Every finding on record at Harrison Healthcare Center

Based on observation, interview and record review, the facility failed to ensure a resident with a history of Urinary Tract Infections (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system off the floor for 2 of 5 residents reviewed for bowel and bladder. (Residents 71 and 86)Findings include:1. During an observation, on 1/22/26 at 9:30 a.m., Resident 71's urinary catheter bag was resting on the floor next to the resident's left side of the recliner. During an observation and interview, on 1/22/26 at 12:17 p.m. Resident 71's urinary catheter bag was on the floor next to the resident's right side of the recliner. The Director of Nursing (DON) was present in the room and indicated the resident moved the catheter bag on his own. The record for Resident 71 was reviewed on 1/26/26 at 8:15 a.m. The diagnoses included, but were not limited to, retention of the urine, benign prostatic hyperplasia (BPH) (enlargement of the prostate gland), with lower urinary tract symptoms, obstructive and reflux uropathy (blockage of the urinary tract and backward flow of urine), and hematuria (blood in urine). The Comprehensive Minimum Data Set (MDS) assessment, dated 1/15/26, indicated the resident was severely cognitively impaired. The care plan, dated 11/24/25 and revised 1/22/26, indicated the resident had an indwelling urinary catheter related to obstructive and reflux uropathy, BPH, urinary retention, and hematuria. Dated 1/22/26, the resident moved the catheter bag at times due to being fidgety. The interventions, dated 11/17/25, staff were to ensure the securement device was in place. The resident's care plan lacked interventions related to the resident moving the catheter bag onto the floor. The physician's order, dated 11/25/25, indicated to secure the indwelling catheter tubing using anchoring device to prevent movement and urethral traction. The nurse's note, dated 12/17/25 at 1:45 p.m., indicated the NP reviewed the 12/4/25 urinalysis. A new order was received for Bactrim. The nurse's note, dated 12/17/25 at 5:19 p.m., indicated the resident's catheter bag had blood in the urine. The resident had blood off and on in the urine since admission. The NP was aware. 2. During an observation on 1/22/26 at 9:40 a.m., the bottom of the Resident 86's urinary catheter bag was resting on the floor. During an observation on 1/23/26 at 9:15 a.m., the bottom of the catheter sitting on the floor attached to the bed rail. The record for Resident 86 was reviewed on 1/26/26 at 9:15 a.m. The diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder (nerve damage which disrupts brain-bladder communication), and chronic kidney disease (progressive and long-term condition where kidneys become damaged and lose ability to filter waste). The nurse's note, dated 7/3/25 at 9:30 a.m., indicated the resident's urinary catheter was found lying beside the resident in her bed. The resident did not know what happened. The urinary catheter was replaced without difficulty. There was clear yellow urine in the bedside drainage bag. The nurse's note, dated 7/24/25 at 12:33 a.m., indicated the resident's urinary catheter had come out and the resident was unsure how it happened. A new 18 French urinary catheter was placed without difficulty. Cloudy dark yellow urine was observed without odor. The nurse's note, dated 11/7/25 at 11:45 p.m., indicated the resident was treated at a local hospital for an admitting diagnosis of a UTI. The physician's order, dated 1/14/26, indicated to monitor the urinary catheter to ensure a privacy bag and catheter leg strap were in place at all times. The physician's order, dated 1/14/26, indicated to secure the urinary catheter tubing and was anchored to prevent movement and urethral traction. The resident's clinical record lacked documentation of a care plan for the indwelling urinary catheter. During an interview, on 1/29/26 at 11:33 a.m., the DON indicated if staff saw the urinary catheter bag on the floor, staff should have placed the catheter bag in a washbasin or had a barrier to prevent infection from bacteria. The current Catheter Drainage Bag and Tube Maintenance policy, included, but was not limited to, . i. Drainage bags will not be placed on the floor . 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure a staff member followed the policy and procedure when administering narcotics for 1 of 4 residents reviewed for pharmaceutical services. (Resident B). Findings include:The clinical record for Resident B was reviewed on 1/28/26 at 11:00 a.m. The resident's diagnoses included, but were not limited to, rheumatoid arthritis with rheumatoid factor (an autoantibody found in patients with rheumatoid arthritis often signaling a more sever, aggressive, and erosive form of the disease), spinal stenosis (narrowing of the spinal canal causing increased pressure on the spinal cord and nerves), and primary osteoarthritis (degenerative joint disease characterized by the progressive breakdown of articular cartilage).A facility document, titled Individual Resident's Controlled Substance Administration Record, dated 10/10/25, indicated the form was for Resident E (a family member) of Resident B. The Morphine Sulfate (Concentrate) Oral Solution 100 milligrams (mg)/5 milliliter (ml) was signed out on the narcotic sheet on the following date and times with a handwritten note on this record that indicated Given to Resident B.-10/17/25 at 2:00 p.m.-10/17/25 at 5:30 p.m.The care plan, dated 10/17/25, indicated the resident was on hospice service. The interventions, dated 10/17/25, included, but were not limited to, administer medications according to the medical provider's orders and report abnormal findings to medical provider, resident representative, and hospice company; offer emotional support to the resident regarding choices with treatment; and administer non-pharmacological interventions and evaluate the effectiveness of interventions.A physician's order, dated 10/17/26, indicated the resident could have Morphine Sulfate (Concentrate) Oral Solution 100 milligrams (mg)/5 milliliter (ml). The resident was to receive 0.25 ml by mouth every hour as needed.The record lacked documentation of the family being notified that Resident B was given Resident E's Morphine until his medication supply arrived.During an interview, on 1/23/26 at 9:30 a.m., Registered Nurse (RN) 8 indicated that Resident B's family member had already been signed up for hospice with her medications brought in from home. Resident B signed up for hospice on 10/17/25 and needed pain medication. His medication had not arrived at the facility. RN 8 called the family member of both residents to get permission to give Resident E's medication to Resident B. The family member agreed and the medication was given to Resident B. RN 8 called the Director of Nursing (DON) to make her aware of his actions.During an interview, on 1/28/26 at 11:50 p.m., Licensed Practical Nurse (LPN) 9 indicated that if she needed liquid oral Morphine for a resident with a new physician order. A code would be requested through the Emergency Drug Kit (EDK), and the pharmacy will then text a code to obtain the medication. The LPN indicated that being a hospice patient did not affect how a new medication was obtained and should always be taken out of the EDK if it has not arrived at the facility.During an interview, on 1/29/26 at 11:25 a.m., the DON indicated that Resident B did not run out of Morphine, but that the Morphine was a new order on 10/17/25 due to the resident being newly enrolled in a hospice company. RN 8 was on duty and had called the family for permission to use the bottle of morphine brought from home for Resident E. The family member wanted Resident B to have a dose of Morphine from Resident E's bottle. The RN gave the medication without contacting leadership.A current facility policy, titled Medication Administration, dated 2013, and provided by the Executive Director on 1/29/26 at 1:00 p.m. The policy indicated, .Policy: The purpose of this policy is to provide guidance for general medication administration.1. f Observe the five rights in giving medication. I. the right resident.1. y Do not share or borrow medications from others. This citation relates to Intake 2648076 3.1-25 (a)3.1-25 (b)(1)3.1-25 (c)

