Every finding on record at Greenwood Village South

Based on observation, record review, and interview, the facility failed to provide reasonable accommodation of needs for 4 of 4 randomly observed residents. Bathroom call lights lacked a pull cord. (Residents 15, Resident 90, Resident 13, Resident 83) Findings include: 1. On 8/5/24 at 9:40 a.m., Residents 13 and Resident 83's bathroom was observed. The emergency call light in the bathroom lacked a pull cord. On 8/6/24 at 10:08 a.m., the same was observed. On 8/7/24 at 8:30 a.m., the same was observed. 2. On 8/5/24 at 9:47 a.m., Residents 15 and Resident 90's bathroom was observed. The emergency call light in the bathroom lacked a pull cord. On 8/6/24 at 10:06 a.m., the same was observed. On 8/7/24 at 8:28 a.m., the same was observed. During an interview on 8/7/24 at 8:53 a.m., Unit Manager 2 indicated residents who used the bathroom could use the call light. During an interview 8/7/24 at 9:50 a.m., the DON indicated all residents should have an accessible call light in their bathroom. On 8/7/24 at 9:50 a.m., the DON provided a policy titled Call System, Residents, dated 9/2022, and indicated it was the current policy being used by the facility. A review of the policy indicated, each resident was provided with a means to call staff directly for assistance from the bedroom, toileting/bathing facilities, the floor. 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to provide care in a dignified manner for 1 of 1 meal observations. Residents sitting at the same table were not served at the same time and residents were not assisted immediately after their meal was served. (Resident 53, Resident 86, Resident 41, Resident 89, Resident 9, Resident 100, Resident 94) Finding includes: During the noon meal the following was observed. On 8/7/23 at 11:55 a.m., Resident 53's food was sitting in front of him covered. Staff were not observed to be assisting Resident 53 with the food. Resident 86 was seated directly beside Resident 53. Resident 86 was observed to be eating the noon meal. At 12:04 p.m., Qualified Medication Aide (QMA) 6 was observed to assist Resident 53 with his noon meal. Resident 41 was observed to be sitting at the same table. Resident 41 was not served the noon meal until 12:06 p.m. Resident 89 was observed to be sitting at the same table. Resident 89 was not served the noon meal until 12:07 p.m. Resident 89's noon meal was observed to remain covered. Resident 9 was observed to be sitting at the same table. Resident 9 was not served the noon meal until 12:11 p.m. Resident 100 was observed to be sitting at the same table. Resident 100 was not served the noon meal until 12:12 p.m. Resident 94 was observed to be sitting at the same table. Resident 94 was not served the noon meal until 12:13 p.m. At 12:17 p.m., QMA 7 was observed to assist Resident 89 with the noon meal. On 8/9/23 at 1:09 p.m., Licensed Practical Nurse (LPN) 75 indicated during meals residents sitting at the same table should be served at the same time. On 8/11/23 at 2:50 p.m., the Corporate Nurse Consultant provided the current Assistance with Meals policy, revised 3/2022. The policy included, but was not limited to, Resident's who cannot feed themselves will be fed with attention to safety, comfort, and dignity. 3.1-3(a)

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 1 random observations. A resident's call light was not within reach. (Resident 73) Finding includes: On 8/8/23 at 10:36 a.m., Resident 73 was observed to be calling out for assistance. Resident 73 indicated she needed assistance to the bathroom but did not know where her call light was. At that time, Resident 73's call light was observed to be behind the resident resting on the beside table, out of reach of Resident 73. On 8/9/23 at 10:15 a.m., Resident 73's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) Assessment, dated 7/14/23, indicated Resident 73 had mild cognitive impairment and required extensive assistance of two persons for transfers. On 8/11/23 at 2:50 p.m., the Corporate Nurse Consultant provided the current Resident Call System policy, dated 9/2022. The policy indicated, each resident is provided with means to call staff directly for assistance. 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure the accuracy of resident assessments for 2 of 3 residents reviewed for resident assessment. (Resident 101, Resident 98) Findings include: 1. On 8/9/23 at 11:06 a.m., Resident 101's clinical record was reviewed. A PASRR (Preadmission Screening and Resident Review) Level 2, dated 3/23/22, indicated Resident 101 had a serious mental illness. The Annual MDS (Minimum Data Set) Assessment, dated 3/9/23, indicated Resident 101 did not have a mental illness. On 8/9/23 at 1:12 p.m., the MDS Coordinator, indicated Resident 101's assessment was inaccurate. 2. On 8/9/23 at 11:11 a.m., Resident 98's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) Assessment, dated 7/7/23 indicated Resident 98 received one insulin injection during the assessment period. The Physician's Orders and July 2023 MAR (Medication Administration Record), lacked an order or administration of an insulin. On 8/9/23 at 1:12 p.m., the MDS Coordinator indicated she thought Trulicity (an injectable medication that increases the body's insulin production) was an insulin. On 8/11/23 at 2:50 p.m., the Corporate Nurse Consultant provided the current Certifying Accuracy of the Resident Assessment policy, revised 11/2019. The policy indicated the information captured on the assessment reflects the status of the resident. 3.1-31(d)

Based on observation, interview and record review, the facility failed assess a resident for polyneuropathy and the need for a topical medication treatment. The facility lacked a Physician's Order for a medicated pain cream for the treatment of leg pain and to allow the resident to keep a medicated pain cream at the bedside. The facility failed to prevent a CNA from applying a medicated pain cream to a resident. (Resident 3, CNA 2, CNA 3) Findings include: On 8/10/23 at 10:30 a.m., CNA (Certified Nurse Aide) 2 and CNA 3 were observed providing personal care to Resident 3. Resident 3's legs were observed; and no pain or skin conditions were noted while personal care was being provided. At the conclusion of the personal care, CNA 2 asked CNA 3, Did you put the pain cream on Resident 3? CNA 3's response was No, not yet. At that time, CNA 2 applied Triderma Pain Relief Cream - Maximum Strength (a medicated topical cream for nerve pain) to Resident 3's legs from the hip area to the toes. During an interview at that time, CNA 2 indicated the medicated cream was used to help decrease pain in Resident 3's legs. During an interview at that time, Resident 3 indicated the cream was for her leg pains. During an observation with the DNS (Director of Nursing Services) on 8/10/23 at 10:55 a.m., a Triderma Pain Relief Cream 4 ounce jar was observed in Resident 3's unlocked top drawer of her bedside table. The jar lacked a pharmacy label that indicated the resident's name or the physician's order for the medication. During an interview at that time, Resident 3 indicated she had ordered the cream, kept it in the top drawer of her bedside table, and staff applied the cream to her legs every day. During an interview on 8/10/23 at 11:05 a.m., the Unit Manager indicated she was unaware that Resident 3 had the Triderma Pain Relief Cream in her room. The Unit Manager was also unaware that CNA 2 had applied the cream to Resident 3's legs. CNA 2 should not have applied the cream to Resident 3's legs. During an interview on 8/10/23 at 11:10 a.m., the DNS indicated it was outside of the scope of practice for a CNA to apply or administer any type of medications to a resident. Resident 3 should not have had the cream at her bedside without a Physician's Order. The facility failed to assess Resident 3 to determine if the Resident was appropriate to keep the medication at her bedside. During an interview on 8/11/23 at 2:20 p.m., the CNA Training Coordinator indicated the CNA staff were not supposed to administer or apply any type of medications to the residents. During an interview on 08/14/23 at 8:41 a.m., Resident 3 indicated she has used the cream for about 5 years. Resident 3 indicated a while ago she had notified the therapy department and a nurse about using the cream. The CNAs applied the cream twice a day to elevate the leg pain. During an interview on 8/14/23 at 10:12 a.m., LPN (Licensed Practical Nurse) 4 indicated it was outside the scope of practice for a CNA to apply medicated creams or ointments to any residents. During an interview on 8/14/23 at 10:14 a.m., CNA 5 indicated CNAs were not supposed to apply any medicated creams to residents. During an interview on 8/14/23 at 10:14 a.m., CNA 8 indicated CNAs were not allowed to apply any medicated creams to residents. On 8/09/23 at 2:11 p.m., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, pain, polyneuropathy (nerve damage affecting many nerves in different parts of the body), and osteoarthritis. A Physician's Order and a nursing measure, effective 2/4/22 with no end date, indicated nursing staff were to assess and record Resident 3's pain level every shift. A review of the August Medication Administration Record (MAR) report indicated Resident 3 was without any pain during that time frame. A Physician's Order and a nursing measure, effective 2/4/22 with no end date, indicated nursing staff were to assess and record Resident 3's skin condition weekly. A review of the August MAR report indicated Resident 3 was without any skin conditions during that time frame. The Quarterly MDS (Minimum Data Set) Assessment, dated 6/21/23, indicated Resident 3 was cognitively intact. The clinical record lacked a Physician's Order for Triderma Pain Relief Cream - Maximum Strength (cream). The clinical record lacked an assessment for Triderma Pain Relief Cream - Maximum Strength (cream) to be kept at Resident 3's bedside. On 8/11/23 at 9:08 a.m., the Corporate Nurse Consultant provided a copy of CNA 2's Job Description. A review of the document indicated, .The Nurses Aide assists the licensed nursing staff by performing routine nursing duties and activities of daily living .assists residents with dressing, grooming, eating, bathing, positioning, turning, toileting, and exercising .Successful completion of a State approved geriatric nursing assistant training program .I understand the information contained in the Job Description . The document was signed by CNA 2 on 6/27/23. On 8/11/23 at 9:08 a.m., the Corporate Nurse Consultant provided a copy of CNA 3's Job Description. A review of the document indicated, .Nurse Aides assist the licensed nursing staff by performing routine nursing duties and activities of daily living .assists residents with dressing, grooming, eating, bathing, positioning, turning, toileting, and exercising .Successful completion of a State approved geriatric nursing assistant training program .I understand the information contained in the Job Description . The document was signed by CNA 3 on 1/15/19. On 8/10/23 at 11:44 a.m., the DNS provided a copy of the Administering Medications policy, dated December 2022, and indicated it was the current policy in use by the facility. A review of the policy indicated, .only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so .Medications must be administered in accordance with the orders .topical medications used in treatments must be recorded on the resident's treatment record .shall reevaluate .examine the individual .determine if there is a clinical reason for .the medication . On 8/10/23 at 11:44 a.m., the DNS provided a copy of the Administering Topical Medications policy, dated October 2010, and indicated it was the current policy in use by the facility. A review of the policy indicated, .this procedure is to provide guidelines for the safe administration of topical medications .verify that there is a physician's medication order .follow the medication administration guidelines in the policy entitled Administering Medications .assess the area for broken skin, drainage, debris, rashes, allergic reaction or signs of infection . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure the daily posted nurse staffing reflected the actual hours worked by staff, as indicated by facility policy for 3 of 7 days during the survey period. Findings include: On 8/7/23 at 9:30 a.m., observed the daily posted nursing hours. The posted nursing hours did not indicate actual worked hours. On 8/8/23 at 8:54 a.m., observed the same. On 8/9/23 at 8:50 a.m., observed the same. On 8/9/23 at 11:30 a.m., the Director of Nursing (DON) indicated the facility posted the shifts daily, and indicated the posting of facility hours had not included the actual working hours. On 8/9/23 at 11:30 a.m., the DON provided a policy titled Posting Direct Care Daily Staffing Numbers, dated August 2022, and indicted it was the current policy being used by the facility. A review of the policy indicated, Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.g. The actual time worked during that shift for each category and type of nursing staff.

