACTED]. THE ORDER HAD NOT BEEN ON THE MAR FOR AUGUST 2010 PRIOR TO THAT. SHE FURTHER INDICATED TO HER KNOWLEDGE THE RESIDENT DID NOT RECEIVE OR WAS HE OFFERED [MEDICATION NAME] DURING THE MONTH OF AUGUST WHILE HE WAS IN THE FACILITY. SHE FURTHER INDICATED TO HER KNOWLEDGE HE DID NOT RECEIVE ANY [MEDICATION NAME] PRIOR TO GOING TO THE hospital on [DATE]. THE DIRECTOR OF NURSING SERVICES INDICATED THE STAFF CONTINUED TO WRITE THE ORDER FOR THE [MEDICATION NAME] ON THE MAR FOR MAY, June AND July AND DID NOT WRITE IT ON THE AUGUST 2010 MAR. SHE ALSO INDICATED THE ORDER WAS NEVER ADDED TO THE PHYSICIAN ORDER [REDACTED]. THIS FEDERAL TAG RELATES TO COMPLAINT NUMBER IN 772. 3.1-25(b)(9) 3.1-48(c)(2)