Based on interview and record review, the facility failed to follow medication administration parameters for a resident's (Resident M) blood pressure for 1 of 3 residents reviewed for quality of care. Findings include:The clinical record for Resident M was reviewed on 8/6/25 at 12:02 p.m. The resident's diagnosis included, but was not limited to, hypertension.The physician's order, dated 6/17/25, indicated the resident was to receive metoprolol (medication for high blood pressure) 25 mg (milligrams) two times a day in the morning and in the evening. The medication was to be held if the resident's systolic blood pressure (SBP) was less than 120.Review of the June 2025 and July 2025 medication administration record indicated the medication was administered on the following dates and times:-On 6/24/25 in the evening, the metoprolol was administered when the resident's SBP was 94-On 6/25/25 in the evening, the metoprolol was administered when the resident's SBP was 115-On 7/01/25 in the evening, the metoprolol was administered when the resident's SBP was 112-On 7/06/25 in the morning, the metoprolol was administered when the resident's SBP was 114-On 7/08/25 in the morning, the metoprolol was administered when the resident's SBP was 104-On 7/08/25 in the evening, the metoprolol was administered when the resident's SBP was 112-On 7/09/25 in the morning, the metoprolol was administered when the resident's SBP was 105-On 7/09/25 in the evening, the metoprolol was administered when the resident's SBP was 112-On 7/10/25 in the evening, the metoprolol was administered when the resident's SBP was 109-On 7/12/25 in the morning, the metoprolol was administered when the resident's SBP was 117-On 7/14/25 in the evening, the metoprolol was administered when the resident's SBP was 119-On 7/16/25 in the morning, the metoprolol was administered when the resident's SBP was 108-On 7/22/25 in the morning, the metoprolol was administered when the resident's SBP was 112-On 7/24/25 in the evening, the metoprolol was administered when the resident's SBP was 112-On 7/29/25 in the evening, the metoprolol was administered when the resident's SBP was 107-On 7/30/25 in the morning, the metoprolol was administered when the resident's SBP was 107During an interview, on 8/6/25 at 2:43 p.m., Licensed Practical Nurse (LPN) 6 indicated if a resident's blood pressure was out of parameters, the resident's medication should not be administered.On 8/6/25 at 1:28 p.m., the Director of Nursing provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, Medication Administration Record .the legal documentation for medication administration .Policy .It is the policy of this facility to provide resident centered care that meets the .physical .needs .of the residents. Safety of residents .is a top priority .Procedure .Administer medication only as prescribed by the provider This Citation relates to Complaint 1274774.3.1-37

Based on interview and record review, the facility failed to ensure a resident (Resident B) was provided catheter care every shift for 1 of 4 residents reviewed for Indwelling catheters.Findings include:The clinical record for Resident B was reviewed on 8/5/25 at 10:01 a.m. The resident's diagnoses included, but were not limited to, acute kidney failure and obstructive and reflux uropathy.The care plan, dated 6/20/25, indicated the resident had an Indwelling catheter and staff were to provide catheter care every shift.Review of the June 2025 Interventions and Tasks lacked documentation of Indwelling catheter care for Resident B from 6/11/25 through 6/13/25 during night shift.During an interview, on 8/6/25 at 2:43 p.m., Licensed Practical Nurse (LPN) 6 indicated catheter care should be provided every shift.On 8/6/28 at 1:28 p.m., the Director of Nursing provided a current, undated copy of the document titled Catheter Care. It included, but was not limited to, Policy.It is the policy of this facility to provide resident care that meets the.needs.of the residents.Catheter care is performed at least twice daily on residents that have indwelling catheters, for as long as the catheter is in place.This Citation relates to Complaint 12747743.1-41(a)(2)

Based on observation, interview and record review, the facility failed to ensure respiratory assessments were completed for a resident and failed to ensure respiratory equipment was changed weekly for 1 of 3 residents reviewed for respiratory care. (Resident D)Findings Include: On 8/5/25 at 11:40 a.m., a nebulizer machine was observed at Resident D's bedside. The handheld mouthpiece was not bagged or dated.The clinical record for Resident D was reviewed on 8/5/25 at 11:16 a.m. The resident's diagnoses included, but were not limited to, anxiety and cough.The physician's order, dated 6/2/25, indicated the resident was to receive Duoneb Solution 0.5-2.5 (3) mg (milligram)/3 ml (milliliters) via nebulizer twice daily at 8:00 a.m. and 8:00 p.m. Review of the June, July, and August 2025 medication administration records, the resident had received the breathing treatments twice daily at the ordered times.The clinical record lacked documentation of a respiratory assessment before and after the breathing treatments and weekly replacement of the nebulizer tubing, chamber and mouthpiece.During an interview, on 8/6/25 at 10:20 a.m., Licensed Practical Nurse (LPN) 8 indicated the nebulizer tubing should be dated and bagged when not in use and respiratory equipment was replaced weekly on Wednesdays. During an interview, on 8/6/25 at 10:55 a.m., the Director of Nursing (DON) indicated respiratory assessments were completed before and after breathing treatments to assess for the effectiveness of the resident's treatment.During an interview, on 8/6/25 at 11:03 a.m., the DON indicated Resident D did not have respiratory assessments in place. She would add the order today.On 8/6/25 the DON provided a current, undated copy of the document titled Nebulizer Treatments. It included, but was not limited to, Nebulizer.A medication delivery system that creates a fine mist or aerosol that is directly inhaled for delivery of the medication to the bronchial tree.Policy.It is the policy of this facility to provide resident-centered care.Safety of residents.is a top priority.Preparation to provide treatment.Collect data for respirations, pulse, oxygen saturation and lung sounds pre-treatment.Repeat collection of data for respirations, pulse, oxygen saturation and lung sounds post-treatment.This Citation relates to Complaint 1274774.3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a resident's (Resident E) medication administration record accurately reflected the administration of narcotic pain medication for 1 of 4 residents reviewed for medication administration.Findings Include:The clinical record for Resident E was reviewed on 8/5/25 at 1:58 p.m. The resident's diagnoses included, but was not limited to, right upper arm pain and low back pain.The July 2025 medication administration record indicated the resident was to receive Oxycodone (narcotic pain medication) IR (immediate release) 5 mg (milligrams) every 6 hours as needed for pain management.The July 2025 controlled drug record indicated the resident received the medication on the following dates and times:-7/04/25 at 6:00 p.m.-7/05/25 at 12:00 a.m., 6:00 a.m. and 6:00 p.m.-7/06/25 at 12:00 a.m., 11:30 a.m. and 6:00 p.m.-7/07/25 at 12:00 a.m. and 6:00 a.m.-7/08/25 at 12:00 a.m., 8:15 a.m., 2:15 p.m. and 8:15 p.m.-7/09/25 at 2:15 a.m. and 10:00 p.m.-7/10/25 at 4:00 a.m., 10:00 a.m. and 11:30 p.m.-7/11/25 at 11:30 p.m.-7/12/25 at 5:00 a.m. and 8:00 p.m.-7/13/25 at 2:00 a.m., 9:00 a.m. and 9:30 p.m.-7/15/25 at 9:30 p.m.-7/16/25 at 9:00 a.m.-7/16/25 at 8:00 p.m.-7/17/25 at 3:00 a.m., 4:40 p.m. and 8:00 p.m.-7/20/25 at 9:00 a.m. and 10:00 p.m.-7/21/25 at 5:00 a.m., 10:30 a.m. and 4:00 p.m.-7/22/25 at 11:00 p.m.-7/23/25 at 5:15 a.m. and 7:00 p.m.-7/24/25 at 2:00 a.m., 8:00 a.m., 2:00 p.m. and 8:00 p.m.On 7/24/25, the resident's Oxycodone IR 5 mg was discontinued and a new order was received for Oxycodone IR 5 mg every 4 hours as needed for pain was implemented.Review of the July and August 2025 controlled drug administration record indicated the resident's narcotic medication was administered on the following dates and times:-7/25/24 at 2:00 a.m., 6:30 a.m. and 10:30 p.m.-7/29/25 at 8:00 p.m.-7/30/25 at 4:00 a.m., 8:30 a.m., 12:30 p.m. and 4:30 p.m.-8/01/25 at 8:00 a.m., 12:30 p.m. and 4:30 p.m.-8/02/25 at 10:00 p.m.-8/03/25 at 2:00 a.m., 6:00 p.m. and 10:00 p.m.-8/04/25 at 2:00 a.m., 6:30 a.m., 10:50 a.m. and 4:00 p.m.The resident's July and August 1 through 4, 2025 medication administration record lacked documentation of the administration of the resident's medication.During an interview, on 8/6/25 at 2:43 p.m., Licensed Practical Nurse (LPN) 6 indicated when administering a routine or as needed narcotic pain medication, both the controlled drug administration record and medication administration record should be signed by the nurse.On 8/6/25 at 1:28 p.m., the Director of Nursing provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, MAR: Medication Administration Record - the legal documentation for medication administration.Policy.It is the policy of this facility to provide resident centered care.Procedure.Medications will be charted when given.Narcotics will be signed out when given.This Citation relates to Complaint 12747743.