Based on interview and record review, the facility failed to provide supervision to prevent elopements for 1 of 3 residents reviewed. A resident that was transferred from a secured memory care unit to a unsecured unit in the same facility exited the facility and was found outside, by a visitor, approximately 100 yards from the facility. (Resident B) Finding includes: During an interview on 10/27/22 at 8:36 a.m., QMA 1 indicated she was made aware of Resident B exiting the facility a few days ago. Resident B was on 15-minute checks and had a wander guard on since the elopement. During an interview on 10/27/22 at 9:19 a.m., the emergency contact for Resident B indicated she was made aware that Resident B and another female resident were exhibiting aggressive behaviors when the staff would try to redirect them. When the emergency contact asked the Director of Nursing (DON) for recommendations, the DON indicated to her that Resident B could be moved to a long-term care unit in the facility, and he would receive a wander guard (a device worn by a resident that will alert staff when that resident opens a door). She was under the impression that the unsecured long-term care unit would be just as secure since Resident B would be wearing the wander guard, so she approved the transfer. The emergency contact called the facility to check on Resident B and LPN 1 (Licensed Practical Nurse) answered the phone and placed her on hold. After a few minutes on hold, LPN 1 came back on and indicated to her that Resident B had left the unit. The emergency contact was never told Resident B exited the facility. During an interview on 10/27/22 at 10:06 a.m., the Administrator indicated Resident B exited the facility through an exit door at the front of the facility. She was not sure if any alarm sounded. Once Resident B walked out the door, he walked behind the independent living building. After approximately 15 minutes, Resident B was found by a visitor and was taken inside the rear entrance of the independent living building. A member of the kitchen staff from the independent living building notified the Administrator, by phone, that Resident B had been brought inside their building. On 10/27/22 at 10:10 a.m., the area where Resident B was found outside the facility was observed to be approximately 100 yards from the facility. The clinical record for Resident B was reviewed on 10/27/22 at 10:15 a.m. The diagnoses included, but were not limited to, Alzheimer's dementia and cognitive communication deficit. A 5-day MDS (Minimum Data Set) assessment, dated 10/12/22, indicated Resident B was not cognitively intact. A progress note, dated 10/24/22 at 9:19 p.m., indicated Resident B was outside facility and escorted back into the building by a staff member. Wander guard is in place to right ankle and functioning. Initiated every 15-minute visual checks for 72 hours. Resident B had just moved over to this unit from another unit earlier in shift. Resident B had been pleasantly confused and cooperative with nursing staff. During an interview on 10/27/22 at 11:07 a.m., LPN 1 indicated she was the nurse caring for Resident B when he exited the facility. However, she did not know how Resident B exited the facility and did not hear any alarm sound. During an interview on 10/27/22 at 11:27 a.m., LPN 2 indicated she was the nurse that assisted with moving Resident B from the secured unit to the unsecured unit. She placed a wander guard on Resident B when he arrived to the new room before he exited the facility. On 10/27/22 at 8:45 a.m., the Director of Nursing provided a copy of a facility policy, titled Wandering and Elopements, dated March 2019, and indicated this was the current policy used by the facility. A review of the policy indicated, The facility will identify resident who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. This Federal tag relates to Complaint IN00393264. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure food being served to residents was covered until served, for 2 of 2 observations. This had the potential to affect 30 of 30 residents who were served meals in the secured unit dining room of 125 residents who reside in the facility> Findings include: Observation of dining room service on the secured unit, on 7/31/18 at 11:30 a.m., indicated 11 uncovered bowls of fruit were delivered on an uncovered food cart. Observation of dining room service on the secure unit, 8/2/18 at 11:35 a.m., indicated the following: -9 muffin halves on plates, uncovered on the kitchen area counter. -2 bowls of watermelon, uncovered on on kitchen area counter. -12 uncovered bowls of fruit and salad on an uncovered food cart, in the dining area. Cook Assistant 1 was standing next to the cart and gave residents a bowl of fruit or salad when they sat down at their table. This process was observed to occur during a period of over 30 minutes. Interview with Cook Assistant 1, at that time, indicated when serving to the residents the bowls are, not normally covered. On 8/3/18 at 4:30 p.m., the Director of nursing provided a policy, dated October, (YEAR), titled, Food Preparation and Service, and indicated it was the policy currently used by the facility. A review of the policy indicated, Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. The policy did not address keeping food covered until served. 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure a staff member honored a family's advanced care choice for a resident for 1 of 1 resident reviewed for death. (Resident 124) Findings include: The closed clinical record of Resident 124 was reviewed on 8/1/18 at 12:53 p.m. [DIAGNOSES REDACTED]. Resident 124 was admitted to the facility on [DATE]. An admission Minimum Data Set assessment, dated 5/9/18, indicated the resident was severely cognitively impaired in his ability to make decisions. The resident was admitted to Hospice, on 5/14/18, with a terminal [DIAGNOSES REDACTED]. A nurse's note, dated 5/16/18 at 8:34 p.m., indicated the resident's daughter, informed this nurse that resident will no longer be hospice. Daughter stated that family has spoken to families priest and due to religious reasons are requesting that resident receive a [DEVICE] (feeding tube) for hydration and nutrition A nurse's note, dated 5/17/18 at 112:52 p.m., indicated the resident had an appointment on 5/20/18 for placement of the feeding tube. Licensed Practical Nurse (LPN) 11's note, dated 5/20/18 at 12:33 p.m., indicated, .Nurse spoke to daughter about the condition of resident and stated, 'in my opinion, from what I have observed as a nurse based on the vitals and condition of resident it looks like his body is trying to shut down.' Nurse made it clear to the daughter that she was not God and could not predict when resident might pass away but based on the assessment of the resident the daughter was advised that comfort care would be a better idea .nurse explained what comfort care consisted of with (medications) and what the purpose of the medications would be to help the resident. Daughter stated that she wanted to call her family and see what they all wanted to do. LPN 11's note, dated 5/20/18 at 2:16 p.m., indicated, Nurse followed up with family and reiterated the conversation earlier about starting comfort care measurements (sic) . POA (Power of Attorney) daughter and other family members approached nurses desk a short time later and stated that they want to stop everything and start comfort care only . LPN 11's note, dated 5/20/18 at 6:02 p.m., indicated Resident 124 had passed away. In an interview, on 8/2/18 at 10:16 a.m., Licensed Practical Nurse 11 indicated it was part of her job as a nurse to advise or suggest what advance care option would be the best for a resident, then leave the decision, up to them. I can tell families what I would do if it was my parent. 3.1-4(f)(A)(ii)

Based on record review, observation, and interview, the facility failed to accurately assess a resident for the presence of an indwelling urinary catheter on their comprehensive Minimal Data Set assessment (MDS) for 1 of 8 residents reviewed for MDS accuracy. (Resident 324) Findings include: During an interview with Resident 324, on 8/1/18 at 1:30 p.m., indicated she would like to have the indwelling catheter removed. Observation, at that time, indicated an indwelling catheter was in use. Resident 324's clinical record was reviewed on 8/2/18 at 10:15 a.m. [DIAGNOSES REDACTED]. A recapitulated Physicians orders, dated for (MONTH) (YEAR) and (MONTH) (YEAR), with an original date of 7/17/18, indicated to change the Foley catheter with dislodgement or obstruction, to change the catheter bag on Thursday night shift every two weeks starting 7/17/18, and an order for [REDACTED]. Resident 324's MDS comprehensive assessment, dated 7/24/18, indicated: The bowel and bladder section for catheters had been check marked; indicating the resident had no indwelling catheter. During an interview, on 8/3/18 at 2:30 p.m., with the MDS Coordinator, she indicated she incorrectly check marked the none of the above box which included an indwelling urinary catheter. 3.1-31(d)

Based on observation, record review, and interview, the facility failed to ensure a hydration care plan was implemented for a resident at risk for dehydration due to medication ([MEDICATION NAME] 20 mg administered twice daily) use, for 1 of 1 resident reviewed for risk for dehydration. (Resident 92) Findings include: During an observation, on 7/30/18 at 10:02 a.m., Resident 92 was in her room. She was reclined in a Broda chair next to her bed. The resident's dresser was behind the Broda chair. A large cup and a straw were sitting on top of the dresser. During an interview, at that time, the resident indicated she did not know how to get to her drink that was sitting on top of the dresser. The clinical record of Resident 92 was reviewed on 08/03/18 at 2:51 p.m. [DIAGNOSES REDACTED]. A recapitulated review of Physicians Orders, dated (MONTH) (YEAR), indicated orders included but were not limited to, [MEDICATION NAME] 20 mg twice daily (diuretic), with a start date of 5/31/18. An annual Minimum Data Set assessment, dated 8/15/17, indicated Resident 92's Activities of Daily Living (ADL) assistance; .B. Transfer - how resident moves between surfaces. Total Dependence, two person physical assist. Resident 92's clinical record lacked a Care Plan for hydration related to the physician's orders [REDACTED]. During an interview on 8/1/18 at 2:00 p.m., the Director of Nursing indicated the facility usually does a hydration Care Plan for any resident that is on a diuretic medication. On 8/6/18 at 10:31 a.m., the Director of Nursing provided a policy titled Care Plans, Comprehensive Person- Centered, dated (MONTH) (YEAR), and indicated it was the current policy being used by the facility. A review of the policy indicated Policy Statement, A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident 8. g. Incorporate identified problems areas; h. Incorporate risk factors associated with identified problems; k. Reflect treatment goals, timetables, and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care. 3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure 2 staff members implemented mechanical lift transfer care resulting in a fall and fractured leg bone for 1 of 3 residents reviewed for accidents (Resident A). Findings include: On 1/31/18 at 1:00 p.m., Resident A's clinical record was reviewed. [DIAGNOSES REDACTED]. Resident A's Minimum Data Set (MDS) assessment, dated 11/21/1017, indicated severe cognitive impairment and being totally dependent of two staff members with transfers. Resident A's care plan, effective 9/23/2016 with a goal date of 2/21/2018, indicated, Problems: At risk for falls . Interventions . hoyer lift (mechanical) and assist of 2 staff for all transfers . A review of Resident A's nursing notes indicated the following: On 12/30/17 at 10:52 a.m., .resident . lowered to the floor by CNA (certified nursing assistant) . Resident denies being able to move left lower extremity. Upon looking at lower left extremity this nurse noted leg to be internally rotated. Resident does complain of pain upon touch and is unable to move extremity . On 12/30/17 at 6:48 p.m., Spoke with nurse from (Doctor's name) office. New order obtained to send resident to ER (emergency room ) . On 1/3/18 at 4:36 p.m., .Resident was readmitted from (hospital name) . following surgery for [REDACTED]. An Interdisciplinary Team (IDT) note, dated 1/5/18 indicated, .ROOT CAUSE: CNA was transferring resident from her bed to her Broda chair when the hoyer sling became detached from the hoyer and CNA assisted resident to the floor . NEW INTERVENTION: resident transferred to ER for eval (evaluation) and tx (treatment) . During an interview, on 1/31/18 at 3:00 p.m., CNA 1 indicated she was transferring Resident A by herself when the right shoulder of the sling slipped off and the resident began to fall out of the sling. The CNA caught the resident from behind and lowered her to the ground. The CNA indicated she should have had another staff member in the room helping with the transfer. On 2/1/18 at 11:00 a.m., the Director of Nursing provided the facility policy, Lifting Machine, Using a Mechanical, revised July, 2017, and indicated it was the policy currently being used. The policy indicated, .1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . This Federal tag relates to Complaint IN 002. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure the use of moist heat packs as indicated by facility policy and procedure for 1 of 1 resident reviewed therapy use of moist heat packs in a sample of 3 (Resident #A). Findings include: Clinical record reviewed on 8/4/16 at 10:30 a.m., indicated Resident A's [DIAGNOSES REDACTED]. Resident #A has documentation of no feeling in legs related to diagnoses. Resident #A had a BIMS (brief mental status) score dated 7/25/15, of 15/15 (cognitively intact). Resident #A's current July and August 2016, plan of care included application of heat therapy to elbows for Resident #A's complaint of elbow and shoulder pain. OT (occupational therapist) notes indicated on 7/25/16 (no time given), pain in elbows and shoulders reported as 3, on a scale of 0 to 10, prior to pain management interventions. OT indicated they performed a skin assessment of lateral elbow region to ensure good skin integrity in addition to prepping moist heat packs with added layers for added protection. Skin was intact prior to application. No assessment of legs were completed. Interview with OT ( occupational therapist) #1 on 8/4/16 at 10:40 a.m., indicated Resident #A's elbows were checked every 5 to 7 minutes and Resident #A did not complain of any burning or pain associated with the moist heat packs. Since the moist heat packs were layered with towels, no assessment of the legs (the moist heat packs were sitting on) was assessed. Review of moist heat packs temperature logs on 8/4/16 at 10:45 p.m., indicated for the months of June and July 2016, temperatures were within the limits (160 to 165 degrees) as indicated in the policy and procedure, dated 7/29/16, presented by the Rehabilitation Director. Skin risk evaluation form dated 7/25/2016, indicated Resident #A's sensory perception was very limited. Blisters measurements to right knee were length 3.00, width 2.00, depth 0.10. Appearance reddened/blanchable. Left knee was length 3.50, width 2.00, depth 0.0 (No indication of whether the measurements were inches or centimeters were noted). Appearance also reddened/blanchable. Nursing comments indicated area sustained when resident placed elbows wrapped with moist heat and dry exterior towels on knees resulting in compromised skin causing a blister. Skin assessment performed 7/29/2016, indicated the left knee blister had been resolved and right knee measurements with small clear drainage, the length was 3.00, width 2.00, depth 1.00, and appearance was non-blanchable. Skin assessment dated [DATE], indicated right knee measurements with small amount of clear drainage, the length was 2.00 (down 1.00), width 1.70 (down 0.30), and depth 0.10 (down 0.90), and appearance was healing pink reddened, non-blanchable. On 8/4/2016 at 10:40 a.m., interview with OT (occupational therapist) #1 who was assisting Resident #A in therapy that day and applied the moist heat packs to be used for Resident #A's complaint of bilateral elbow pain. OT #1 indicated the moist heat packs are wrapped with 10-12 layers to help prevent burns. OT #1 indicated Resident #A wanted to relax their elbows on their knees with the moist heat packs positioned on their legs, as it was more comfortable position for them. Interview with Resident #A on 8/4/2016 at 11:30 a.m., Resident #A did indicate they requested to rest elbows on legs and does not have any feeling, nor did they feel anything was wrong while implementation of moist heat packs. Upon record review at 8/4/16 at 1:00 p.m., of the rehab policy related to hydrocollator packs (moist heat packs), provided by the rehab director on 8/4/16, at 10:30 a.m., and indicated it was the one used within the facility, indicated on page 3 guideline #7 do not leave the resident unattended, checking the skin under the hot pack after the first 5 minutes .#8 (in bold lettering) it is recommended to place hot pack on the patient vs allowing the patient's weight to rest on the pack, as this may cause burns . This Federal tag relates to Complaint #IN 073 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a potentially hazardous situation was prevented with the use of oxygen in the beauty salon for 6 residents sitting in the beauty salon. (Residents #181, #58, #190, #69, #25, #15) Findings include: During an initial tour of the facility on 5/10/16 at 10:35 a.m., the Beautician was observed using a hand-held hair dryer to dry Resident #190's hair while the resident was receiving oxygen through a nasal cannula. The oxygen tank was close to the resident's chair. A nasal cannula is a two prong hollow plastic piece which fits in the resident's nose, and is attached to hollow plastic tubing which connects with the oxygen supply. Two other residents (Resident #181 and #58) were in the beauty salon at that time. In a second observation, on May 10, 2016, at 10:50 a.m., Resident #69 was observed sitting in the beauty salon wearing oxygen, while 2 other residents were sitting, approximately 5 feet away, under hair dryers with the motors turned on (Resident #25 and #15). Resident #69's oxygen tank was hooked on to the wheelchair she was sitting in. Two cans of flammable aerosol hair spray and 1 can of flammable aerosol cleaning spray were observed in the salon. On May 10, 2016 at 10:50 a.m., the Beautician indicated she was not sure what the facility oxygen policy was. On 5/10/16 at 11:29 a.m. the Administrator provided a policy titled, Oxygen Administration, dated October, 2010, and indicated it was the policy currently used by the facility. The policy indicated, 2. Resident's having services in beauty shop: Facilities should consider alternatives such as intermittent discontinuation of oxygen therapy while the resident is under the hair dryer hood (only if medically acceptable), or air-drying of the hair. b. If oxygen therapy is utilized and necessary to continue, handheld hairdryers are permitted with close observation to settings on lower heat to prevent air from becoming too warm . An Indiana State Department of Health (ISDH) newsletter, dated November 30, 2009, indicated, .resident use of oxygen while sitting under a hair dryer is a hazardous situation .keeping the oxygen tank as far from the dryer unit as the tubing will allow . The November 30, 2009 ISDH newsletter referred facilities to a document written by the NFPA (National Fire Protection Association), titled, Safety precautions to use with medical oxygen, .Oxygen should be stored at least 8 feet .away from .heat-producing devices .hair dryers .Keep in mind that furnishings and clothes can become saturated with oxygen, and this saturation will cause a small fire to spread and intensify quickly . 3.1-45(a)(1)

Based on observation, record review, and interview, the facility failed to ensure knives used on a secured dementia unit were secured in a locked drawer. This had the potential to affect 12 of 24 residents residing on the unit. (Residents #3, #83, #65, #50, #86, #60, #34, #92, #143, #138, #1, and #127) Findings include: During a tour of the secured dementia unit on 3/30/15 at 9:45 a.m., 2 knives were found in an unlocked drawer in an open, centralized kitchen area on the unit, which could be easily assessed by a resident. The blade of 1 knife was approximately 10 inches long with a sharp, serrated edge. The blade of the other knife was approximately 10 inches long with a sharp, smooth edge. The drawer was located on the left side of the stove. An annual Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #65 was severely impaired in her ability to make decisions. An admission MDS assessment, dated 2/21/15, indicated Resident #3 was moderately impaired in his ability to make decisions. A quarterly MDS assessment, dated 3/3/15, indicated Resident #83 was moderately impaired in her ability to make decisions. A quarterly MDS assessment, dated 2/17/15, indicated Resident #50 was severely impaired in her ability to make decisions. A quarterly MDS assessment, dated 1/6/15, indicated Resident #86 was severely impaired in his ability to make decisions. A quarterly MDS assessment, dated 1/6/14, indicated Resident #60 was severely impaired in his ability to make decisions. A quarterly MDS assessment, dated 1/6/15, indicated Resident #34 was severely impaired in her ability to make decisions. A significant change MDS assessment, dated 1/30/15, indicated Resident #92 was severely impaired in her ability to make decisions. An admission MDS assessment, dated 1/22/15, indicated Resident #143 was severely impaired in her ability to make decisions. A quarterly MDS assessment, dated 1/2/15, indicated Resident #138 was severely impaired in her ability to make decisions. A significant change MDS assessment, dated 1/17/15, indicated Resident #1 was severely impaired in her ability to make decisions. A quarterly MDS assessment, dated 2/5/15, indicated Resident #127 was moderately impaired in her ability to make decisions. On 4/1/15 at 11:20 a.m., the Unit Manager of the secured dementia unit provided a list of residents who were independently mobile (either ambulatory or in a wheel chair). The list included Residents #65, #3, #83, #50, #86, #60, #34, #92, #143, #138, #1, and #127. On 3/10/15 at 10:09 a.m., Dining Service Staff #9 indicated she was not aware the drawer was unlocked. She indicated the knives were kept in the drawer to be used everyday for lunch preparation. On 3/10/15 at 10:10, the Unit Manager indicated the drawer had a lock on it, but it wasn't catching. 3.1-45(a)(1)

Based on observation, interview and record review, the facility failed to develop comprehensive care plans for 1 of 5 residents reviewed for unnecessary medication use (Resident #41) and for 1 of 3 residents reviewed for accidents (Resident #104) and failed to revise comprehensive care plans for 1 of 1 resident reviewed for dental health (Resident #104) and 1 of 3 residents reviewed for incontinence (Resident #40). Findings include: 1. The clinical record for Resident #41 was reviewed on 4/01/2015 at 3:09 p.m. [DIAGNOSES REDACTED]. Admission physician orders [REDACTED]. Per pharmacy recommendation 3/9/2015, physician decreased [MEDICATION NAME] to a 4 mg tablet by mouth three times a day as needed for anxiety. Minimum Data Set (MDS) admission comprehensive assessment, reference date 3/15/2015, indicated a care plan would be developed for psychoactive medications with the date of completion being 3/19/2015. The Care Area Assessment (CAA) dated 3/16/2015, addressed use of the antidepressant medication, but not the antianxiety medication. The analysis of findings included [DIAGNOSES REDACTED]. CAA lacked further analysis of use of the psychoactive medications, including, but not limited to, cause and contributing factors and risk factors related to psychoactive medication use, did not identify behaviors associated with medication use and did not address possible non-drug interventions prior to the use of the anti-anxiety medication. As of 3/26/2015, a comprehensive care plan relative to psychoactive medications had not been completed for Resident #41. During interview 04/01/2015 at 4:30 p.m., MDS Coordinator #2 indicated Social Service staff were responsible for the completion of care plans for psychoactive medications. MDS Coordinator #2 indicated a comprehensive care plan relative to psychoactive medications had not been completed for Resident #41 by 3/26/2015, as defined by MDS regulation and facility policy. During interview 04/02/2015 at 12:01 p.m., Social Service Director indicated Social Service staff were responsible for the completion of care plans for psychoactive medications. Social Service Director verified a comprehensive care plan relative to psychoactive medications had not been completed for Resident #41 by 3/26/2015. On 4/2/2015 at 10:40 a.m., the Director of Nursing presented the policy on Comprehensive Care Plans, not dated, and indicated the policy was the current one being used. Policy indicated that the resident's comprehensive care plan was to be developed within 7 days of the completion of the resident's comprehensive assessment. 2. The clinical record for Resident #104 was reviewed 4/2/2015 at 2:29 p.m. [DIAGNOSES REDACTED]. Minimum Data Set (MDS) Comprehensive assessment, reference date 10/12/2014, and MDS Quarterly assessment, reference date 1/23/2015, indicated the cognition of Resident #104 was intact and resident required extensive assistance with 1 person physical support for majority of activities of daily living. Review of fall incidents for Resident #104 from September 2014 through March 2015, indicated the resident deliberately placed herself on floor in her room on 9/15/2014, 10/4/2014, and 2/24/2015. Fall incident on 9/15/2015, indicated cause of incident was attention seeking and occurred when resident felt like she did not get enough attention from staff. Nurse progress notes dated 10/4/2014, indicated the resident gave a reason why she continued to place self on floor as being that she wanted to slide to floor, because there was nothing better to do. Resident told nurse that maybe her daughter would come if staff called her and told daughter resident was on the floor. During an interview on 04/02/2015 at 3:40:07 p.m., RN #4 indicated resident deliberately puts herself on floor and tells staff she does it on purpose as she knows staff will come. Psychotherapy progress notes 2/4/2015, 2/18/2015, and 3/18/2015, identified that a stressor of Resident #104 was worrying about others. Notes identified resident's coping skills included distraction techniques, prayer, resting and visiting. Psychotherapy progress note 2/26/2015, indicated resident seemed to enjoy manipulating staff to do tasks that resident was capable of accomplishing herself. As of 4/6/2015 a comprehensive care plan had not been developed to address the specific behavior of Resident #104 routinely placing self on floor. Only an intervention on the fall care plan of educating resident on risks and benefits of placing self on floor and potential injury addressed resident's behavior. Frequency and impact of behavior on resident or others had not been analyzed to assist in development of a care plan. An in-depth evaluation relative to resident's need for attention and manipulative behavior, as well as stress factors and coping skills, had not been completed to address in care plan. During interview on 4/6/2015 at 2:00 p.m., Social Service Director and RN #4 indicated a comprehensive care plan had not been developed for Resident #104 specific to the behavior of deliberately placing self on floor. 3. The clinical record for Resident #104 was reviewed 4/2/2015 at 2:29 p.m. [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) assessment with reference date 1/23/2015, indicated resident's cognition was intact, received a mechanically altered diet and had no dental issues. On 04/01/2015 at 10:49 a.m., lower teeth of Resident #104 were observed to be either missing and/or broken with fragments. Teeth were discolored dark yellow/brown with the appearance of decay. In interview 04/01/2015 at 10:51 a.m., resident indicated her bottom teeth were always sensitive and she knew they were decayed. Resident indicated she thought her daughter was going to take her to the dentist, but did not know if or when the appointment was scheduled. Clinical record indicated Resident #104 had a dental exam 6/3/2014, with recommendation that a tooth be extracted due to caries. Extraction was performed 6/9/2014. Dental oral assessment on 6/3/2014, identified plaque, calculus, stains, inflammation, recession, bleeding and gingivitis of resident's lower teeth. Care plan for Resident #104 with effective date 11/3/2013, identified problem of resident having upper dentures and her own lower teeth. Problem included a note "6/9/14 tooth pulled." Goal was that resident would maintain adequate intake of nutrients over the next 90 days. One intervention was to schedule dental evaluation and arrange for follow-up care as indicated. Another intervention included the instructions for care post tooth extraction with status of intervention being active and current. Care plan problem had not been updated to address issues of sensitive, broken, and discolored teeth that appeared decayed, nor was the periodontal disease identified in dental exam 6/3/2014, addressed in care plan. Care plan did not identify potential risks, nor impact periodontal disease would have on resident's overall health, nor address goals of prevention of systemic disease or other complications related to poor oral health. In interview 4/2/2015 at 2:00 p.m., MDS Coordinator #3 indicated the care plan had not been updated to reflect the current dental status of resident. 4. The clinical record for Resident #40 was reviewed on 4/6/2015 at 9:13 a.m. [DIAGNOSES REDACTED]. Admission care plan, effective date 8/7/2014, identified problem of resident having episodes of bladder incontinence. Goal was for resident to have no more than three incontinent episodes in a 24 hour period. Interventions included assist to commode upon rising in the am, after meals, at bedtime,upon request and prn (as needed); apply moisture barriers: provide hygiene after voiding and bowel movements to prevent skin breakdown; check for incontinence and change if wet/soiled; clean skin with mild soap and water; apply moisture barrier; implement safety measures and select clothing that is easily removed for toileting. Upon readmission from an acute care hospital on [DATE], voiding diary and elimination summary dated 10/20-10/23/2014, indicated a goal of continent 100% of time. Care plan problem did not include any factors that may have predisposed resident to having urinary incontinence, had not identified the possible cause of incontinence or classified the type of incontinence. Care plan goal did not reflect the current goal on the voiding diary and elimination summary. Interventions remained unchanged. In interview 4/6/2015 at 4:49 p.m., Minimum Data Set Coordinator #2 indicated the care plan had not been updated for incontinence of Resident #104. 3.1-35 (a) 3.1-35 (c)(1) 3.1-35 (d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure that each resident had the right to be free from mistreatment for 1 of 3 residents reviewed for skin tears. (Resident #A) Findings include: Resident #A's arm was observed on August 29, 2014 at 2:00 p.m. LPN # 1 (Resident #A's nurse) unwrapped Resident #A's left forearm to reveal a large skin tear to the left forearm, healing without concern, and with 6 steri strips (sticky strips of a white see thru material that is placed over a cut on one side and brought over to the other side of the cut to bring closure to the area) in place from an incident which occurred on 8/10/14. The facility's self reported incident dated 8/10/14 indicated, "(Resident #A's name) sustained bruising to left arm ... X-ray services came to our community to complete X-ray. Upon completion of the X-ray the technician stated to CNA 'she (Resident #A) is bleeding. If her arm isn't fractured it probably is now.' The technician immediately left the building without speaking to licensed personnel. Staff immediately entered resident's (Resident #A's) room to find 4 bleeding skin tears measuring 3 cm X (by) 3 cm; 3 cm X 2 cm; 3 cm X 3 cm; and 5 cm X 3 cm ... Resident stated to administrator 'A man came in here and hurt me and he was a bad man I think he was a Doctor. He grabbed my hand and yanked it.' ...." Resident #A's clinical record was reviewed on 8/29/14 at 10:30 a.m. [DIAGNOSES REDACTED]. Resident #A's emergency room record dated 8/10/14 (no time noted), indicated Resident #A's arm was not broken, however, Resident #A did have a 8-10 cm laceration (cut to the arm)/skin tear to her left forearm, resulting in closure with steri-strips and not sutures or staples due to Resident #A's paper thin skin. Interview with RN #1 on 4/28/14 at 4:15 p.m., indicated the X-Ray technician, needed the X-ray paperwork. The paperwork was it ready and given to him. The technician the went down the hall to Resident #A's room. RN #1 indicated, three times, to the X-ray technician she would be more than happy to help and each time he indicated he did not need any help. CNA #1 also offered to help and the technician again indicated, " 'I just got it.' " After the X-Ray technician was finished and heading toward the door, CNA #1 came to her and stated what he had said. " 'If her arm was not broken before, than it was now.' " RN #1 went running after him, noted that he went in the bathroom, so she waited outside the bathroom door for him. When he came out, he walked right by her. RN #1 asked what he had done to her Resident (#A). The technician asked what type of a doctor would order an X-Ray on her. RN# 1 indicated to the X-Ray tech that Resident #A's arm was bleeding and she asked him if he had done anything to Resident #A. He did not respond. RN#1 then ran back to Resident #A's room, assessed her, and then made sure the Administrator, DON, and the police had all been notified; and indicated the Administrator arrived first. Interview with CNA #1 on 4/28/14 at 4:30 p.m., indicated she did not see the X-Ray technician until he was coming out of the Resident #A's room. Who at that time advised CNA #1 he did not know what type of a doctor would order an X-Ray, and if " 'It was not broken, it probably is now' " and that Resident #A's arm was "bleeding pretty badly." CNA #1 asked the X-Ray technician to please wait for the nurse, but he started down the hall to