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure oxygen concentrator filters were placed and maintained for 5 of 11 residents reviewed for respiratory care. (Residents 9, 14, 32, 45, 61) Findings include: 1. During an observation on 12/12/24 at 9:57 a.m., Resident 9's oxygen concentrator filter was 100% heavily covered with a white powdery substance. The oxygen tank's concentrator filter was pushed against the outer wall of the room. During an observation on 12/13/24 at 12:34 p.m. with the Director of Nursing (DON), the resident's oxygen concentrator filter was 100% (percent) heavily covered with a white powdery substance. The oxygen tank's concentrator filter was pushed against the outer wall of the room. The record for Resident 9 was reviewed on 12/17/24 at 8:14 a.m. The resident's diagnoses included, but were not limited to, emphysema, chronic obstructive pulmonary disease (COPD), malignant cancer of the bronchus or lung, and anxiety disorder. The physician's order, dated 1/19/22, indicated staff were to administer oxygen at 2.5 liters via nasal cannula, continuously and as needed every shift for shortness of breath. The Annual Minimum Data Set (MDS) assessment, dated 2/28/24, indicated the resident was moderately cognitively impaired. The resident required oxygen therapy. The care plan, revised 10/23/24, indicated the resident had oxygen therapy related to ineffective gas exchange, hypoxia, and COPD. The interventions, dated 12/13/21, indicated to administer 2.5 liters by nasal cannula for hypoxia and COPD diagnoses: Monitor for signs and symptoms of respiratory distress; and report to the MD (physician) PRN (as needed). The Nurse Practitioner (NP) note, dated 7/17/24 at 1:00 a.m., indicated therapy had informed her that the resident's O2 saturation was in the 70's on 4 liters of oxygen, per nasal cannula. She was usually on 2 liters. The resident was sitting in her wheelchair at the table in the gym doing some hand and arm exercises. She admitted to feeling short of breath and more tired. Her O2 (oxygen) saturation on the oximeter was 79%. Therapy increased the oxygen to 5 liters. A new machine was used to check the O2 saturation, and it indicated 96%. The resident's respiratory rate and pulse rate were slightly elevated. The physician's order, dated 10/23/24, indicated staff were to clean the oxygen concentrator filter with soap and water weekly and PRN (as needed) every day shift every Tuesday and Sunday and as needed for O2 care. The December 2024 Treatment Administration Record (TAR) indicated the oxygen concentrator filter was last cleaned on 12/10/24 by Licensed Practical Nurse (LPN) 6. During an interview on 12/13/24 at 1:50 p.m., the DON indicated the Patient Resident Scheduler 7 was responsible for cleaning the oxygen concentrator filters in the building. She also was responsible for documenting the cleaning of the filters in the TAR (Treatment Administration Record). During an interview on 12/13/24 at 2:00 p.m., Patient Resident Scheduler 7 indicated she normally cleaned the filters on Wednesdays. She was behind and didn't get to the filters until 12/12/24. She thought she had cleaned Resident 9's oxygen concentrator filter. Upon seeing the filter, she pulled it out of the concentrator and cleaned it in the resident's bathroom without hand hygiene or gloves. She indicated she must have just missed cleaning it. She felt that the heavy buildup of the white powdery substance was because the filters just became that way, quickly sometimes. It could have also been due to the filters being wet when she placed it back into the oxygen concentrators. The oxygen concentrator filters should be cleaned regularly, because the substance went into the resident's oxygen supply, and she didn't want it to do that. 2. During an observation on 12/12/24 at 9:19 a.m., Resident 14's oxygen concentrator filter was moderately covered at the corners with a white powdery substance. The record for Resident 14 was reviewed on 12/16/24 at 2:04 p.m. The resident's diagnoses included, but were not limited to, solitary pulmonary nodule, pulmonary embolism, heart failure, atherosclerotic heart disease, cardiac arrhythmia, anxiety disorder, and hospice care. The Annual MDS assessment, dated 4/27/24, indicated the resident was cognitively intact. The care plan, last reviewed 10/4/24, indicated the resident had congestive heart failure (CHF) with or without difficulty breathing. The interventions, dated 10/21/21, indicated to elevate the head of the bed as needed, for ease of breathing and monitor vitals; report abnormal findings to medical provider, resident or resident representative; observe for signs or symptoms of CHF; report any abnormal findings to medical provider, resident or resident representative; report resident complaints of chest pain to the medical provider, resident or resident representative; and dated 10/23/24 provide hospice services. The physician's order, dated 10/15/24, indicated to wean the resident off of O2. Check the O2 saturation every six hours. If the O2 saturation was greater than 90%, remove the oxygen and if the resident maintained at greater than 90% after five minutes, leave off. If the O2 saturations dropped to less than 90%, keep the oxygen on. Check the oxygen every six hours. The physician's orders and December TAR lacked documentation for staff to clean the oxygen concentrator filters. The nurse's note, dated 11/25/24 at 2:52 p.m., indicated a Certified Nurse Aide (CNA) reported that Resident 14 passed out when transferring to her wheelchair. Upon assessment, the resident was minimally responsive to verbal stimuli but was able to track the nurse with her eyes. After approximately 30 seconds, the resident became more alert, and close to baseline. Her vital signs were obtained and were within normal limits. The hospice nurse was in the room and assisted the resident to bed with the assistance of two staff members. Once abed, the resident complained of chest pain to the hospice nurse. The PRN nitroglycerin was administered once and was effective with no further complaints voiced. 3. During an observation on 12/12/24 at 9:38 a.m., Resident 32's oxygen concentrator filter was moderately coated at the corners with a white powdery substance. The record for Resident 32 was reviewed on 12/17/24 at 10:14 a.m. The resident's diagnoses included, but were not limited to, COPD, heart failure, insomnia, and morbid obesity due to excess calories. The physician's order, dated 6/15/23, indicated to administer oxygen at 3 liters per minute via nasal cannula, continuously every shift for shortness of breath and as needed for shortness of breath. The physician's order, dated 6/18/23, indicated to clean the oxygen concentrator filter with soap and water weekly and PRN in the morning every Sunday for O2 care. The Quarterly MDS assessment, dated 6/18/24, indicated the resident was cognitively intact. The resident required oxygen therapy. The care plan, last reviewed 10/1/24, indicated the resident had oxygen therapy related to COPD and hypoxia. The interventions, dated 10/6/20 and revised 1/5/21, indicated to monitor for signs and symptoms of respiratory distress and report to the MD, PRN; dated10/6/20 and revised 8/29/22, the resident had O2 via nasal prongs at 3 liters continuously, humidified; dated 10/6/20 provide reassurance and allay anxiety; have an agreed-on method for the resident to call for assistance (e.g., call light, bell); and stay with the resident during episodes of respiratory distress. The December TAR indicated the oxygen concentrator filter was cleaned on 12/8/24 by LPN 6. 4. During an observation on 12/12/24 at 9:45 a.m., Resident 45's bilateral oxygen concentrator filters were both 100% heavily coated with a white powdery substance. The record for Resident 45 was reviewed on 12/16/24 at 9:20 a.m. The resident's diagnoses included, but were not limited to, old myocardial infarction, COPD, morbid obesity due to excess calories, atherosclerotic heart disease with unstable angina pectoris, anxiety disorder, adult failure to thrive, altered mental status, vascular dementia, anxiety, and seizures. The physician's order, dated 3/15/23, indicated to clean the oxygen concentrator filter with soap and water weekly and PRN every day shift every Wednesday for O2 care. The Annual MDS assessment, dated 2/28/24, indicated the resident was moderately cognitively impaired. The resident required oxygen therapy. The nurse's note, dated 6/9/24 at 12:25 a.m., indicated the resident experienced occasions of shortness of air with exertion. The care plan, dated 11/26/24, indicated the resident had oxygen therapy related to ineffective gas exchange and hypoxia. The interventions, dated 3/9/23, indicated to administer 2 liters by nasal cannula for hypoxia and COPD; dated 10/23/24 encourage or assist the resident with ambulation as indicated; and dated 3/9/23 monitor for signs or symptoms of respiratory distress and report to the MD. The December TAR indicated the resident's oxygen concentrator filter was last cleaned on 12/11/24 by RN 4. 5. During an observation on 12/12/24 at 9:27 a.m., Resident 61's bilateral oxygen concentrator filters were moderately coated with a white powdery substance. The record for Resident 61 was reviewed on 12/17/24 at 10:59 a.m. The resident's diagnoses included, but were not limited to, emphysema, personal history of transient ischemic attack and cerebral infarction, paranoid schizophrenia, anxiety disorder, and a personal history of venous thrombosis and embolism. The physician's order, dated 1/1/24, indicated to administer O2 at 2 liters for O2 saturations of less than 90 and/or shortness of air, every 12 hours as needed for hypoxia. The Annual MDS assessment, dated 8/5/24, indicated the resident was cognitively intact. The nurse's note, dated 8/31/24 at 11:25 a.m., indicated the resident complained of chest pain, which had started prior to the nurse taking over the hall at 11:00 a.m. The resident was administered nitroglycerin. When the nurse entered the room, the resident was nauseated, and his oxygen was on the floor. The nasal cannula was applied at 2 liters per minute. His vital signs were a blood pressure of 190/102 mg/dL, a pulse of 103 beats per minute, and oxygen saturations of 90% on 2 liters of oxygen. His respirations were at 20. The resident was yelling for help during the documentation by the nurse. Two nitroglycerin tablets were administered while the nurse was typing the note. The nurse's note, dated 9/25/24 at 11:30 a.m., indicated new orders were received to obtain a STAT (urgent) chest x-ray related to wheezing. The physician's order, dated 10/23/24, indicated to clean the oxygen concentrator filter every 7 days and PRN, every day shift on Wednesday. The care plan, reviewed 11/19/24, indicated the resident received oxygen therapy related to ineffective gas exchange and hypoxia. The interventions, dated 5/30/24 and revised 10/23/24, included, but was not limited to, 2 liters of O2 by nasal cannula, as needed routinely, for hypoxia and emphysema diagnoses; and dated 5/30/24 monitor the resident for signs or symptoms of respiratory distress and report to the MD, PRN. The December TAR indicated the resident's oxygen concentrator filter was last cleaned on 12/11/24 by LPN 5. The current Oxygen Therapy Using Concentrators policy included, but was not limited to, . Care and Maintenance a. Filters and maintenance are to be cleaned once a week .Perform hand hygiene and don gloves. ii. Remove filter .Rinse with running water until clean. iv. Squeeze water from filter .Dry with towel (cloth or paper) .Replace filter . 3.1-47(a)(6)