leave. CNA #1 advised RN #1 of the situation and she went running after the X-RAY technician to stop him to ask him what happened. CNA #1 then indicated both she and CNA #2 went in to check on Resident #A, noticed the arm bleeding, and the geri sleeves (skin protector placed over arms for protection) and the derma sleeve (also used for protecting fragile skin) were next to Resident #A. CNA #1 indicated Resident #A asked her, " 'Why would this man hurt me.' " CNA #1 had also heard the RN repeatedly advise, three times, the X-Ray technician that she (RN#1) would be more than willing to help with Resident #A, because she (Resident #A) knows her voice and maybe not be frightened with the X-Ray and the X-Ray technician stated, "no." Interview with CNA #2 on 8/28/2014 at 4:03 p.m., indicated she was informed by RN #1 that an X-Ray was going to be taken of Resident #A's left forearm. She indicated at 4:40 a.m., the X-Ray technician arrived. She had heard RN #1 advise the X-Ray technician Resident #A's left arm had a contracture and they were not able to straighten her arm out. When the X-Ray technician came out of the Resident #A's room the X-Ray technician indicated Resident #A's arm was bleeding. CNA #2 went into Resident's #A's room and looked at Resident #A's arm and stated, "It looked terrible." CNA #2 indicated it was CNA #1 who told her the X-Ray technician had mentioned if the arm wasn't broken, it was now. CNA #2 indicated when Resident #A was toileted and changed right before X-Ray arrived. Resident #A's Geri and Derma sleeves were on. When CNA #2 came into the room after the X-Ray technician left, both Resident #A's geri-sleeve and derma sleeve were down near her wrist, with a lot of blood around them. The X-Ray technician gave his own statement to his company, who furnished a copy to the facility. There the X-Ray technician indicated he first asked RN #1 for the paperwork, which she handed him, and then he went to her (Resident #A's) room (note: this room is a to person room, one on each side, head of beds near the wall - North & South). The right arm was bandaged so he checked his phone to see which one needed the X-Ray and it was the left (L) one. Resident #A was moaning and indicating she was in pain. Repeatedly I (the X-Ray) technician told the Resident that I needed to take an X-Ray of their L arm. She (Resident #A) told me to leave and that she hated me. I thought she (Resident #A) was confused. She (Resident #A) was noted to have paper-like thin skin and a retracted left arm. Was wondering what doctor ordered this X-Ray. Staff offered to help, but I told them I would let them know, but did not see how helping could make it any better, plus they were all afraid of [MEDICAL CONDITION]. When finished and wrapping up the cord to the machine, she (Resident #A) indicated she was bleeding. I walked over and saw a little blood distal (lower) posterior (back) of her L forearm. The CNA came and told X-Ray technician the staff had to hold Resident #A's arm for bloodwork, and that caused a small bruise. X-Ray indicated they (facility staff) then stated, " 'Well I hope I didn't break her arm doing this.' " What I meant by that was I guess this was a waste of time putting Resident #A through this and doubted it would be any use to the doctor. Then the nurse came running after me indicating, I indicated Resident #A's arm was broke really bad and I said that I did not think that the arm was broken. I said I hoped I didn't break it doing all those X- Ray's. He (X-Ray tech) indicated that he did not think he caused the laceration, because he was not using any sharp objects. This Federal tags relates to Complaint IN 817. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to provide services to promote the healing of an unstageable pressure ulcer and failed to revise interventions for 1 of 1 residents reviewed for pressure ulcers in a sample of 1 who met the criteria for review of pressure ulcers. (Resident #102) Resident #102 experienced deterioration of a Stage 3 pressure ulcer; the facility failed to implement recommended changes to the plan of care of a treatment to promote healing. Resident #102 experienced further deterioration of the pressure ulcer and an oral antibiotic was prescribed as an addition to the wound care. Findings include: The clinical record of Resident #102 was reviewed on 3/6/14 at 10:15 a.m. [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment ((MDS) dated [DATE], indicated Resident #102 required extensive assistance of two persons for bed mobility, transfers, dressing, and toileting and required total assistance of two persons for bathing. A review of the wound sheets in the clinical record indicated the wound to the left buttocks was first observed on 9/6/2013. The wound was evaluated by the wound specialist nurse practitioner (NP) on 9/11/2013, and measurements were recorded as 1.7 cm (length) x 2.3 cm (width) x 0.1 (depth) cm and was a Stage 3 pressure ulcer, defined as full thickness skin loss with damage to the underlying tissue. The wound sheet indicated the wound type as "2". The scoring code for the wound type indicated, "1 = Pressure 2 = Stasis". The measurements for 2/18/2014 were 1.6 cm (length) x 1.9 cm (width) x 0.5 cm (depth); for 2/25/2014 measurements were 2.5 cm (length) x 2.6 cm (width) x 0.8 cm (depth). The measurements for 3/4/2014 were 3.0 cm (length) x 2.5 cm (width) x 0.8 cm (depth), indicating the wound had increased in size and depth. Exudate (fluid that has been forced out of the tissues because of inflammation or injury) was coded as "1." The scoring code for exudate indicated, "...1 = Clear...." In the section titled, "Wound Tissue," the granulization (a term used to describe pink-red moist tissue that fills an open wound, when it starts to heal), was documented as 100% granulation on 2/18/2014, 25% granulation and 75% slough (dead tissue) on 2/25/2014, and 100% slough on 3/4/2014, which indicated the wound was not healing. The actual clinical stage of the wound was coded as "3" on the wound sheet for 2/18/2014, 2/25/2014, and 3/4/2014. The scoring code for clinical stage indicated, "...3 = Stage Three...." A Visit Report, electronically signed by a NP specializing in wound care, dated 2/25/2014 at 1:58 p.m., indicated the wound to the left buttock of Resident #102 was deteriorating. "...Location: left buttock...Severity: now unstageable pressure...previous tx (treatment) hydrogel (a treatment of [REDACTED]." On the second page of the Visit Report, a section titled "Integumentary (Hair,Skin)..." indicated, "Wound #4 Left Superior Buttock is a Necrotic (dead) Tissue (unstageable) Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.5 cm (centimeter) length x (by) 2.6 cm width x 0.8 cm depth...There is a small amount of serous (watery) drainage noted which has no odor...Wound bed is 76-100% (percent) slough, 1-25% granulation. The wound is deteriorating...Discussed plan with nurse at bedside: Yes...Wound Orders: Wound #4 Left Superior Buttock Santyl (treatment for [REDACTED]. Pat dry. Apply skin prep or barrier cream to periwound. Santyl to wound bed followed by hydrogel moistened, fluffed gauze, then cover with dry gauze and secure daily and PRN (as needed), soiled...." A form titled "RESIDENT RISK MEETING" indicated Resident #102 was reviewed for "Wounds, Weight, Hydration, Pain, and Falls" on 2/27/2014. The form indicated Resident #102 had a Stage 3 wound to the left superior buttocks and included measurements dated 2/25/2014. No documentation was noted in the column titled "IDT (Interdisciplinary Team) Risk Team Interventions/Recommendations/Plan." The recapitulation of physician's orders [REDACTED]. The order indicated the treatment to the left buttocks wound was "Sod Chloride 0.9% (Sodium chloride) Cleanse coccyx (left buttocks) wound, pat dry, apply [MEDICATION NAME], apply Iodosorb, change daily--may leave open to air." During an interview with RN #2 on 3/6/2014 at 11:15 a.m., RN #2 indicated the wound on the left buttocks should have been coded on the wound sheets as a pressure ulcer and not as a stasis ulcer. "It has always been pressure." When asked about the staging of the wound on the wound sheet, RN #2 indicated, "She (NP) changed that after the last visit, on 2/25/2014. I need to update the sheet. It should be unstageable, not a Stage 3." RN #2 indicated the current treatment order for the left buttocks wound was, "Cleanse with NS, apply the [MEDICATION NAME] around the wound, and then apply the Iodosorb and cover with a dry dressing." During an observation of a dressing change to the left buttocks wound on 3/6/2014 at 2:30 p.m., LPN #1 indicated the dressing was changed daily and as needed if Resident #102 was incontinent of stool. LPN #2 indicated the indwelling catheter was placed soon after the pressure ulcer developed, as Resident #102 was incontinent of urine and the urine was soiling the wound. LPN #1 removed the dressing to the left buttocks wound. The dressing contained a small amount of serosanguinous (watery pinkish yellow fluid) drainage; no odor was noted. The wound bed appeared as 75% yellow slough (dead tissue), and 25 % dark gray/black color, with an open area of deeper indentation. LPN #1 indicated the wound measurements were done weekly by the clinical leader and the wound specialist. LPN #1 cleansed the area with NS, patted the area with a dry gauze, and then applied [MEDICATION NAME] to the area around the wound, applied Iodosorb with a cotton tipped applicator to the wound bed, then packed the wound with gauze, and covered with gauze tape. LPN #1 indicated the area, "Seems to be about the same as it was when the treatment was changed to this one." Resident #102 was awake during the changing of the dressing and indicated, "It feels like a Band-Aid would feel if you ripped it off." During an interview with the Director of Nursing (DoN) on 3/7/2014 at 3:15 p.m., the DoN indicated she would need to investigate the current treatment order for Resident #102 to the left buttocks wound. On 3/8/2014, a telephone order was received from the Wound Specialist NP, "D/C (Discontinue) current tx (treatment) to (L) (Left) Superior Buttock. Cleanse (L) superior buttock wound /c (with) NS. Pat dry. Apply skin prep or barrier cream to periwound. Santyl to wound bed followed by hydrogel moistened, fluffed gauze then cover /c dry gauze. Secure daily & (and) prn soilage." A physician's orders [REDACTED]. Cleanse sacral wound w/ns (with normal saline) & pat dry. Apply skin prep to periwound skin. Lightly pack wound w (with) 1/4 strength Dakins (solution used in wound treatment to remove bacteria) and moistened Kerlix. Cover w/ dry gauze, abd (abdominal) pad & secure w/ tape. (Triangle) (change) bid (twice a day) & prn soiling & saturation. Keflex (an antibiotic treatment of [REDACTED]." On 3/11/2014 at 1:50 p.m., the NP visited Resident #102 for a scheduled wound assessment. The NP removed the dressing from the left buttocks wound. The dressing contained a moderate amount of malodorous (foul smelling) brown drainage. Upon observation of the wound, the NP indicated the wound had deteriorated from the last visit (2/25/2014), and measurements were 4.7 (length) cm x 3.3 (width) cm x 1.7 cm (depth), with undermining (term used to describe an ulcer larger at the base than at the surface of the skin) at the deepest depth of 2.4 cm, and was 95% necrotic (dead) tissue. During an interview with the Director of Nursing (DoN) on 3/11/2014 at 10:25 a.m., the DoN indicated the wound specialist NP had been contacted regarding the wound orders documented from the Visit Note from 2/25/2014. The DoN indicated the NP had failed to write the new treatment orders in the physician's orders [REDACTED]." During an interview with the NP on 3/11/2014 at 1:30 p.m., the NP indicated she had assessed Resident #102 on 2/25/2014 and had failed to write a new treatment order in the physician's orders [REDACTED]. The NP indicated she could not remember if she had discussed the change in treatment with the facility nurse at the time of the visit. During an interview with the NP on 3/11/2014 at 1:50 p.m., the NP indicated the expectation was for the facility staff to review the Visit Notes and to notify the NP if the Visit Note indicated a treatment was to be changed and the NP had failed to write the order. On 3/12/2014 at 1:05 p.m., the Administrator provided an undated policy titled, "PRESSURE ULCER PREVENTION AND MANAGEMENT POLICY AND PROCEDURE," and indicated the policy was the policy currently used by the facility. "...For an Actual Pressure Ulcer... 8. Daily monitoring is to be in place to assess the effectiveness of the plan of care and to ensure the care plan is followed i.e.: wound status pain, s/s infection or change and the need to notify the physician. 9. Weekly progress will be documented by in (sig) nurse to assess to (sig) location, stage, size, shape, depth size and depth of sinus track, surrounding tissue, and drainage (type, color, odor, and amount), wound bed, wound edges, and related pain. PUSH scale may be used for clinical validation of healing. 10. If progress is not noted in 3 weeks or deterioration is present, Physician is notified for treatment order review...." 3.1-40(a)2

Based on interview and record review, the facility failed to revise a care plan treatment of [REDACTED]. (Resident #102) Findings include: The clinical record of Resident #102 was reviewed on 3/6/14 at 10:15 a.m. [DIAGNOSES REDACTED]. The significant change Minimum Data Set assessment ((MDS) dated [DATE], indicated Resident #102 required extensive assistance of two persons for bed mobility, transfers, dressing, and toileting and required total assistance of two persons for bathing. A review of the wound sheets in the clinical record indicated a wound to the left buttocks was first observed on 9/6/2013. The wound was evaluated by the wound specialist nurse practitioner (NP) on 9/11/2013, and measurements were recorded as 1.7 cm (length) x 2.3 cm (width) x 0.1 cm (depth), and the wound was coded as a Stage 3 pressure ulcer, a full thickness skin loss involving damage to the underlying tissue. The recapitulation of physician's orders [REDACTED]. The order indicated the treatment to the left buttocks wound was, "Sod Chloride 0.9% (Sodium chloride) Cleanse coccyx (left buttocks) wound, pat dry, apply [MEDICATION NAME] (a cream used to treat minor skin irritations), apply Iodosorb (an antimicrobial agent used to promote a clean wound healing environment), change daily--may leave open to air." A Visit Report, electronically signed by the NP specializing in wound care, dated 2/25/2014 at 1:58 p.m., indicated the wound to the left buttock of Resident #102 was deteriorating. "...Location: left buttock...Severity: now unstageable pressure...previous tx (treatment) hydrogel (treatment used to create a moist wound healing environment) with no improvement; changed to Iodosorb however wound is now deteriorating...Associated Signs and Symptoms: no s/sx (sign/symptom) of infection...." On the second page of the Visit Report, a section titled "Integumentary (Hair,Skin)..." indicated, "Wound #4 Left Superior Buttock is a Necrotic (dead) Tissue (unstageable) Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.5 cm (centimeter) length x (by) 2.6 cm width x 0.8 cm depth...There is a small amount of serous (watery) drainage noted which has no odor...Wound bed is 76-100% (percent) slough (dead tissue), 1-25% granulation (outgrowth of new tissue). The wound is deteriorating...Discussed plan with nurse at bedside: Yes...Wound Orders: Wound #4 Left Superior Buttock Santyl (treatment for [REDACTED]. Pat dry. Apply skin prep or barrier cream to periwound. Santyl to wound bed followed by hydrogel moistened, fluffed gauze, then cover with dry gauze and secure daily and PRN (as needed), soiled...." A form titled "RESIDENT RISK MEETING", indicated Resident #102 was reviewed for "Wound, Weight, Hydration, Pain, and Falls" on 2/27/2014. The form indicated Resident #102 had a Stage 3 wound to the left superior buttocks, and included measurements dated 2/25/2014. No documentation was noted in the column titled "IDT (Interdisciplinary Team) Risk Team Interventions/Recommendations/Plan." During an interview with RN #2 on 3/6/2014 at 11:15 a.m., RN #2 indicated indicated the current treatment order for the left buttocks wound was "Cleanse with NS, apply the [MEDICATION NAME] around the wound, and then apply the Iodosorb and cover with a dry dressing." On 3/8/2014, a telephone order was received from the wound specialist NP, "D/C (Discontinue) current tx (treatment) to (L) (Left) Superior Buttock. Cleanse (L) superior buttock wound /c (with) NS. Pat dry. Apply skin prep or barrier cream to periwound. Santyl to wound bed followed by hydrogel moistened, fluffed gauze then cover /c dry gauze. Secure daily & (and) prn soilage," as indicated by report dated 2/25/2014. During an interview with the Director of Nursing (DoN) on 3/11/2014 at 10:25 a.m., the DoN indicated the wound specialist NP had been contacted regarding the wound orders in the Visit Note from 2/25/2014. The DoN indicated the NP had failed to write the new treatment orders in the physician's orders [REDACTED]." During an interview with the NP on 3/11/2014 at 1:30 p.m., the NP indicated she had assessed Resident #102 on 2/25/2014, and had failed to write a new treatment order in the physician's orders [REDACTED]. During an interview with the NP on 3/11/2014 at 1:50 p.m., the NP indicated the expectation was for the facility staff to review the Visit Notes and to notify the NP if the Visit Note indicated a treatment was to be changed and the NP had failed to write an order to change the treatment. On 3/12/2014 at 1:05 p.m., the Administrator provided an undated policy titled, "PRESSURE ULCER PREVENTION AND MANAGEMENT POLICY AND PROCEDURE," and indicated the policy was the policy currently used by the facility. "...For an Actual Pressure Ulcer... 8. Daily monitoring is to be in place to assess the effectiveness of the plan of care and to ensure the care plan is followed i.e.: wound status pain, s/s infection or change and the need to notify the physician. 9. Weekly progress will be documented by in (sig) nurse to assess to (sig) location, stage, size, shape, depth size and depth of sinus track, surrounding tissue, and drainage (type, color, odor, and amount), wound bed, wound edges, and related pain. PUSH scale may be used for clinical validation of healing. 10. If progress is not noted in 3 weeks or deterioration is present, Physician is notified for treatment order review...." 3.1-35(d)2(B)