Based on record review and interview, the facility failed to follow physician's order with obtaining laboratory services for 2 of 5 residents reviewed for laboratory services. (Residents 25 and 14) Findings include: 1. The clinical record for Resident 25 was reviewed on 12/16/24 at 11:32 a.m. A Quarterly Minimum Data Set (MDS) assessment, dated 12/4/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, seizures, hypertension, anxiety, depression, and bipolar. A current physician's order, with a start date of 7/1/24, indicated the staff were to obtain a Complete Blood Count (CBC), Complete Metabolic Panel (CMP), Oxcarbazepine level, Keppra level, A1C (average blood sugar over three months, thyroid stimulating hormone (TSH), Vitamin D level, and Vitamin B-12 level every three months, starting on 7/1/24. The resident's record lacked documentation of a CMP, A1C, TSH, Vitamin D, and Vitamin B-12 in July 2024. The resident's record lacked documentation of a CBC, CMP, Oxcarbazepine level, Keppra level, A1C, TSH, Vitamin D level, and Vitamin B-12 level, in October 2024. An open-ended physician's order with a start date of 11/13/24, indicated the staff were to obtain a CBC, CMP, Oxcarbazepine level, Keppra level, A1C, TSH, Vitamin D level, and Vitamin B-12 level every three months, starting on 11/13/24. The resident's record lacked documentation of an Oxcarbazepine level in November 2024. During an interview on 12/18/24 at 9:54 a.m., Licensed Practical Nurse (LPN) 10 indicated when the Nurse Practitioner ordered labs (laboratory tests) for a resident, she would input the order herself. The nurse would be alerted that there was a pending order for the residents. The nurse would have to transcribe the labs into the lab courier system for them to come and obtain the laboratory tests. The lab company would come Monday through Friday to obtain labs. Once the labs were obtained and taken to the lab, the lab company would post the results in the resident's clinical record and send them a fax. If the labs were urgent, then the facility nurse would call the Nurse Practitioner. If they were not urgent, she would review them on her next visit. The Nurse Practitioner was in the facility Monday through Friday. The labs were obtained based on how the nurse put the order into the lab companies' system. During an interview on 12/18/24 at 11:13 a.m., the Director of Nursing (DON) indicated the resident's labs were not completed per the physician's order. There were no labs obtained in October and a new order was placed in November. 2. The clinical record for Resident 14 was reviewed on 12/13/24 at 10:05 a.m. A Significant Change Minimum Data Set (MDS) assessment, dated 9/29/24, indicated the resident was cognitively intact. The residents' diagnoses included, but were not limited to, cardiorespiratory conditions, atrial fibrillation, heart failure, and hypertension. The resident had received an anticoagulant during the assessment review period. An open-ended physician order, with a start date of 9/21/24, indicated the resident was to receive Warfarin (Coumadin, a blood thinning medication) 2 milligrams (mg), on Tuesday, Wednesday, Saturday, and Sunday for arterial fibrillation. An open-ended physician's order, with a start date of 9/21/24, indicated the resident was to receive Coumadin 2.5 mg, on Monday, Thursday, and Friday for arterial fibrillation. A Progress Note, dated 11/8/24 at 2:11 P.M., indicated the resident's physician was notified of the International Normalized Ratio (INR) results. A new order was obtained for Coumadin 2 mg, every day and the resident's INR was to be rechecked on 11/15/24. The resident had an INR level drawn on 11/22/24. The clinical record lacked indication that the physician was notified of the result, nor was there an order in place for another INR until 12/13/24. The Coumadin Anticoagulation Record, indicated the following: - 11/8/24, new dose of 2 mg daily, and recheck INR on 11/22/24, - 11/22/24, no change in dose, and recheck INR on 12/16/24. During an interview on 12/13/24 at 9:57 A.M., Licensed Practical Nurse (LPN) 9 indicated if a resident received Coumadin and had to get an INR level drawn, then there should be an order for that to be obtained. The INR result should be reviewed by the physician before the next scheduled dose of the medication. During an interview on 12/13/24 at 10:17 A.M., the Director of Nursing (DON) indicated the resident's coumadin order didn't get changed on 11/8/24 and the order and INR order should have been confirmed with the physician on 11/22/24. The current, undated, facility policy titled, Warfarin Monitoring was provided by the DON on 12/17/24 at 1:20 P.M. The policy indicated, .The prescriber/physician will provide an order for INR monitoring for warfarin use .The facility will have an established communication method between the facility and the prescriber/physician for monitoring residents on the drug Warfarin .The nurse will update the log with new INR values, and adjusted doses as the medical order changes and lab values are known .The nurse will change the eMAR [Electronic Medication Administration Record] to reflect the new dose of Warfarin The nurse will discontinue the previous dose of Warfarin in eMAR . The current, undated, facility policy, titled Laboratory and Radiological Services and Results Reporting, was provided by the DON on 12/18/24 at 11:50 a.m. The policy indicated, .The facility will secure laboratory and radiological services that meet the needs of the resident population served . 3.1-49(a)

Based on observation, record review and interview, the facility failed to respect the dignity of residents related to ensuring the urine side of the indwelling catheter bag was not in sight of those who passed by a resident's room and to ensure a staff member spoke to a resident in a dignified manner for 2 of 20 residents reviewed for Resident Rights. (Residents 283 and 34) Findings include: 1. During an observation on 12/12/24 at 10:00 a.m., Resident 283's indwelling catheter bag was not in a dignity bag and hanging off the right side of the resident's bed. The bag showed clear urine in the bag visible from the hallway. During an observation on 12/12/24 at 12:43 p.m., the resident's indwelling catheter bag was not in a dignity bag and hanging off the right side of the resident's bed. The bag showed clear urine in the bag visible from the hallway.the catheter bag was hanging off the right side of the bed which showed the clear urine side of the bag. There was urine in the bag. During an observation on 12/12/24 2:15 p.m., the resident's indwelling catheter bag was not in a dignity bag and hanging off the right side of the resident's bed. The bag showed clear urine in the bag visible from the hallway.the catheter bag was hanging off the right side of the bed which showed the clear urine side of the bag. There was urine in the bag. During an observation on 12/13/24 10:15 a.m., the resident's indwelling catheter bag was not in a dignity bag and hanging off the right side of the resident's bed. The bag showed clear urine in the bag visible from the hallway.the catheter bag was hanging off the right side of the bed which showed the clear urine side of the bag. There was urine in the bag. During an observation on 12/16/24 10:15 a.m., the resident's indwelling catheter bag was not in a dignity bag and hanging off the right side of the resident's bed. The bag showed clear urine in the bag visible from the hallway.the catheter bag was hanging off the right side of the bed which showed the clear urine side of the bag. There was urine in the bag. On 12/17/24 at 10:25 a.m., the resident's indwelling catheter bag was visible on the left side of the resident's bed. The indwelling catheter bag was without a dignity cover. The resident's urine was visible in the bag. The record for Resident 283 was reviewed on 12/13/24 at 10:00 a.m. The resident's diagnoses included, but were not limited to, immobility syndrome (paraplegic), malignant neoplasm of the prostate, and obstructive uropathy. During an interview on 12/17/24 at 11:10 a.m., CNA (Certified Nursing Aide) 2 indicated the resident was confused, required extensive assist of two staff members for transfers and bed mobility. He had an indwelling catheter and was incontinent of bowel. A physician's order, dated 12/11/24, indicated staff were to ensure the indwelling urinary catheter was in a privacy bag and catheter leg strap was on at all times A care plan, dated 12/13/24, indicated the resident had an indwelling catheter due to urinary retention and a malignant neoplasm of the prostate. The interventions included, but were not limited to, ensure securement device in place and provide catheter care every shift and PRN (as needed). During an interview on 12/17/24 at 11:17 a.m., CNA 2 indicated all residents whom had an indwelling catheter were supposed to have them in a privacy bag or be covered at all times to protect the resident's privacy. If a resident did not have a privacy bag staff were supposed to let the nurse know so she could get them one. During an interview on 12/17/24 at 11:20 a.m., LPN (Licensed Practical Nurse) 3 indicated residents with indwelling catheters were supposed to have them in some sort of protective covering so people couldn't see the urine. If the resident did not have a privacy bag, then nursing staff should have been notified to get them one. During an interview with the Director of Nursing (DON) on 12/17/24 at 1:17 p.m., she indicated any resident with an indwelling catheter should have a dignity cover on it. If the resident did not have a dignity cover then staff were to get them one. 51675 2. The record for Resident 34 was reviewed on 12/16/24 at 10:44 a.m The residents' diagnoses included, but were not limited to, bipolar disorder, severe with psychotic features; dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; major depressive disorder, recurrent, severe with psychotic symptoms; personal history of suicidal behavior; immobility syndrome, and falls. The care plan, dated 11/26/24, indicated the resident was prescribed mood stabilizing medication related to behavior management. The interventions, dated 11/26/24, included, but were not limited to, provide mood-stabilizing medication per the medical provider's orders, provide a calm environment and limit over stimulation, encourage the resident to voice feelings, discuss coping skills, and maintain consistent daily routine when possible. A Progress Note, dated 12/4/2024 at 16:48 p.m., indicated that a staff member was overheard cursing in Resident 34's room. There was no distress noted to the resident and the physician, ED (Executive Director), DON (Director of Nursing), and family were made aware of the incident. During an interview on 12/16/24 at 10:08 a.m., the DON indicated an incident had occurred on 12/04/24 involving Resident 34. LPN 12 had gone to complete an assessment on Resident 34 due to CNA 13 reporting a change in condition. The LPN found the resident was asleep and attempted to complete a set of vital signs. Resident 34 was startled with a male nurse in the room. Resident 34 started to be combative with the LPN and the LPN had told her to shut up. The LPN was suspended, pending investigation. He would return that day (12/16/24) to complete education on Abuse and Burnout education. During a phone interview on 12/17/24 at 10:25 a.m., LPN 12 indicated he had been in Resident 34's room to assess a change in condition that had been reported to him. He reported that he did yell back at Resident 34 to Shut the f*** up. He then stated that he had been asked to leave the building. He reported that he had not returned to work and that he completed in-services on customer service, Alzheimer's Dementia and Burn out. During an interview with the Activity Director on 12/17/24 at 10:44 a.m., she indicated hearing LPN 12 curse at Resident 34 while in her room providing care. The Progress Notes for Resident 34 was reviewed on 12/16/24 at 10:44 a.m. The progress notes were dated 10/28/24 through 12/10/24 and indicated the resident had continued to have behaviors, but has had no increase in behaviors, or any new behaviors related to the incident on 12/04/24. On 12/17/24 at 1:20 p.m., the Regional Director of Clinical Operations provided the most current facility policy titled Resident Rights. Review of this policy included, but was not limited to, indicated Scope: The policy is applicable to all adult living centers. Definitions: DIGNITY: a state of worthy of honor or respect: includes but not limited to speaking respectively to the resident, providing privacy for care and treatment, .respecting resident choice and attending to needs in a timely fashion. Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents .The purpose of this policy is to guide employees in the general principles of dignity and respect of caring for residents .Care for residents will be provided in safe and respectful manner that includes care in a private setting, as appropriate .Procedure: 1. Residents will be treated with dignity and respect including but not limited to: .b. iii. Staff will speak respectfully to residents .d. To have their privacy respected . 3.1-3(a) 3.1-3(t)

Based on record review and interview, the facility failed to ensure an appointment was scheduled for the placement of a port for 1 of 1 resident's reviewed for intravenous therapy. (Resident 63) Findings include: The record for Resident 63 was reviewed on 12/17/24 at 9:12 a.m. The resident's diagnoses included, but were not limited to, immobility syndrome (paraplegic), chronic inflammatory demyelinating polyneuritis, and bed confinement. The Admission MDS (Minimum Data Set) assessment, dated 9/27/24, indicated the resident was cognitively intact. The physician's order, dated 10/30/24, indicated a referral to the surgeon for port (venous) placement for intravenous (IV) access. The resident received IgG (Immunoglobulin) infusions long term care related to poor venous access. The care plan, dated 10/30/24, indicated Resident 63 was currently on intravenous therapy for infusion therapy related to chronic inflammatory demyelination. The interventions included, but were not limited to, administer IV medications and flushes per medical provider's orders. Observe for side effects and effectiveness. Report abnormal findings to medical provider, resident and the resident representative. Change the midline dressing 24 hours post insertion and then weekly. Observe for intact sutures. Change the tubing every 72 hours, or as needed. Flush with 10cc (cubic centimeters) of normal saline, followed by 3cc of heparin. Evaluate for signs and symptoms of infection. Obtain and monitor laboratory and diagnostic studies, as ordered. Report abnormal findings to medical provider, resident or resident representative. Visually inspect the midline site each shift and note any bleeding redness, swelling, pain or drainage. The nurse's note, dated 10/28/24 at 5:59 p.m., indicated the resident had a midline placed to the right arm due to the IVIG transfusions. Vascular access indicated the resident needed a port placed if she was going to receive further infusions. The NP was made aware. The Nurse Practitioner (NP) note, dated 10/30/24, indicated the resident reported that her family physician had referred her for a port placement back in August, but it may have been ignored. The NP indicated she called the physician's office and spoke to staff, who indicated that a referral was sent to the physician's office in August. She was kind enough to re-fax that today at her request. The facility scheduler was informed of this and asked to follow up with the surgeon's office later that day or tomorrow. She was to ensure they received it and if an appointment was scheduled. The resident would keep the midline in place for now. The staff at the physician's office indicated the resident would be on those infusions for a long time. The nurse's note, dated 10/30/24 at 11:08 a.m., indicated a referral for the resident's port placement was ordered at that time. The scheduler was made aware to proceed with faxing the referral packet. The NP note, dated 11/25/24 at 1:00 a.m., indicated the office was called on 11/23/24 related to red, tender, warm to touch, and slightly puffy around the midline (IV) site. The order was given to remove the midline. During her visit on 11/25/24, the resident's right upper arm was not swollen or warm to touch, but was tender. Her next infusion was the following week and would have to get another midline placed. The scheduler was supposed to call the surgeon's office where the resident was referred for port placement and to get an update on her referral status. The nurse's note, dated 11/29/24 at 1:06 p.m., indicated the resident had a midline placed to the left upper arm by the IV access team. The NP note, dated 12/2/24 at 1:00 a.m., indicated per the facility scheduler, the patient's previous physician was sending a referral for port placement as requested by surgeon's office. The NP was hoping this could be moved along quickly so a port could be placed and no further midlines. During an interview on 12/13/24 at 10:00 a.m., the resident indicated she was supposed to have a port put in but that hasn't happened yet. She thought that was two months ago and she did not understand why she had not seen the doctor for her port placement. She had a blood clot in her right arm. She had a Peripherally Inserted Central Catheter (PICC) line in her left upper arm and she was concerned she would get another blood clot. During an interview on 12/16/24 at 1:20 p.m., Patient Scheduler 7 indicated the resident's insurance company had her primary physician listed as her doctor and the facility had to get a referral from him. She indicated she was working on it. During an interview on 12/16/24 at 1:40 p.m., Business Office Manager (BOM) indicated the resident scheduler would schedule the appointment. The resident already have their Medicaid or Medicare numbers, and a face sheet would be sent with the resident to the appointment. The face sheet had all the information the doctor would need to bill the insurance company. The doctor's name would not need to be on the insurance because all they needed would be the insurance numbers. If the doctor or hospital had any questions, they would call the facility. During an interview on 12/16/24 at 2:11 p.m., the DON indicated she thought the delay had to do with the resident's insurance. Something about the primary physician. She would need to investigate it. During the survey, the DON did not present documentation indicating why the placement of the port was not scheduled as ordered by the physician. During an interview on 12/17/24 at 1:30 p.m., the Regional Director of Clinical Operations (RDCO) indicated it should not have taken months to get an appointment scheduled for the resident's port placement. 3.1-47(a)(2)