Based on observation, record review, and interview, the facility failed to ensure plans of care were followed for the administration of antipsychotic and antianxiety medications, (Residents #106 and #25) and correct application of a self-release seat belt (Resident #58) for 3 of 30 residents whose plans of care were reviewed in a Stage 2 sample of 30. Findings include: 1. The clinical record of Resident #106 was reviewed on 3/7/14 at 10:05 a.m. [DIAGNOSES REDACTED]. A care plan for Resident #106, created 5/28/13, and current through 4/24/14, indicated she, "has a history of falls (due to) unsteady gait, trouble maneuvering walker, rolls out of bed, has poor safety awareness and impulsive movements." The goal was she would have no fall related injury. Interventions included: "Effective 8/23/13 - Present, "Therapy as ordered." "Effective 2/25/14 - Present PT (Physical Therapy)/OT consult." Fall Risk Evaluations for Resident #106, dated 1/22/14, 2/14/14, and 2/25/14, indicated she was a high risk for falls. A Fall/Event Investigation, dated 1/22/14, indicated Resident #106 fell in the bathroom. In addition to the current safety interventions already in place, a new intervention added after this fall was for a PT consult. A Fall/Investigation, dated 2/25/14, indicated Resident #106 had an un-witnessed fall in the dining room. The report indicated, "Resident fell when lost balance due to way walks." In addition to current safety interventions already in place, a new intervention of PT/OT consult was added. After this fall, the resident was sent to a hospital to be evaluated, due to complaints of headache and nausea. She returned to the facility that evening, with no new orders, "all results negative." No information was found in Resident #106's record, which indicated a PT consult had been done after her fall on 1/22/14. During an interview with the Unit Manager and the Administrator on 3/7/14 at 3:54 p.m., they indicated a PT consult had not been done after this fall. They indicated they didn't know why it hadn't been done. No information was found in Resident #106's record, which indicated a PT consult had been done after her fall on 2/25/14. During an interview with Physical Therapy Assistant #3 on 3/7/14 at 3:50 p.m., she indicated the resident was not screened by physical therapy after her falls on 1/22/14 and 2/25/14. She indicated she was not able to find any referrals for PT screens after those falls. 2. The clinical record of Resident #25 was reviewed on 3/6/14 at 9:55 a.m. [DIAGNOSES REDACTED]. a. A physician's orders [REDACTED].#25 was to receive [MEDICATION NAME] 2.5 mg. (milligrams) daily. [MEDICATION NAME] is an antipsychotic medication used to treat the symptoms of [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. A physician's orders [REDACTED]. was to be discontinued. The Medication Administration Record [REDACTED]. The Medication Administration Record [REDACTED]. on March 1, 2, 3, 4, and 5, 2014. An order was not found in the resident's clinical record to restart the [MEDICATION NAME]. During an interview with the Director of Nursing on 3/6/14 at 2:40 p.m., she indicated a "transcription error" had occurred. She indicated Resident #25 had received [MEDICATION NAME] on March 1-5, 2014, in error. She indicated notification of the error to the physician was being done at that time. b. A recapitulated physician's orders [REDACTED].#25 could receive [MEDICATION NAME], 0.25 mg. twice a day as needed. [MEDICATION NAME] is an antianxiety medication. A care plan for Resident #25, dated 7/27/11 and current through 5/3/14, indicated a problem of, "(resident's name) is receiving an antianxiety drug on a regular basis as needed for anxiety. She has anxiety related to oxygen levels, staff, schedule, (bowel movements) and lab work. During periods of anxiety she becomes short-tempered, seeks extra attention from staff (i.e. calls the nurse on the phone, requests additional time for care), she becomes verbally abusive toward staff at times, is accusatory of staff at times, refuses care from specific staff members.... " Interventions for this problem included: "Engage (resident name) in group/individual activities that reduce periods of anxiety and promote socialization" "Administer antianxiety meds as ordered. Monitor for side effects of medication..." "Provide quiet atmosphere with one-on-one support during periods of increased anxiety. Allow (resident's name) to talk about event and causes, if known." "Record behavior in the Lifestyle Support Log..." "Encourage (resident's name) to breathe deeply, through the nose, during periods of anxiety." "Encourage (resident's name) to speak slowly and calm down prior to speaking during periods of anxiety as rapid speech hinders her breathing and increases anxiety levels." "Encourage (resident's name) to use her call light to request assistance with care and to use the phone for non-care related assistance. Reassure her that staff will respond to the call light." "Explain how much time is available to provide her care prior to giving it. Ask her if this amount of time is acceptable and reschedule care or proceed with care per her preference." "Encourage (resident's name) to collaborate with staff to create a care/activity schedule that will meet her needs and preferences. Refer to her care schedule during periods of anxiety and explain that staff does not have an unlimited amount of time to spend with her. Reassure her that her schedule can be modified as needed to accommodate her preferences or medical state." "If (resident's name) is upset, give her time to calm down. Encourage relaxation techniques for anxiety...Reapproach her at a later time to provide care if needed." A Medication Administration Record [REDACTED].., on 2/10, 2/13, and 2/28, 2014. A nurse's note dated 2/10/14 at 1:28 a.m., indicated, "Resident has been on call light for several times and doesn't remember or know what she wants. Prn (as needed) [MEDICATION NAME] given with positive results." The nurse's note did not indicate any alternative non-pharmacological interventions from the resident's anxiety care plan were attempted by staff prior to giving the prn [MEDICATION NAME]. A nurse's note dated 2/13/14 at 1:16 a.m. indicated, "Prn [MEDICATION NAME] given...resident request. No behavior noted..." The nurse's note did not indicate any alternative, non-pharmacological interventions from the resident's anxiety care plan were attempted by staff prior to giving the prn [MEDICATION NAME]. A nurse's note dated 2/28/14 at 10:42 p.m. indicated, "At change of shift, resident (complained of) increased anxiety. Res(ident) assessed and asked to describe how she felt. Res(ident) stated she felt like she had a lot of anxious energy. Res(ident) administered prn ([MEDICATION NAME]). Res(ident) reassessed half hour later and resident stated she felt a lot better..." The nurse's note did not indicate any alternative, non-pharmacological interventions from the resident's care plan were were attempted prior to giving the prn [MEDICATION NAME]. A review of the Behavior Tracking Log for Resident #25 for February, 2014, did not indicate any behaviors during the month. During an interview with the Director of Nursing on 3/7/14 at 8:45 a.m., she indicated she was not able to find any other documentation in Resident #25's record, regarding assessments and interventions provided to the resident prior to giving the prn [MEDICATION NAME] on 2/10, 2/13, and 2/28, 2014. 3. The clinical record of Resident #58 was reviewed on 3/7/2014 at 2:45 p.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #58 required extensive assistance of 2 persons for bed mobility, dressing, and toileting and required total assistance of 2 persons for transfers and bathing. A careplan dated 9/11/2011, indicated Resident #58 was at risk for falls related to weakness and poor safety awareness. Interventions included, but were not limited to, "...Resident prefers to have a self release seat belt on her broda chair (not a restraint is able to release upon command 100% (percent) of the time) prefers it because it makes her feel safe...." Resident #58 was observed sitting up in the hallway by the nurse's station on 3/7/2014 at 10:30 a.m. Resident #58 was asked to release the self releasing seat belt. Resident #58 indicated she was unable to release the belt. Resident #58 indicated she leans forward in her chair and the belt helped her to feel more secure. Resident #58 indicated she did not want to remove the belt. During an interview with CNA #8 on 3/7/2014 at 10:45 a.m., CNA #8 indicated Resident # 58, "Some days she can release her belt and some days she cannot release it. I have seen her pop it right off." On 3/7/2014 at 3:15 p.m., Resident #58 was taken to her room by RN #2. RN #2 asked Resident #58 to release her self releasing belt. Resident #58 attempted to release the belt, but indicated she wasn't able to release it. RN #2 indicated Resident #58 can usually release the belt but, "The belt is on backwards, which is why she cannot release it. If the belt is not properly applied, she will not be able to release it." The seat belt had a typed note taped to the buckle, which read, "Velcro to the front, buckle to the back." The buckle was resting on the right lower abdomen of Resident #58 (applied backwards). Resident #58 was taken to the bathroom and upon return to the hallway, was asked by RN #2 to release the seat belt. Resident #58 pulled on the velcro strap and was able to release the belt. An untitled and undated document was provided by the DoN on 3/12/2014 at 1:05 p.m. The heading at the top of the document read, "4.10 BRODA Unpadded Seat Belt...Properly attached this accessory securely holds a resident in a chair with a minimum of risk from the belt...." 3.1-35(g)(2)

Based on record review and interview, the facility failed to adequately assess, measure, and document a resident's hematoma upon admission and upon the worsening of that resident's hematoma which had resulted in a lack of care and treatment, and the resident requiring three subsequent surgeries after having left the facility. This deficient practice affected 1 of 3 residents reviewed for wounds in a sample of 3 (Resident #A). Findings include: Review on 08/17/11 at 10:40 a.m., of Resident #A's closed clinical record indicated: Resident #A had the [DIAGNOSES REDACTED]. A hospital history and physical dated 06/01/11, indicated the resident had fallen while at home and had sustained a large hematoma (a blood-filled raised area) to the right lower extremity. The resident had gone to the emergency room (ER) to be checked out, and had been advised to not take [MEDICATION NAME] (an anticoagulant) upon discharge from the ER. The resident had resumed taking the [MEDICATION NAME] and had then experienced increased pain, swelling, and leakage of fluid from open areas of the right lower extremity. The area to the resident's right lower leg was indicated as "quite a big hematoma in the mid to distal leg on the right side...is also having some tear posteriorly with weeping bloody serosanguinous drainage...does have [DIAGNOSES REDACTED] and tenderness...does have some black ischemic spots which can be due to necrosis." The resident had again been taken to the ER and was placed on intravenous antibiotics for [MEDICAL CONDITION]. This document contained no measurements of the resident's hematoma. The admission physician's orders [REDACTED]. A telephone order dated 06/04/11, indicated "...Change dsg (dressing) to RLL q (every) day. Clarification: [MEDICATION NAME] 1% to RLL (right lower leg) q d (every day)." An admission nursing assessment dated [DATE], failed to document the presence of the resident's hematoma injury to the right lower leg. The facility was unable to produce any documentation of weekly skin assessments performed on the resident. Nurse's note entries regarding the resident's wound/hematoma indicated the following entries: 06/04/11 @ (at) 5 p.m.: The resident was admitted to the facility and was indicated as having an "intact dsg (dressing) c (with) some blood on dsg (bright red from wound)." The resident had refused for the nurse to remove the dressing for assessment, so the nurse had documented the dressing had been "reinforced with 2 ABD's and Kerlix." 06/06/11 @ 4 a.m.: "Dressing CDI (clean/dry/intact) to R (right) lower leg...remains on IV (intravenous) [MEDICATION NAME] (an antibiotic) for right leg [MEDICAL CONDITION]" 06/06/11 @ 6:45 p.m.: "...Drsg (dressing) intact to hematoma R lower leg..." 06/07/11 @ 11:58 p.m.: "...On IV ATB (antibiotics) for [MEDICAL CONDITION]. Drsg CDI to bilat legs..." 06/08/11 @ 10:30 p.m.: "...R lower leg area is seeping blood and the dsg was [MEDICATION NAME] being used to tx (treat) rt (right) lower leg [MEDICAL CONDITION]" 06/09/11 "Late entry for 06/09/11 @ 10 a.m.: "...BLE (both lower extremities) c drsg change daily. Rt leg with large hematoma bleeding when changed..." 06/09/11 @ 6 p.m.: "...The hematoma is leaking dark blood...tx (treatment)/dsg done daily and prn (as needed)..." 06/09/11 @ 10:30 p.m.: "...RLE (right lower extremity) had very minimal amount blood on dsg..." 06/10/11 (no time documented) The nurse practitioner visited the resident and gave orders for the resident to be seen by a surgeon for I & D (incision and drainage) of the hematoma to the RLE, extended the intravenous [MEDICATION NAME] for 5 more days, and gave orders for labs (CBC (complete blood count) and BMP (basic metabolic profile)). 06/10/11 (no time documented) "changed dsg to RLL (right lower leg) hematoma, scheduled surgical consult for Thursday..." 06/11/11 @ 3:50 p.m.: "...Dsg to LLE changed. No drainage. No S/S (sign/symptom) of infection. Hematoma remains to R lower extremity..." 06/13/11 (no time documented): "...Hematoma remains to R lower leg..." 06/14/11 (no time documented): "...Dsg change to RLL, draining, mod (moderate) amt (amount) of sanguinous fluid..." 06/15/11: There were no entries regarding the hematoma to the right lower extremity for this date. 06/16/11 (no time documented): The resident was sent to the ER (emergency room ) from the surgeon's office as the surgeon had deemed the hematoma to the resident's right lower leg as "out of control." Review on 08/18/11 at 10:20 a.m., of a surgical consult report dated 06/17/11, indicated "Physical examination: ...extremities: She has a 15 x (by) 10 cm (centimeters) area on the right pretibial region which appears to be a mixture of hematoma, which has underlying necrotic skin. This necrotic skin now separated by some space from the surrounding tissue, which appears cellulitic and has [DIAGNOSES REDACTED] and tenderness associated with it...Impression and Plan: ...had a discussion with the patient's husband regarding the proposed treatment, which included excision of, what appeared to be, necrotic tissue that was caused by a pressure phenomenon from a traumatic hematoma while she was on [MEDICATION NAME]" (The emergency room report failed to document a description of the hematoma). Review on 08/18/11 at 10:20 a.m., of the hospital operative report dated 07/05/11, indicated the resident "has had multiple operations, including debridement, followed by debridement and homograft placement of the wound, scheduled now for debridement and autograft placement of the same wound as the final stage of the reconstruction of this wound. She originally sustained the wound from a fall while on [MEDICATION NAME]. (She) Had a large, subcutaneous hematoma which through pressure necrosis, caused loss of the overlying skin....Procedure: Debridement of 170 square cm right lower extremity wound and split thickness skin grafting of 170 square cm right lower extremity wound..." (Surgery dates were: 06/18/11: debridement; 06/29/11: debridement and cadaver skin graft; 07/05/11: debridement and placement of skin graft from the resident's own thigh). During interview on 08/17/11 at 2:45 p.m., LPN #1 indicated (after going through the resident's closed record) she could find no documentation of skin assessment which should have been done at the time of admission, nor could she find any weekly wound assessment documentation. LPN #1 also indicated she could not account for a lack of documentation on 06/15/11, on any shift, nor regarding the fact staff had failed to recognize the resident had necrotic tissue in the hematoma when first admitted to the facility. LPN #1 further indicated the nurse practitioner had indicated to her at one point (date uncertain) the resident should have had debridement of the hematoma before having been admitted to the facility (no documentation was found in the physician/nurse practitioner progress notes to this effect). During a phone interview on 08/17/11 at 2:55 p.m., LPN #2 indicated he had only seen the resident's wound to the right lower leg on 2 occasions, and indicated "the wound had not looked any different on 06/16/11, when had gone to see the surgeon than had looked previously (date uncertain)." This Federal tag relates to complaint IN 734. 