Based on record review and interview, the facility failed to follow a physician's order related to hold parameters for insulin for 1 of 6 residents reviewed for Insulin. (Resident 39) Findings include: The clinical record for Resident 39 was reviewed on 12/13/24 at 1:30 p.m A Quarterly MDS (Minimum Data Set) assessment, dated 12/6/2024, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, hypertension, congestive heart failure, and cognitive communication deficit. The resident received insulin for 7 of 7 days during the review period. The current physician's order, with a start date of 8/14/24, indicated the resident was to receive Insulin Aspart Injection Solution 30 units subcutaneously three times a day. The staff were to hold (not administer) the insulin if the resident's blood sugar was less than 150. The October, November, and December 2024 Electronic Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) indicated the Resident received the insulin when their blood sugar was less than 150 on the following dates and times: - 10/01/24 at 12:00 p.m , when the blood sugar was 101, - 10/01/24 at 16:00 p.m., when the blood sugar was 106, - 10/02/24 at 16:00 p.m., when the blood sugar was 132, - 10/03/24 at 12:00 p.m., when the blood sugar was 102, - 10/08/24 at 8:00 a.m., when the blood sugar was 139, - 10/09/24 at 12:00 p.m., when the blood sugar was 146, - 10/09/24 at 16:00 p.m., when the blood sugar was 130, - 10/10/24 at 08:00 a.m., when the blood sugar was 132, - 10/10/24 at 16:00 p.m., when the blood sugar was 135, - 10/15/24 at 8:00 a.m., when the blood sugar was 132, - 10/15/24 at 12:00 p.m., when the blood sugar was 105, - 10/15/24 at 16:00 p.m., when the blood sugar was 131, - 10/16/24 at 8:00 a.m., when the blood sugar was 113, - 10/16/24 at 16:00 a.m., when the blood sugar was 138, - 10/17/24 at 8:00 a.m., when the blood sugar was 113, - 10/19/24 at 12:00 p.m., when the blood sugar was 117, - 10/22/24 at 8:00 a.m., when the blood sugar was 124, - 10/22/24 at 12:00 p.m., when the blood sugar was 119, - 10/22/24 at 16:00 p.m., when the blood sugar was 140, - 10/24/24 at 8:00 a.m., when the blood sugar was 111, - 10/24/24 at 12:00 p.m., when the blood sugar was 117, - 10/24/24 at 16:00 a.m., when the blood sugar was 146, - 10/28/24 at 8:00 p.m., when the blood sugar was 108, - 10/29/24 at 12:00 p.m., when the blood sugar was 119, - 10/30/24 at 8:00 a.m., when the blood sugar was 123, - 10/30/24 at 12:00 p.m., when the blood sugar was 123, - 10/31/24 at 8:00 a.m., when the blood sugar was 124, - 11/05/24 at 08:00 a.m., when the blood sugar was 130, - 11/05/24 at 12:00 p.m. when the blood sugar was 101, - 11/06/24 at 8:00 a.m., when the blood sugar was 113, - 11/06/24 at 12:00 a.m., when the blood sugar was 103, - 11/07/24 at 8:00 a.m., when the blood sugar was 103, - 11/09/24 at 12:00 a.m., when the blood sugar was 135, - 11/13/24 at 12:00 p.m., when the blood sugar was 105, - 11/20/24 at 16:00 p.m., when the blood sugar was 126, - 11/21/24 at 8:00 a.m., when the blood sugar was 118, - 11/21/24 at 12:00 a.m., when the blood sugar was 134, - 11/26/24 at 16:00 a.m. when the blood sugar was 142, -11/27/24 at 8:00 a.m., when the blood sugar was 113, -11/27/24 at 12:00 p.m., when the blood sugar was 108, -12/03/24 at 12:00 p.m., when the blood sugar was 116, and -12/03/24 at 16:00 p.m., when the blood sugar was 101. During an interview on 12/17/24 at 1:33 p.m., Licensed Practical Nurse (LPN) 11 indicated generally, all insulins here had parameters. If a resident had a hold parameter on an insulin, she would obtain the blood sugar and hold the medication per the physician's order. She found no reason to give insulin outside of the physician's ordered parameters. The Nurse Practitioner (NP) or physician should be notified immediately if blood glucose values were below the critical low or high range. The care plan, dated 2/22/2022, indicated the resident had diabetes type II with hyperglycemia, neuropathy, neurologic complication. The interventions, dated 2/22/2022, included, but were not limited to, administer insulin injections per physician's orders, obtain blood sugars per orders, and report abnormal findings to medical provider, resident/resident representative. The current policy included, titled Medication Administration, was provided by the AIT (Administer in Training) on 12/18/24 at 10:52 a.m The policy indicated, .Administer medication only as prescribed by the provider .Observe the five rights in giving each medication that it is the right resident, the right time, the right medicine, the right dose, the right route . 3.1-48(a)(6)

Based on observation and interview, the facility failed to clean air conditioning filters and ensure resident rooms provided a homelike environment for 6 out of 7 rooms observed for environment. (Rooms 107, 109, 111, 215, 306, 309, and 311) Findings include: 1. During an observation on 10/17/24, at 10:48 a.m., in room [ROOM NUMBER], the wallpaper to the left of the air conditioning was observed to be buckled and peeled back from the wall. During an observation on 10/17/24 at 10:58 a.m., in room [ROOM NUMBER], the wall across and at bottom of the second bed was observed with a area that had been cut out and replaced. The area measured 18 inches in length and 3 ft in width. There area directly above and to the left side of where the new wall was placed, was discolored and observed to be pea green/gray in color. On 10/17/24 at 11:15 a.m., the Maintenance Director indicated the wall had mold on it from a water leak from the air conditioner which had only leaked a couple of days. He cut the molded area out last Friday (10/11/24) and placed the new wall either the same day or the following Monday (10/14/24). He wanted the area to dry out before he covered it up. During an observation on 10/17/24 at 1:42 p.m., a dark black substance was observed on the wall, behind the wallpaper, next to the air conditioning unit in room [ROOM NUMBER]. On 10/17/24 at 4:17 p.m., the Maintenance Director was observed to remove the wallpaper from the wall next to the air conditioning unit. The wall was approximately 5 ft wide and 8 feet tall. The bottom of the entire wall was observed with a dark black substance, with the highest area observed to be 2 1/2 feet from the bottom and directly beside the air conditioning unit. Sporadic areas of the dark substance covered the wall up to 5 1/2 feet. The maintenance director indicated he would clean the wall with bleach as it would kill the mold. During an interview on 10/17/24, between 11:00 a.m. and 4:20 p.m., Staff Member 5 indicated the air conditioning unit in room [ROOM NUMBER] had leaked so badly that it seeped under the wall into room [ROOM NUMBER]. It had leaked for months, and they had to put blankets down on the floor and a bath pan under the unit to catch the water to prevent falls. The leakage had been reported to multiple staff and the former ED (Executive Director). The unit had not leaked in a while since it was repaired. 2. During an observation on 10/17/24, between 11:20 a.m. and 11:33 a.m., the following air conditioning filters were observed: - room [ROOM NUMBER], the air filter was observed with a light gray dusting throughout the filter. - room [ROOM NUMBER], there was no air filter in the unit. The inner grill was observed with small clumps of dust throughout. - room [ROOM NUMBER], the air filter was observed with a thick layer of dust. - room [ROOM NUMBER], the air filter was covered with a light layer of dust particles. - room [ROOM NUMBER], the air filter was observed with a thick layer of dust. - room [ROOM NUMBER], the air filter was covered with a thick layer of dust. On 10/17/24 at 11:15 a.m., the Maintenance Director indicated he cleaned the air conditioning filters on one hallway a month. The 100 Hall was last cleaned in July 2024. During an interview on 10/18/24 at 9:16 a.m., the Director of Nursing indicated the air conditioning filters were to be cleaned monthly, facility wide. On 10/18/24 at 9:12 a.m., the facility interim ED provided a copy of the document titled Inspect air filters, clean as needed. It included, but was not limited to, Recurrence .Monthly .Category .HVAC (PTAC [packaged terminal air conditioner]) On 10/18/24 at 11:07 a.m., the interim ED provided an undated copy of the document titled Policy for Inspecting and Cleaning/Changing PTAC Filters in Resident Rooms. It included, but was not limited to, Purpose .The purpose of this policy is to ensure the health and comfort of residents .To promote a safe and comfortable living environment, PTAC filters in resident rooms will be inspected, cleaned, or changed monthly On 10/18/24 at 10:50 a.m., the Director of Nursing provided a current, undated copy of the document titled Resident Rights. It included, but was not limited to, Dignity .at state worthy of honor or respect .includes but not limited to .providing safe .housing This Citation relates to Complaints IN00443927 and IN00444964 3.1-19(a)(4) 3.1-19(f)(5)

Based on observation, interview and record review, the facility failed to maintain a sanitary environment for 2 of 3 Hallways observed. (200 Hall and 300 Hall) Findings include: 1. Upon facility entrance on 6/8/24, between 10:16 a.m. and 10:55 a.m., the following was observed on the 300 Hallway: At 10:27 a.m., in room [ROOM NUMBER], there were 2 towels and a bath blanket on the floor under the heating and air unit in room [ROOM NUMBER]. The bedside commode, across from the 2nd bed, had a dried, speckled brown substance stuck on the commode seat. The substance had a strong odor of stool. The bathroom had an out of order sign posted on it. At 10:36 a.m., room [ROOM NUMBER] had 2 towels on the floor, to the left of the bathroom door. An out of order sign was posted on the bathroom door. There was a strong urine odor in the bathroom and the floor had a puddle of water next to the toilet. A brown substance was observed on the toilet seat and on the floor, to the left of the toilet. The piping from the back of the toilet had been removed and was lying on the the bathroom floor. The trash can by bed 2 was observed out of reach and without a trash bag. There was an empty chocolate milk container, 2 straws, 2 plastic lids, unopened jelly and a snack wrapper next to the bed on the floor. On 6/8/24 at 10:41 a.m., RN (Register Nurse) 5 indicated a sewer pipe had collapsed and plumbers were in the building working on it last night and they were coming back today. She did not work yesterday and was unsure why the bathroom looked like it did. At 10:43 a.m., by room [ROOM NUMBER], there was a large shop vac sitting next to the wall in the hallway. During an interview on 6/8/24 at 11:55 a.m., the Administrator indicated the contractors had left the shop vac in the hallway. At 10:44 a.m., a small puddle of water was observed on the left side of bed 2 with an empty plastic glass on the floor. On bed 2's bed side table, located at the end of the bed, sat a can of air freshener. During an interview on 6/8/24 at 10:55 a.m., the Central Supply Clerk indicated the can of air freshener spray should not have been in the resident's room as it was a chemical. 2. On 6/8/24, between 10:58 a.m. and 11:12 a.m., the following was observed on the 200 Hallway: At 11:00 a.m., bed linens were observed on the floor at the end of bed A in room [ROOM NUMBER]. The resident's bedside commode was next to the bathroom . The commode was observed with urine and toilet paper and a quarter of the way full. During an interview on 6/10/24 at 11:10 a.m., CNA (Certified Nursing Aide) 8 indicated it was not appropriate for soiled linens to be on the floor. Linens should be bagged and placed in the dirty linen container. Bedside commodes, she assumed, should be checked every 2 hours and emptied like a bed check. On 6/9/24 at 12:55 p.m., the Regional Director of Clinical Operations provided a current copy of the document titled Infection Control Practices for Laundry/Linen dated 10/29/13. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .The safety of residents .will be primary consideration This Citation relates to Complaint IN00434995 3.1-19(a)(4) 3.1-19(f)(5) 3.1-19(g)(1)

Based on interview and record review, the facility failed to ensure monitoring was in place for a resident (Resident B) with a chole drain and to ensure the nursing staff followed medication parameters (Resident B, C, D and E) for 4 of 5 residents reviewed for quality of care. Findings include: 1.a. The clinical record for Resident B was reviewed on 6/8/24 at 12:13 p.m. The resident's diagnoses included, but were not limited to, cholecystitis and hypertension. The hospital discharge summary, dated 5/17/24 at 10:36 a.m., indicated the resident had acute cholecystitis with sepsis and discharged with a percutaneous chole tube (drain). The admission assessment, dated 5/17/24 at 2:07 p.m., indicated the resident was admitted with a chole drain to the right side. The progress note, dated 5/17/24 at 1:51 p.m., indicated the resident had a chole drain to the right side of the abdomen with no signs or symptoms of infection observed. The nurse practitioner note, dated 5/20/24 at 12:50 p.m., indicated the resident supposedly admitted with a chole drain in the right side, however, there was only a short suture hanging from her bed. The drain was either accidentally pulled our or it fell out. The clinical record lacked documentation of any monitoring of the resident's chole drain between 5/17/24 at 1:51 p.m. and 5/20/24 at 12:50 p.m. when it was observed not in place by the nurse practitioner. During an interview on 6/10/24 at 10:47 a.m., the Director of Nursing indicated the staff should have been monitoring the resident's drain. 1.b. The physician's order, dated 5/18/24, indicated Resident B was to receive Metoprolol Succinate ER (extended release), 100 mg (milligrams) daily for arrhythmia. Staff were to hold the resident's medication if the resident's systolic blood pressure was less than 110 or the resident's pulse was less than 60. Review of the May 2024 medication administration record indicated the resident's systolic blood pressure was 108 and the medication was administered. During an interview on 6/9/24 at 11:30 a.m., RN (Registered Nurse) 5 indicated if a resident's blood pressure was not within the parameters listed, the medication should be held and blood pressure should be obtained prior to the administration of the medication. 2. The clinical record for Resident C was reviewed on 6/8/24 at 1:11 p.m. The resident's diagnosis included, but was not limited to, orthostatic hypotension. The physician's order, dated 5/30/24, indicated the resident was to receive Midodrine HCl (hydrochloride) 10 mg three times a day at 8:00 a.m., 12:00 p.m. and 4:00 p.m. for hypotension (low blood pressure). The resident's medication was to be held if the resident's systolic blood pressure was greater than 120. Review of the June 2024 medication administration record indicated the medication was administered on the following dates and times: On 6/4/24 at 8:00 a.m. , the resident's systolic blood pressure was 130. On 6/4/24 at 12:00 p.m., the resident's systolic blood pressure was 126. On 6/4/24 at 4:00 p.m., the resident's systolic blood pressure was 125. On 6/5/24 at 12:00 p.m., the resident's systolic blood pressure was 122. On 6/6/24 at 8:00 a.m., the resident's systolic blood pressure was 141. 3. The clinical record for Resident D was reviewed on 6/8/24 at 1:44 p.m. The resident's diagnoses included, but were not limited to, acute kidney failure and hypertension. The care plan, dated 9/7/21, indicated the resident had hypertension and staff were to administer the resident's medications as ordered by the medical provider. The physician's order, dated 3/18/24, indicated the resident was to receive Hydralazine 100 mg three times a day at 11:00 a.m., 4:00 p.m. and 11:00 p.m. for hypertension. The resident's medication was to be held by staff if the resident's systolic blood pressure was less than 110. Review of the June 2024 medication administration record indicated the resident received the medication on the following dates and times: On 6/3/24 at 11:00 a.m., the resident's systolic blood pressure was 102. On 6/4/24 at 4:00 p.m., the resident's systolic blood pressure was 107. On 6/5/24 at 4:00 p.m., the resident's systolic blood pressure was 106. The physician's order, dated 3/7/24, indicated the resident was to receive Metoprolol Tartrate 25 mg twice a day at 11:00 a.m. and 11:00 p.m. for hypertension. The resident's medication was to be held by staff if the resident's systolic blood pressure was less than 110 or the resident's pulse rate was less than 60. Review of the May 2024 medication administration record indicated the resident received the medication on the follow dates and times: On 5/01/24 at 11:00 p.m., the resident's pulse was 55. On 5/02/244 at 11:00 a.m., the resident's pulse was 57 and at 11:00 p.m., the resident's pulse was 58. On 5/03/24 at 11:00 p.m., the resident's pulse was 55. On 5/05/24 at 11:00 p.m., the resident's pulse was 56. On 5/06/24 at 11:00 p.m., the resident's pulse was 57. On 5/07/24 at 11:00 p.m., the resident's pulse was 59. Review of the June 2024 medication administration record indicated the resident received the medication on 6/3/24 at 11:00 a.m. with a systolic blood pressure of 102. 4. The clinical record for Resident E was reviewed on 6/8/24 at 2:13 p.m. The resident's diagnoses included, but were not limited to, heart failure and hypertension. The care plan, dated 8/16/22, indicated the resident had hypertension and staff were to administer the resident's medications as ordered by the medical provider. The physicians' order, dated 10/25/22, indicated the resident was to receive Carvedilol 6/25 mg every morning for hypertension. The medication was to be held by staff if the resident's systolic blood pressure was less than 110. Review of the May 2024 and June 2024 medication administration record lacked documentation of a recorded blood pressure, prior to the administration of the medication, on the following dates: 5/02/24 5/07/24 through 5/09/24 5/14/24 -through 5/16/24 5/20/24 5/22/24 and 5/23/24 5/28/24 5/30/24 6/01/24 6/04/24 through 6/06/24 On 6/9/24 at 12:55 p.m., the RDCO (Regional Director of Clinical Operations) provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .Safety of residents .is a top priority of care .Administer medication only as prescribed by the provider .Record pertinent information prior to giving medication .Blood pressure .Apical pulse This Citation relates to Complaint IN00434995 3.1-37