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident was free from fear and mental anguish when 1 licensed nurse and 2 certified nursing assistants (C.N.A.) went into the resident's room at 12:30 A.M., awakened the resident and participated in 2 attempts to do an invasive procedure (in and out catheterization to obtain a urine specimen) while holding back the arms and legs of the resident. During those 2 attempts the resident yelled and screamed "Help" hit, bit at the staff, and yelled they were all going to jail, in an attempt to stop them. This affected 1 of 24 residents reviewed for being free from fear and mental anguish in a sample of 24. (Resident #A) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 11/19/10 and began on 9/20/10. The Administrator and Director of Nursing (DoN) were informed of the Immediate Jeopardy on 11/19/10 at 6:00 P.M. The Immediate Jeopardy was removed on 11/22/10 at 6:00 P.M., but the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, because the facility plans ongoing monitoring of staff related to identifying and reporting allegations of abuse and to complete thorough investigations of any allegations of abuse and provide ongoing inservice education on abuse. The facility updated their Abuse Policy and Procedure and will notify ISDH (Indiana State Department of Health) of all allegations of abuse and/or neglect per ISDH guidelines. All staff have received education on what constitutes abuse and will continue to receive ongoing education. Findings include: A facility policy, received from the administrator on 11/15/10 at 12:30 P.M., dated January 2010, deemed current, and titled "Abuse Prevention" indicated, "It is the goal of this facility to establish a resident sensitive and secure environment to assure proper and respectful treatment of [REDACTED]." Resident #A's record was reviewed on 11/18/10 at 4:20 P.M. The resident's [DIAGNOSES REDACTED]. A Minimum Data Set assessment, dated 9/12/10 indicated Resident #A's cognitive status was a "2...moderately impaired--decisions poor; cues/supervision required...." A nurses' note written by LPN #1, dated "Late entry for 9/20/10", no time given, indicated, "At approximately 12:30 A.M. entered the residents room. The resident was lying in bed with eyes closed. Explained to the resident that doctor had ordered a UA. (urinalysis) Asked res (resident) if she wanted to get up and try to use restroom. Res stated she did not want to get out of bed." The nurse indicated she explained the in and out cath (catheter) procedure to the resident and the resident agreed to have it done. "Prep resident for procedure. Res calm, lying with knees bent, eyes opened, and arms resting at her side. Bruises noted on (upper)(lower) extremities. As cath was advanced res had (increased) agitation, and became physically abusive to staff." The attempt to get the specimen was unsuccessful and the procedure was halted. She then explained the procedure again and the resident agreed for the nurse to try again. The resident was, again, calm during the preparation but when the catheter was advanced the resident became agitated again and "physically and verbally abusive towards staff. Resident picked up lotion bottle from bedside table, and attempted to hit staff." The procedure was then stopped and the 2nd attempt to obtain the UA was unsuccessful. "Another nurse was called in to assist. Nurse explained procedure to resident. Res agreed to have procedure. Res again had (increased) agitation and, and was physically abusive towards staff as cath (catheter) was advanced. Third attempt was successful, and UA sample was obtained. Res cont (continued) to have (increased) agitation and (increased) confusion. Explained procedure to resident again Res had (decreased) agitation and (decreased) confusion after hearing explanation. Res denied having any pain @ at that time." The nurse further indicated at approximately 3:00 A.M. the resident was lying bed with her eyes closed, without signs of discomfort or distress. A nurse's note dated 9/21/10, no time given, indicated at approximately 8:00 P.M. Resident #A indicated, "she did not want to be bothered by many people at bedtime...." A nurses's note dated 9/22/10, no time given, indicated, "Resident remains upset about incident earlier in the week, wanted to talk to writer to report what happened, showed writer her bruises & became increasingly upset. Wanted to go to another room to sleep, finally agreed to move to empty bed in same room...." A nurse's note dated 9/23/10 at 6:00 P.M. indicated, "Resident began reliving incident of 9/2/10 & accused writer of one of five who "raped me this morning." Resident again wanted another room for the night, moved to bed in...for the night. Resident later apologized to writer for earlier accusations...." A form "Skin Tear or Bruise or Other Injury..." for Resident #A, dated 9/20/10 at 6:45 A.M., indicated, "Resident statement...Resident stated 3 girls and a man radiologist came into her room last night while she was asleep and assaulted her. She stated that she tried to fight them off...." The skin/bruise report further indicated, "Describe injury...Rt (right) hand bruise 3 1/2 (inches) long, 1 1/2 (inches) wide. Rt. (right) upper forearm 3 in long 2 inches wide, Rt lower forearm 4 inch (sic) long 2 inches wide..." Section 11: "Bruises/...Residents skin condition and risk factors..." indicated the resident had medical conditions and behaviors that contributed to her bruises, also that she was prone to bruise, her skin was fragile and dry. "Section 111: Investigation Summary and final Action Plan... "...examined resident peri area for trauma, none was found. Resident very combative during catheterization, bruises measurement: Rt hand 3 1/2 (inches) x 1 1/2 (inches), RUFA (right upper forearm) 3 (inches) x 2 inches, RLFA (right lower forearm) 4 inches x 2 1/2 (inches)..." "Staff...stated bruises present before combative episode, bruising...not wrapped around arm or hand...." The facility provided an initial, required notification to the Indiana State Department of Health for incidents and unusual occurrences, which was faxed on 9/20/10. The report indicated, "Brief Description of incident...(resident name) stated...3 females came into her room this morning and 1 of the females place (sic) a finger in her 'v....a'...further states she fought...them...also a radiologist...on the vacant side...room...." The writer indicated, "In reality (resident name) was being catheterized for a urine specimen." "Type of Injury/Injuries...bruising to RFA (right forearm), (right) hand. Measurements - hand 3 1/2 in (inches) by 1 1/2 inches. R (right) upper forearm 3 (inches) x 2 (inches)...(right) lower forearm 4 (inches) x 2 (inches)..." "Immediate action taken...assessed for injuries, reassured emotionally..." "Preventative measures taken...will not have non-emergency procedure completed on third shift...seemed to...exacerbate her confusion." Resident #A's care plans were reviewed and are as follows, but they are not all inclusive of the resident's plan of care to be followed: 1) "I have a [DIAGNOSES REDACTED]..9/10...2. Reassure me that I am safe and stay with me if possible...3. Reduce sensory stimuli by maintaining a quiet environment...." 2) "I am at risk for...behavior issues due to my dx (diagnosis) dementia...am verbally abusive to staff...9/10...6. Attempt my care later...." 3) "I become agitated and combative, even after explanation, during invasive procedures during sleeping hours..;.9/20/10...1. I will not have any invasive nursing procedures during sleeping hours...." There were no care plans located which addressed 'bruising' or 'fragility of skin.' A physician's orders [REDACTED]." A physician's orders [REDACTED]." There were no nurses' notes on this date regarding the order to obtain the UA. During an interview with LPN #1 on 11/21/10 at 6:47 A.M., with the DoN present, she was asked why the UA, originally ordered on [DATE], wasn't obtained until until 9/20/10 during the night while the resident was asleep and LPN #1 indicated, "I guess it hadn't been done and it was important that we got it done so we could get her started on her antibiotics." The DoN indicated up to 9/20/10 it was "normal" to obtain specimens on the night shift to have them ready for the laboratory to pick up at 6:00 A.M. She indicated since that date the staff had been inserviced regarding no invasive procedures for specimen collection should be done while the residents are sleeping at night time. A Weekly Nursing Assessment and Review, dated 9/2/10 indicated, "...skin is bruised x 4 ext.(extremities) normal for this res (resident), skin very fragile...." A nurse's note dated 9/13/10 at 10:42 A.M. indicated, " Weekly Skin Assess Complete. Bruised areas to ext(enmities) x 4. Normal for res(resident)...." A skin assessment, dated 9/20/10, no time noted, indicated: "...3) Any Bruises?...'Yes'...7) excessively dry or flaky skin? 'Yes' legs and arms, skin fragile..." Information written by an LPN (licensed practical nurse) indicated: "Rt hand bruise on top - 3 1/2 in long, 1/1/2 in wide...2) Rt upper Forearm - 3 in long 2 inches wide...3) Rt Lower Forearm - 4 in long 2 inches wide...." There were no other skin assessment sheets located in the resident's record for the dates between 9/2/10 and 9/20/10. During an interview with the DoN on 11/21/10 at 7:00 A.M., she indicated she was unable to locate any other skin assessment sheets for this time period. The facility investigation of the incident which happened to Resident #A indicated only three interviews were completed. The written interviews were from the two CNA's and the one nurse who made the first two attempts to I&O Cath Resident #A., when it was noted she screamed and yelled for help and attempted to fight the staff off. The male nurse was not interviewed, which the DoN indicated on 11/19/10 at 6:00 P.M. during a daily conference. The DoN indicated there were no other staff interviewed related to the incident and there were no other residents interviewed, other than Resident #A. The DoN indicated an attempt was made to reassure the resident that nothing bad had happened to her and the staff had tried to obtain a urine specimen by doing an I & O cath. The DoN indicated the episode was emotional for Resident #A. There was no reason given which explained the staff not obtaining the UA with C & S on the original order date of 9/17/10, nor the reason for waking a resident, with known behaviors, confusion and a [DIAGNOSES REDACTED].M. The nurse who attempted the unsuccessful I & O catheterizations wrote what events had transpired on 9/20/10 at 12:30 A.M. from her point of view. She indicated she offered to take the resident to the bathroom so a urine specimen could be obtained. She indicated an explanation was given to the resident about what an I & O cath was and said the resident agreed to the procedure. She indicated, on advancement of the catheter, the resident "...started beating me...I stopped...(resident)...screaming stuff like 3 girls one old lady and we were going to go to jail...attempted to reorient her...second attempt (name) tried to hold back her legs from kicking me, because she had kicked me...the first attempt...(name)...trying to hold her hands back...as I started to advance the cath...trying to bite (name)...scratched her...kneed (sic) me in throat...kicked hard in...stomach and ribs...had (name)...go get (male nurse)...(name) came in...girls held (resident) legs and arms...was able to get the sample... stayed with her, tried to explain what happened...tried to (decrease her confusion)...." A second, hand written explanation dated 9/21/10 was completed by the nurse. It indicated, "I did a late entry in the nurses notes...that cath was the 1st one I have ever done...when she started beating us up I stopped...was scared to advance it any farther...had to get (male nurse)...aides weren't using force when they were trying to protect me...I am really upset...just feel terrible...been a mess all shift...just want to be a good nurse...." The first (name) C.N.A. had hand-written, on 9/20/10, no time noted, how she thought the incident had taken place. She indicated the 3 staff (identified by each name) went in Resident #A's room on the "...morning of 9/20/10 around 12:30 A.M....to obtain a UA...we explained what we were going to do...was okay with it until...procedure began...(name) on...(right) side and (name) on (left) side..bottom of leg and I stood...left side by arms and upper body, (name)started to push cath in resident started screaming help...tried to hit (name), so I held her (right) arm down...kicked (name)...in stomach...kneed her in the neck all the while screaming for help...also said we were all going to jail...resident scratch (sic) my neck...scratched my arm...tried to bite me...when I was holding arm down I never gripped it...held it down with...hand open the whole time...had prior bruising to me touching her. After attempting twice to collect UA...got (male nurse)...for help...came into room...on first try successful...I cleaned resident...asked...if was okay...if needed anything, resident did not respond...." The second (name) CNA had hand written an explanation of the incident with Resident #A. She indicated on the morning of 9/20/10 the nurse "needed to get a urine sample.." (Resident name) had multiple bruises before this procedure even began. Most...on her right hand...turned the light on...woke (name) up...explained...procedure. (Name) did not refuse. (Nurse's name)...stood on...right side...(name) and I ...on...left...(name) was by (resident) head...I was by...legs...attempted to put... cath in...(resident name) started screaming help...told us we were going to jail. I was holding...legs apart and up for (name)...(resident) kept repeating we were going to jail...trying to bite and hit (name)...(name) tried to prevent (resident) from hitting us...(name) tried one more time...(resident) picked up lotion bottle...tried to throw it at us. (Resident) kicked (name) in throat...scratched (name) face and neck...then called (male nurse)...." During an interview with the DoN on 11/19/10 at 6:00 P.M., she indicated if a resident was experiencing fear during a procedure, the procedure should be immediately stopped. She indicated further attempts to I & O Resident #A should not have taken place on 9/20/10. During an interview with L.P.N. #1 on 11/21/10 at 6:47 A.M. further information was requested regarding the facility's obligation to protect a resident from fear and mental anguish during an invasive procedure. She indicated if the resident was afraid, the procedure should be stopped immediately. She indicated further attempts to I & O Resident #A on 9/20/10 should not have taken place. An Immediate Jeopardy was identified on 11/19/10. The Immediate Jeopardy began on 9/20/10 when nursing staff at the facility made three attempts on the night shift to in and out catheterize Resident #A, holding her arms and legs down while she was yelling and screaming for help. The Administrator and Director of Nursing were notified on 11/19/10 at 6:00 P.M. of the Immediate Jeopardy related to the facility's failure to ensure a resident was free from fear and mental anguish. The Immediate Jeopardy was removed on 11/22/10 at 6:00 P.M. when, through interview and record review, it was determined that the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The updated Abuse Policy and Procedure was reviewed and inservice forms indicated all staff had received education on what constitutes abuse. During an interview with the Administrator and Director of Nursing on 11/22/10 at 6:00 P.M., they indicated they were continuing to randomly question staff, would ensure all allegations of abuse and/or neglect would be thoroughly investigated and reported per ISDH guidelines. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not an Immediate Jeopardy. 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure its policy related to abuse was followed so that a resident was free from fear and mental anguish when 1 licensed nurse and 2 certified nursing assistants (C.N.A.) went into the resident's room at 12:30 A.M., awakened the resident and participated in 2 attempts to do an invasive procedure (in and out catheterization to obtain a urine specimen) while holding back the arms and legs of the resident. During those 2 attempts the resident yelled and screamed "Help," hit, bit at the staff, and yelled they were all going to jail in an attempt to stop them. This affected 1 of 24 residents reviewed for being free from fear and mental anguish in a sample of 24. (Resident #A) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 11/19/10 and began on 9/20/10. The Administrator and Director of Nursing (DoN) were informed of the Immediate Jeopardy on 11/19/10 at 6:00 P.M. This Immediate Jeopardy was removed on 11/22/10 at 6:00 P.M., but the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, because the facility needs to monitor staff related to identifying and reporting allegations of abuse, to complete thorough investigations of allegations of abuse, and provide ongoing inservice education on abuse. The facility updated its Abuse Policy and Procedure and will notify ISDH Indiana State Department of Health) of all allegations of abuse and/or neglect per ISDH guidelines. All staff have received education on what constitutes abuse and will continue to receive ongoing education. Findings include: A facility policy, received from the Administrator on 11/15/10 at 12:30 P.M., dated January 2010, deemed current, and titled "Abuse Prevention" indicated, "It is the goal of this facility to establish a resident sensitive and secure environment to assure proper and respectful treatment of [REDACTED]." Resident #A's record was reviewed on 11/18/10 at 4:20 P.M. The resident's [DIAGNOSES REDACTED]. A Minimum Data Set assessment, dated 9/12/10 indicated Resident #A's cognitive status was a "2...moderately impaired--decisions poor; cues/supervision required...." A nurses' note written by LPN #1, dated "Late entry for 9/20/10", no time given, indicated, "At approximately 12:30 A.M. entered the residents room. The resident was lying in bed with eyes closed. Explained to the resident that doctor had ordered a UA. (urinalysis) Asked res (resident) if she wanted to get up and try to use restroom. Res stated she did not want to get out of bed." The nurse indicated she explained the in and out cath procedure to the resident and the resident agreed to have it done. "Prep resident for procedure. Res calm, lying with knees bent, eyes opened, and arms resting at her side. Bruises noted on (upper)(lower) extremities. As cath(eter) was advanced res had (increased) agitation, and became physically abusive to staff." The attempt to get the specimen was unsuccessful and the procedure was halted. She then explained the procedure again and the resident agreed for the nurse to try again. The resident was, again, calm during the preparation but when the catheter was advanced the resident became agitated again and "physically and verbally abusive towards staff. Resident picked up lotion bottle from bedside table, and attempted to hit staff." The procedure was then stopped and the 2nd attempt to obtain the UA was unsuccessful. "Another nurse was called in to assist. Nurse explained procedure to resident. Res agreed to have procedure. Res again had (increased) agitation and, and was physically abusive towards staff as cath (catheter) was advanced. Third attempt was successful, and UA sample was obtained. Res cont (continued) to have(increased) agitation and (increased) confusion. Explained procedure to resident again Res had (decreased) agitation and (decreased) confusion after hearing explanation. Res denied having any pain @ at that time." The nurse further indicated at approximately 3:00 A.M. the resident was lying bed with her eyes closed, without signs of discomfort or distress. A nurse's note dated 9/21/10, no time given, indicated at approximately 8:00 P.M. Resident #A indicated, "she did not want to be bothered by many people at bedtime...." A nurses's note dated 9/22/10, no time given, indicated, "Resident remains upset about incident earlier in the week, wanted to talk to writer to report what happened, showed writer her bruises & became increasingly upset. Wanted to go to another room to sleep, finally agreed to move to empty bed in same room..." A nurse's note dated 9/23/10 at 6:00 P.M. indicated, "Resident began reliving incident of 9/2/10 & accused writer of one of five who "raped me this morning." Resident again wanted another room for the night, moved to bed in...for the night. Resident later apologized to writer for earlier accusations...." A form "Skin Tear or Bruise or Other Injury..." for Resident #A, dated 9/20/10 at 6:45 A.M. indicated, "Resident statement...Resident stated 3 girls and a man radiologist came into her room last night while she was asleep and assaulted her. She stated that she tried to fight them off..." The skin/bruise report further indicated, "Describe injury...Rt (right) hand bruise 3 1/2 (inches) long, 1 1/2 (inches) wide. Rt. (right) upper forearm 3 in long 2 inches wide, Rt lower forearm 4 inch (sic) long 2 inches wide..." Section 11: "Bruises/...Residents skin condition and risk factors..." indicated the resident had medical conditions and behaviors that contributed to her bruises, also that she was prone to bruise, her skin was fragile and dry. "Section 111: Investigation Summary and final Action Plan... "...examined resident peri area for trauma, none was found. Resident very combative during catheterization, bruises measurement: Rt hand 3 1/2 (inches) x 1 1/2 (inches), RUFA (right upper forearm) 3 (inches) x 2 inches, RLFA (right lower forearm) 4 inches x 2 1/2 (inches)..." "Staff...stated bruises present before combative episode, bruising...not wrapped around arm or hand...." The facility provided an initial, required notification to the Indiana State Department of Health for incidents and unusual occurrences, which was faxed on 9/20/10. The report indicated, "Brief Description of incident...(resident name) stated...3 females came into her room this morning and 1 of the females place (sic) a finger in her 'v....a'...further states she fought...them...also a radiologist...on the vacant side...room..." The writer indicated, "in reality (resident name) was being catheterized for a urine specimen." "Type of Injury/Injuries...bruising to RFA (right forearm), (right) hand. Measurements - hand 3 1/2 in (inches) by 1 1/2 inches. R (right) upper forearm 3 (inches) x 2 (inches)...(right) lower forearm 4 (inches) x 2 (inches)..." "Immediate action taken...assessed for injuries, reassured emotionally..." "Preventative measures taken...will not have non-emergency procedure completed on third shift...seemed to...exacerbate her confusion." Resident #A's care plans were reviewed and are as follows, but they are not all inclusive of the resident's plan of care to be followed: 1) "I have a [DIAGNOSES REDACTED]..9/10...2. Reassure me that I am safe and stay with me if possible...3. Reduce sensory stimuli by maintaining a quiet environment...." 2) "I am at risk for...behavior issues due to my dx (diagnosis) dementia...am verbally abusive to staff...9/10...6. Attempt my care later..." 3) "I become agitated and combative, even after explanation, during invasive procedures during sleeping hours..;.9/20/10...1. I will not have any invasive nursing procedures during sleeping hours..." There were no care plans located which addressed 'bruising' or 'fragility of skin.' An physician's orders [REDACTED]." A physician's orders [REDACTED]." There were no nurses' notes on this date regarding the order to obtain the UA. During an interview with LPN #1 on 11/21/10 at 6:47 A.M., with the DoN present, she was asked why the UA, originally ordered on [DATE], wasn't obtained until until 9/20/10 during the night while the resident was asleep and LPN #1 indicated, "I guess it hadn't been done and it was important that we got it done so we could get her started on her antibiotics." The DoN indicated up to 9/20/10 it was "normal" to obtain specimens on the night shift to have them ready for the laboratory to pick up at 6:00 A.M. She indicated since that date the staff had been inserviced regarding no invasive procedures for specimen collection should be done while the residents are sleeping at night time. A Weekly Nursing Assessment and Review, dated 9/2/10 indicated, "...skin is bruised x 4 ext.(extremities) normal for this res, skin very fragile...." A nurse's note dated 9/13/10 at 10:42 A.M. indicated, " Weekly Skin Assess Complete. Bruised areas to ext x 4. Normal for res...." A skin assessment, dated 9/20/10, no time noted, indicated: "...3) Any Bruises?...'Yes'...7) excessively dry or flakey skin? 'Yes' legs and arms, skin fragile..." Information written by an LPN (licensed practical nurse) indicated: "Rt hand bruise on top - 3 1/2 in long, 1/1/2 in wide...2) Rt upper Forearm - 3 in long 2 inches wide...3) Rt Lower Forearm - 4 in long 2 inches wide...." There were no other skin assessment sheets located in the resident's record for the dates between 9/2/10 and 9/20/10. During an interview with the DoN on 11/21/10 at 7:00 A.M., she indicated she was unable to locate any other skin assessment sheets for this time period. Review of the facility investigation of the incident which happened to Resident #A indicated only three interviews were completed. The written interviews were from the 2 CNA's and the one nurse who made the first two attempts to I&O Cath Resident #A, when it was noted she screamed and yelled for help and attempted to fight the staff off. The male nurse was not interviewed, which the DoN indicated on 11/19/10 at 6:00 P.M. during a daily conference. The DoN indicated there were no other staff interviewed related to the incident and there were no other residents interviewed, other than Resident #A. The DoN indicated an attempt was made to reassure the resident that nothing bad had happened to her and the staff had tried to obtain a urine specimen by doing an I &O cath. The DoN indicated the episode was emotional for Resident #A. There was no reason given which explained the staff not obtaining the UA with C & S on the original order date of 9/17/10, nor the reason for waking a resident, with known behaviors, confusion and a [DIAGNOSES REDACTED].M. The nurse who attempted the unsuccessful I & O catheterizations wrote what events had transpired on 9/20/10 at 12:30 A.M. from her point of view. She indicated she offered to take the resident to the bathroom so a urine specimen could be obtained. She indicated an explanation was given to the resident about what an I & O cath was and said the resident agreed to the procedure. She indicated, on advancement of the catheter, the resident "...started beating me...I stopped...(resident)...screaming stuff like 3 girls one old lady and we were going to go to jail...attempted to reorient her...second attempt (name) tried to hold back her legs from kicking me, because she had kicked me...the first attempt...(name)...trying to hold her hands back...as I started to advance the cath...trying to bite (name)...scratched her...kneed (sic) me in throat...kicked hard in...stomach and ribs...had (name)...go get (male nurse)...(name) came in...girls held (resident) legs and arms...was able to get the sample... stayed with her, tried to explain what happened...tried to (decrease her confusion)...." A second, hand written explanation dated 9/21/10 was completed by the nurse. It indicated, "I did a late entry in the nurses notes...that cath was the 1st one I have ever done...when she started beating us up I stopped...was scared to advance it any farther...had to get (male nurse)...aides weren't using force when they were trying to protect me...I am really upset...just feel terrible...been a mess all shift...just want to be a good nurse...." The first (name) C.N.A. had hand-written, on 9/20/10, no time noted, how she thought the incident had taken place. She indicated the 3 staff (identified by each name) went in Resident #A's room on the "...morning of 9/20/10 around 12:30 A.M....to obtain a UA...we explained what we were going to do...was okay with it until...procedure began...(name) on...(right) side and (name) on (left) side..bottom of leg and I stood...left side by arms and upper body, (name) started to push cath in resident started screaming help...tried to hit (name), so I held her (right) arm down...kicked (name)...in stomach...kneed her in the neck all the while screaming for help...also said we were all going to jail...resident scratch (sic) my neck...scratched my arm...tried to bite me...when I was holding arm down I never gripped it...held it down with...hand open the whole time...had prior bruising to me touching her. After attempting twice to collect UA...got (male nurse)...for help...came into room...on first try successful...I cleaned resident...asked...if was okay...if needed anything, resident did not respond...." The second (name) CNA had hand written an explanation of the incident with Resident #A. She indicated on the morning of 9/20/10 the nurse "needed to get a urine sample.." (Resident name) had multiple bruises before this procedure even began. Most...on her right hand...turned the light on...woke (name) up...explained...procedure. (Name) did not refuse. (Nurse's name)...stood on...right side...(name) and I ...on...left...(name) was by (resident) head...I was by...legs...attempted to put... cath in...(resident name) started screaming help...told us we were going to jail. I was holding...legs apart and up for (name)...(resident) kept repeating we were going to jail...trying to bite and hit (name)...(name) tried to prevent (resident) from hitting us...(name) tried one more time...(resident) picked up lotion bottle...tried to throw it at us. (Resident) kicked (name) in throat...scratched (name) face and neck...then called (male nurse)...." During an interview with the DoN on 11/19/10 at 6:00 P.M., she indicated if a resident was experiencing fear during a procedure, the procedure should be immediately stopped. She indicated further attempts to I & O Resident #A should not have taken place on 9/20/10. During an interview with L.P.N. #1 on 11/21/10 at 6:47 A.M. further information was requested regarding the facility's obligation to protect a resident from fear and mental anguish during an invasive procedure. She indicated if the resident was afraid, the procedure should be stopped immediately. She indicated further attempts to I & O Resident #A on 9/20/10 should not have taken place. An Immediate Jeopardy was identified on 11/19/10. The Immediate Jeopardy began on 9/20/10 when nursing staff at the facility made 3 attempts on the night shift to in and out catheterize Resident #A, holding her arms and legs down while she was yelling and screaming for help. The Administrator and Director of Nursing were notified on 11/19/10 at 6:00 P.M. of the Immediate Jeopardy related to the facility's failure to ensure a resident was free from fear and mental anguish. The Immediate Jeopardy was removed on 11/22/10 at 6:00 P.M. when, through interview and record review, it was determined that the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The updated Abuse Policy and Procedure was reviewed and inservice forms indicated all staff had received education on what constitutes abuse. During an interview with the Administrator and Director of Nursing on 11/22/10 at 6:00 P.M. they indicated they were continuing to randomly question staff, would ensure all allegations of abuse and/or neglect would be thoroughly investigated and reported per ISDH guidelines. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not an Immediate Jeopardy. 3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure physician's orders were followed regarding lab draws for PT/INR's for a resident with a confirmed [MEDICAL CONDITIONS], which required a newly initiated [MEDICATION NAME] regimen with coagulation monitoring, for 1 of 6 residents on [MEDICATION NAME] reviewed for PT/INR draws in a sample of 24. This could potentially affect an additional 14 residents in the facility, who were on [MEDICATION NAME] therapy. (Resident # B) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 11/17/10 and began on 7/15/10. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 11/18/10 at 3:25 P.M. The Immediate Jeopardy was removed on 11/22/10 at 6:00 P.M., but the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not an Immediate Jeopardy, because the facility needs to show its system is effective for monitoring the followup of ordered labs through review of Medication Administration Records (MAR's), monthly recapitulations of physician's orders, transcription of lab orders to the MARs, and communications with the (vendor name) lab. Findings include: The record of Resident #B was reviewed on 11/17/10 at 8:35 A.M. [DIAGNOSES REDACTED]. A physician's progress note dated 7/12/10 indicated the resident had [MEDICAL CONDITION] (swelling) in her left foot and lower leg. An ultrasound report of a venous study of the left lower extremity, dated 7/13/10, indicated the resident had a "Localized acute [MEDICAL CONDITION] left popliteal vein, nonocclusive." A physician's progress note dated 7/14/10 indicated resident had a left popliteal [MEDICAL CONDITION], "Start [MEDICATION NAME] - treat X 4 mos(months) then DC (discontinue) (not) good candidate for long term tx (treatment) (secondary to) debility, fall risk." A physician's order dated 7/14/10 indicated Resident #B was to receive [MEDICATION NAME] (an anticoagulant medication) 2 mg. (milligrams) every day and she was to have a PT/INR (a blood test measuring how quickly blood coagulates/clots) in the morning on 7/15/10, another PT/INR on 7/16/10, and then every Monday and Thursday for 2 weeks, then every Monday. The 2010 Nursing Spectrum Drug Handbook, pages 1238 and 1239 indicate the following regarding [MEDICATION NAME]: "...Therapeutic class: Anticoagulant...FDA Boxed Warning: Drug may cause major or fatal bleeding. Bleeding is more likely during starting period...Monitor INR regularly in all patients...Indications...Venous [MEDICAL CONDITION] adjustment...Elderly or debilitated patients...Precautions Use cautiously in:...elderly or debilitated patients..." During an interview with the Director of Nursing (DoN) on 11/18/10 at 10:15 A.M. she indicated when an physician's order to draw labs is received, a form is filled out by the nurse and it is faxed to the lab. The lab furnishes a list to the facility each month regarding labs they are scheduled to draw the following month. She indicated no specific person is assigned to monitor to see if the laboratory tests were drawn as ordered. Review of a "PHARMACY PRODUCTS, SERVICES AND CONSULTANT AGREEMENT", received from the Administrator on 11/17/10 at 4:00 P.M., dated 2/18/09 and deemed current, indicated "...3. Pharmacy Consultant Services (d) review the drug regimen of each resident on a monthly basis...and report in writing any irregularity..." During the interview with the DoN on 11/18/10 at 10:15 A.M. she indicated routine (repeated) lab orders are also given to the pharmacy and they are responsible for getting these lab orders on the monthly physician order recapitulations. The pharmacist will review the medications and make recommendations as needed. She indicated "Somehow or other she (the pharmacist) missed the order for [MEDICATION NAME] for (Resident #B)." There were no test results located in the clinical record for the PT/INR blood draws ordered 7/14/10. A physician's progress note dated 8/2/10 indicated "[MEDICAL CONDITION] (left) leg, on [MEDICATION NAME] 1. [MEDICAL CONDITION] 1. PT/INR..." A physician's order, dated 8/2/10, indicated Resident #B was to have a PT/INR drawn in the morning and then every other day (QOD). A PT/INR was drawn on 8/3/10. The INR results were 1.1. This result was low, an indication the blood was clotting more quickly than normal. On this day, 8/3/10, Resident #B's [MEDICATION NAME] dose was increased to 2.5 mg. per day. There were no test results, located in the resident's record, to confirm the PT/INR's were drawn from 8/05/10 through 8/29/10. . Physician's progress notes from 8/9/10 and 8/16/10 did not refer to Resident #B having a [MEDICAL CONDITION] or being on [MEDICATION NAME]. A physician's progress note dated 8/30/10 indicated [MEDICAL CONDITION] in left lower leg, "...Assessment...2. [MEDICAL CONDITION] L leg...Plan...2. stat PT/INR..." A physician's order, dated 8/30/10, indicated the resident was to have a PT/INR drawn STAT (as soon as possible). Test results for the STAT PT/INR, drawn on 8/30/10, again indicated an INR of 1.1, which indicated the blood was clotting more quickly than normal. There were no new orders located in the resident's clinical record for any changes in the [MEDICATION NAME] dose at this time. A physician's progress note dated 8/31/10 did not refer to the resident's [MEDICAL CONDITION], [MEDICATION NAME] or PT/INR labs. A physician's progress note dated 9/24/10 did not refer to the resident's [MEDICAL CONDITION], [MEDICATION NAME] or PT/INR labs. A physician's progress note dated 10/4/10 indicated the resident had [MEDICAL CONDITION] in her left lower leg and..."Diagnosis...2. hypercoagulant...Plan...2. PT/INR..." A physician's progress notes dated 10/15/10, 10/25/10 and 11/1/10 did not refer to the resident's [MEDICAL CONDITION], [MEDICATION NAME] or PT/INR labs. A physician's order dated 11/17/10 indicated the resident was to have a PT/INR lab drawn on 11/17/10 and then every Monday. Results of the lab test indicated the residents INR was 1.1 (which indicated her blood was still clotting more quickly than normal). A physician's order dated 11/17/10 indicated Resident #B's [MEDICATION NAME] was to be increased to 3 mg every day. A review of a nurse's note from 7/13/10 indicated, "Doppler ultrasound completed, (positive) [MEDICAL CONDITION]" The nurses' notes from 7/14/10 through 11/17/10 indicated the resident's left leg was assessed only once, on 10/12/10 at 9:00 P.M. "Weekly skin assessment...Res(ident) con(tinues) [MEDICATION NAME] tx.(treatment) L(eft) leg +1 [MEDICAL CONDITION] 0 (no) warmth noted...0 (no) c/o (complaints of) discomfort." On 11/17/10 at 4:55 P.M. with LPN #1, the resident was observed sitting in her recliner with her feet elevated. Her left leg was pale with minimal [MEDICAL CONDITION]. Her left heel was covered with a dressing. Her left foot was a medium red in color with a moderate amount of [MEDICAL CONDITION] in the toes and 2/3 way up the foot. Review of the Medication Administration Records (MAR) for Resident #B indicated she received [MEDICATION NAME] 2.5 mg. daily, as ordered by the physician on 8/3/10 for the rest of August, all of September, October and through November 17, 2010. The recapitulated orders for September, 2010, signed by the physician, indicated the resident was to have a PT/INR drawn QOD. The original date of the order was 8/2/10. The recapitulated orders for October, 2010, signed by the physician, indicated the resident was to have a PT/INR drawn QOD. The original date of the order was 8/2/10. The recapitulated orders for November, 2010, signed by the physician, indicated the resident was to have a PT/INR drawn QOD. The original date of the order was 8/2/10. No test results for PT/INR draws, after the lab drawn on 8/30/10, were located in the resident's clinical record for September, October, and November 1 through November 16, 2010. During an interview with the Director of Nursing on 11/17/10 at 12:15 P.M. she indicated none of the labs had been drawn. She said she had spoken with the lab and they had indicated the the orders to draw the QOD PT/INR's had not been received . She stated "I guess they just got missed." No care plan was found in the current record regarding the resident's care related to the [MEDICAL CONDITION] and [MEDICATION NAME] therapy. Further information was requested from the DoN on 11/22/10 at 5:05 PM. regarding Resident #B not having a care plan for [MEDICATION NAME] therapy. On 11/22/10 at 5:20 P.M. she provided a care plan initiated on 8/3/10 and updated 8/30/10. She indicated she had found the care plan in the resident's overflow chart and not the current record. The care plan indicated a problem of "At risk for abnormal bleeding (related to) [MEDICATION NAME] use. Approaches included "..2. Monitor labs-report abnormals to MD...8/30/10 6. PT & INR - stat..."There were no further updates to the care plan after 8/30/10. There were no further PT/INR labs drawn after 8/30/10 until 11/17/10. During an interview with the Medical Director, on 11/17/10 at 2:25 P.M., a brief explanation was given related to Resident #B's [MEDICATION NAME] therapy since August, 2010, the order for PT/INR tests ordered to be drawn QOD, and the fact that no labs had been drawn since 8/30/10. He indicated "Well, that's a problem." An Immediate Jeopardy was identified on 11/17/10. The Immediate Jeopardy began on 7/15/10 when the facility failed to ensure a PT/INR lab draw was done on that day, per physician's order, after the resident was started on [MEDICATION NAME] therapy on 7/14/10. The Administrator and Director of Nursing were notified on 11/18/10 at 3:25 P.M. of the Immediate Jeopardy related to the lack of monitoring the resident's INR after she began taking the anticoagulant medication. The Immediate Jeopardy was removed on 11/22/10 at 6:00 P.M. when through interview and record review it was determined that the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility reviewed all residents receiving [MEDICATION NAME] to ensure most recent labs had been drawn as ordered. New procedures for ensuring orders were sent to and received by the lab, placed on the Medication Administration records and lab results documented were put in place and staff was inserviced. Ongoing monitoring will occur. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not an Immediate Jeopardy. 3.1-48(a)(3)

Based on observation, record review and interview, the facility failed to provide ordered PT/INR laboratory tests for the monitoring of blood coagulation for therapeutic levels of [MEDICATION NAME] for a resident with a confirmed [MEDICAL CONDITIONS], newly initiated on a [MEDICATION NAME] regimen 1 of 6 residents on [MEDICATION NAME] reviewed for PT/INR draws in a sample of 24. This could potentially affect an additional 14 residents in the facility who were on [MEDICATION NAME] therapy. (Resident # B) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 11/17/10 and began on 7/15/10. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 11/18/10 at 3:25 P.M. This Immediate Jeopardy was removed on 11/22/10 at 6:00 P.M., but the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not an Immediate Jeopardy, because the facility needs to show their system is effective for monitoring the followup of ordered labs through review of Medication Administration Records (MAR's), monthly recapitulations of physician's orders [REDACTED]. Findings include: The record of Resident #B was reviewed on 11/17/10 at 8:35 A.M. [DIAGNOSES REDACTED]. A physician's progress note dated 7/12/10 indicated the resident had [MEDICAL CONDITION] (swelling) in her left foot and lower leg. An ultrasound report of a venous study of the left lower extremity, dated 7/13/10, indicated the resident had a "localized acute [MEDICAL CONDITION] left popliteal vein, nonocclusive." A physician's progress note dated 7/14/10 indicated the resident had a left popliteal [MEDICAL CONDITION],"Start [MEDICATION NAME] - treat X 4 mos (months) then DC (discontinue) (not) good candidate for long term tx (treatment) (secondary to) debility, fall risk." A physician's orders [REDACTED]. (milligrams) every day and she was to have a PT/INR (a blood test measuring how quickly blood coagulates/clots) in the morning on 7/15/10, another PT/INR on 7/16/10, and then every Monday and Thursday for 2 weeks, then every Monday. The 2010 Nursing Spectrum Drug Handbook, pages 1238 and 1239 indicate the following regarding [MEDICATION NAME]: "...Therapeutic class: Anticoagulant...FDA Boxed Warning: Drug may cause major or fatal bleeding. Bleeding is more likely during starting period...Monitor INR regularly in all patients...Indications...Venous [MEDICAL CONDITION] adjustment...Elderly or debilitated patients...Precautions Use cautiously in:...elderly or debilitated patients...." There were no test results indicated in the clinical record for the PT/INR tests ordered on [DATE]. A physician's progress note dated 8/2/10 indicated, "[MEDICAL CONDITION] (left) leg, on [MEDICATION NAME] 1. [MEDICAL CONDITION] 1. PT/INR...." A physician's orders [REDACTED]. A PT/INR was drawn on 8/3/10. The INR results were 1.1. The reference range given by the lab was 2.0 - 3.0. The resident's test result was low, an indication the blood was clotting more quickly than normal. On this day, 8/3/10, a physician's orders [REDACTED]. per day. There were no test results, indicated in the resident's record, to confirm the PT/INR's were drawn from 8/05/10 through 8/29/10. Physician's progress notes from 8/9/10 and 8/16/10 did not refer to Resident #B having a [MEDICAL CONDITION] or being on [MEDICATION NAME]. A physician's progress note dated 8/30/10 indicated [MEDICAL CONDITION] in left lower leg, "...Assessment...2. [MEDICAL CONDITION] L leg...Plan...2. stat PT/INR...." A physician's orders [REDACTED]. Test results for the STAT PT/INR, drawn on 8/30/10, again indicated an INR of 1.1, which indicated the blood was clotting more quickly than normal. There were no new orders indicated in the resident's clinical record for any changes in the [MEDICATION NAME] dose at this time. Nurse's notes for 8/30/10 and 8/31/10 did not indicate the physician was notified of these lab results. On the copy of the lab results in the resident's record, initials were observed under a handwritten date of 8/31/10. In an interview with the Director of Nursing (DoN) on 11/19/10 at 3:25 P.M., she indicated the initials belonged to the nurse practitioner and the initials indicated the nurse practitioner was aware of the lab results. A physician's progress note dated 8/31/10 did not refer to the resident's [MEDICAL CONDITION], [MEDICATION NAME] or PT/INR labs. A physician's progress note dated 9/24/10 did not refer to the resident's [MEDICAL CONDITION], [MEDICATION NAME] or PT/INR labs. A physician's progress note dated 10/4/10 indicated the resident had [MEDICAL CONDITION] in her left lower leg and "Diagnosis...2. hypercoagulant...Plan...2. PT/INR...." A physician's progress notes dated 10/15/10, 10/25/10 and 11/1/10 did not refer to the resident's [MEDICAL CONDITION], [MEDICATION NAME] or PT/INR labs. A physician's orders [REDACTED]. Results of the lab test indicated the residents INR was 1.1 (which indicated her blood was still clotting more quickly than normal). A physician's orders [REDACTED]. A review of a nurse's note from 7/13/10 indicated, "Doppler ultrasound completed, (positive) [MEDICAL CONDITION]" The nurses' notes from 7/14/10 through 11/17/10 indicated the resident's left leg was assessed only once, on 10/12/10 at 9:00 P.M. "Weekly skin assessment...Res (resident) con (continues) [MEDICATION NAME] tx.(treatment) L (left) leg +1 [MEDICAL CONDITION] 0 (no) warmth noted...0 (no) c/o (complaints of) discomfort." On 11/17/10 at 4:55 P.M. with LPN #1, the resident was observed sitting in her recliner with her feet elevated. Her left leg was pale with minimal [MEDICAL CONDITION]. Her left heel was covered with a dressing. Her left foot was a medium red in color with a moderate amount of [MEDICAL CONDITION] in the toes and 2/3 way up the foot. Review of the Medication Administration Records (MAR) for Resident #B indicated she received [MEDICATION NAME] 2.5 mg. daily, as ordered by the physician on 8/3/10 for the rest of August 2010, all of September 2010 and October 2010 and through November 17, 2010. The recapitulated orders for September 2010, signed by the physician, indicated the resident was to have a PT/INR drawn QOD. The original date of the order was 8/2/10. The recapitulated orders for October 2010, signed by the physician, indicated the resident was to have a PT/INR drawn QOD. The original date of the order was 8/2/10. The recapitulated orders for November 2010, signed by the physician, indicated the resident was to have a PT/INR drawn QOD. The original date of the order was 8/2/10. No test results for PT/INR draws, after the lab drawn on 8/30/10, were indicated in the resident's clinical record for September 2010, October 2010, and November 1 through November 16, 2010. During an interview with the DoN on 11/17/10 at 12:15 P.M., she indicated none of the labs had been drawn. She indicated she had spoken with the lab and they had indicated the orders to draw the QOD PT/INR's from 8/2/10 had not been received. She stated, "I guess they just got missed." During an interview with the Director of Nursing (DoN) on 11/18/10 at 10:15 A.M. she indicated when an physician's orders [REDACTED]. The lab furnishes a list to the facility each month regarding labs they are scheduled to draw the following month. She indicated no specific person is assigned to monitor to see if the laboratory tests were drawn as ordered. During an interview with the Medical Director, on 11/17/10 at 2:25 P.M., a brief explanation was given related to Resident #B's [MEDICATION NAME] therapy since August 2010, the order for PT/INR tests ordered to be drawn QOD, and the fact that no labs had been drawn since 8/30/10. He indicated, "Well, that's a problem." On 11/19/10 at 1:40 P.M., information was requested from the DoN regarding whether, during the monthly medication regimen reviews, the Consultant Pharmacist had made any recommendations for Resident #B regarding her daily [MEDICATION NAME] dose, the QOD PT/INR lab orders and the record not indicating any PT/INR lab results between 8/31/10 and 11/16/10. At 2:00 P.M. on 11/19/10, the DON indicated no recommendations had been made. During an interview with the DoN on 11/19/10 at 2:00 P.M., she indicated she had been able to contact the owner of the lab on this morning and he was able to find the QOD PT/INR lab orders from 8/2/10 that the facility had faxed to him. She indicated the owner of the lab said the lab had missed the order. A copy of the faxed order was provided. An Immediate Jeopardy was identified on 11/17/10. The Immediate Jeopardy began on 7/15/10 when the facility failed to ensure a PT/INR lab draw was done on that day, per physician's orders [REDACTED]. The Administrator and Director of Nursing were notified on 11/18/10 at 3:25 P.M. of the Immediate Jeopardy related to the lack of monitoring the resident's INR after she began taking the anticoagulant medication. The Immediate Jeopardy was removed on 11/22/10 at 6:00 P.M. when through interview and record review it was determined that the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility reviewed all residents receiving [MEDICATION NAME] to ensure most recent labs had been drawn as ordered. New procedures for ensuring orders were sent to and received by the lab, placed on the Medication Administration records and lab results documented were put in place and staff was inserviced. Ongoing monitoring will occur. Even though the facility's corrective action removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with the potential for more than minimal harm that is not an Immediate Jeopardy. 3.1-49(a)