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was bagged, when not in use, for 3 of 3 residents reviewed for respiratory care. (Residents C, D and E) Findings include: 1. The clinical record for Resident C was reviewed on 6/8/24 at 1:11 p.m. The resident's diagnosis included, but was not limited to, tracheostomy status. During an observation on 6/8/24 at 10:27 a.m., the resident was observed resting in bed with her eyes open and a tracheostomy in place. There was a suction matching on the resident's night stand with a yankauer (oral suctioning tool) and tubing connected to it. The yankauer was lying directly on the night stand and not in a bag. The physician's order, dated 6/6/24, indicated staff were to suction the resident's tracheotomy every shift and as needed. On 6/10/24 at 10:49 a.m., LPN (Licensed Practical Nurse) 6 indicated respiratory equipment and suctioning yankauers, should be bagged when not in use due to germs and infection control. 2. The clinical record for Resident D was reviewed on 6/8/24 at 1:44 p.m. The resident's diagnoses included, but were not limited to, congestive heart failure and asthma. During an observation on 6/7/24 at 11:06 a.m., there was a nebulizer machine sitting in the resident's recliner with tubing attached to a hand held nebulizer. The hand held nebulizer was lying on the recliner and not bagged. The nebulizer machine was not in use. The physician's order, dated 3/18/24, indicated the resident was to receive ipratropium-albuterol solution 0.5-2.5 mg (milligrams)/ml (milliliter), 3 ml via nebulizer inhalation three times a day for wheezing. 3. The clinical record for Resident E was reviewed on 6/8/24 at 2:13 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic respiratory failure and congestive heart failure. \ During an observation on 6/7/24 at 11:06 a.m., there was a nebulizer machine sitting in the resident's bed with the tubing attached to a hand held nebulizer. The hand held nebulizer was not being used or in a bag. The physician's order, dated 5/23/24, indicated the resident was to receive ipratropium-albuterol solution 0.5-2.5 mg (milligrams)/ml (milliliter), 3 ml via nebulizer inhalation three times a day for congestion. On 6/10/24 at 10:58 a.m., the Regional Director of Clinical Operations provided an undated, current copy of the document titled Nebulizer Treatments. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .Safety of residents .is a top priority of care This Citation relates to Complaint IN00434995 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure the physician was promptly notified of the resident's urinalysis preliminary results and timely assessment of the resident's urinary symptoms resulting in hospitalization for a sepsis secondary to urinary tract infection for 1 of 3 residents reviewed for urinary tract infections. (Resident C) Findings include: The record for Resident 20 was reviewed on 11/2/23 at 1:00 p.m. The diagnoses included, but were not limited to, dementia and unspecified urinary incontinence. The care plan, initiated on 10/6/20 and last revised on 7/8/21, indicated the resident had a potential for complications with bowel and bladder incontinence. The interventions included, but were not limited to, monitor labs as ordered, report results to the physician, and staff were to report changes in the urinary status to the physician. The nurse's note, dated 10/9/23 at 11:49 a.m., indicated the resident was refusing to turn and reposition. The nurse's note, dated 10/10/23 at 12:16 p.m., indicated the resident continued to refuse to turn and reposition. The Social Services note, dated 10/10/23 at 3:27 p.m., indicated the resident was having behaviors of being resistive to care. A care plan meeting was requested with the family. The physician's order, dated 10/10/23, indicated to collect a urinalysis (U/A), one time only, to rule out infection. The lab results report indicated a urinalysis specimen, collected on 10/11/23 at 12:00 a.m., was received at 2:30 a.m. The urine clarity was turbid (cloudy or thick), was 1+ (abnormal) for protein, positive for nitrates 2+ for leukocytes, greater than 50 for red blood cells, 6 to 20 for white blood cells, many bacterial cells, had calcium oxalate crystals, mucous, budding yeast, and white blood cell clumps present, and the specimen met criteria for a culture. The record lacked documentation of any communication with the physician regarding infection concerns, any follow up on the urinalysis preliminary results, any assessment of the resident's urinary symptoms, or monitoring between 10/10/23 and 10/13/23 for signs of infection. The physician's note, dated 10/13/23 at 6:48 p.m., indicated the nurse called reporting the patient had altered mental status and was all slumped over. The resident was twitching and had foaming secretions coming out of her mouth. She was cool and clammy. Her blood pressure was 242/84 mmHg (millimeters of mercury), her respirations were 24 breaths per minute, her heart rate was 100 beats per minute, and her oxygen was 82% on 3 lpm. The resident was a DNR, so the physician instructed the nurse to contact the family and see what they preferred to be done for her. If they wanted the resident to go to the ER (emergency room ) or stay in the facility. The physician's note, dated 10/13/23 at 6:56 p.m., indicated the resident's family requested to send the resident to the ER. The nurse's note, dated 10/13/23 at 7:27 p.m., indicated the resident was taken to the ER via EMS (emergency medical services) and a report was called. The nurse's note, dated 10/13/23 at 7:30 p.m., indicated two CNAs had asked the nurse to look at the resident. She was quiet, eyes closed, and had not eaten her supper. Her nasal cannula was in place with oxygen set at 3 lpm (liters per minute). The resident roused to her name and opened her eyes. She then rolled her eyes and closed them. The physician was contacted and indicated to ask the family what they wanted. The family was contacted and requested to send the resident to the ER. The physician was contacted again and agreed to send her out. EMS was called. She was taken to the ER via EMS. The hospital report, dated 10/13/23, indicated the resident presented to the hospital on 10/13/23 with confusion. She was sent from the facility for altered mental status. She had a history of dementia but was more confused than her baseline. She was found without oxygen, but usually wore 3 liters per minute via nasal cannula. In the ER she was placed on heated high flow oxygen at 55 liters per minute with an FiO2 of 48%. Her chest x-ray was highly concerning for pulmonary edema versus multifocal pneumonia. Her labs were remarkable for a WBC (white blood cell) count of 22.8, her urinalysis was positive for nitrates, leukocytes, WBC, and bacteria. She was started on vancomycin and Zosyn. She was asleep but arousable. She was alert to herself, but unable to answer any questions. Her active diagnosis included acute or chronic respiratory failure, sepsis secondary to a UTI and multifocal pneumonia and acute on chronic respiratory failure COPD. The patient met criteria for inpatient status. The plan for the resident's care included gentle IV (intravenous) hydration, IV antibiotics, continuing oxygen supplementation, weaning as tolerated, with the patient's baseline being 3 lpm via nasal cannula. The final culture report for the urinalysis obtained on 10/10/23 resulted on 10/14/23. The report indicated the resident had 70-99,000 CFU/mL (colony-forming units per milliliter) of Escherichia Coli. The nurse's note, dated 10/16/23 at 10:52 a.m., indicated the resident was admitted to the hospital with a UTI (urinary tract infection), sepsis, and pneumonia. During an interview on 11/2/23 at 8:39 a.m., Resident C's family member indicated she had requested the resident have a urinalysis back on 9/28/23 and no testing had been done. She now believed she'd had a UTI from then until she went out to the hospital. They told her at the hospital she had a severe UTI. During an interview on 11/6/23 at 12:43 p.m., LPN 8 indicated a urinalysis was typically done for signs and symptoms of a UTI if they were trying to rule out an infection. If she did a urinalysis on a resident, she would think they would want to monitor the resident's temperature, and especially with the resident's age range they would want to monitor for any type of behaviors, how often she was being changed. She would expect nursing staff would want to monitor and chart on any type of urinary symptoms. If she obtained an order for a urinalysis, she would document the order and the conversation with the doctor, however sometimes that didn't happen. She could not see any reason why the urinalysis was ordered or any monitoring of the resident for infection after it was obtained. During an interview on 11/6/23 at 1:22 p.m., the RDCO indicated when the resident had the urinalysis they needed to put in a nurse's note, documenting they'd received the order, which would of course include the assessment and a nurse's note after they got the results indicating if they got new orders or not. The most current Clinical Documentation Standards policy included, but was not limited to, . b. The nurse is expected to: i. Document accurately and truthfully to the best of his/her knowledge, what is heard or seen during assessments or encounters that concern the resident . iv. Document the status of the resident including changes . The most current Notification of Change in Condition policy included, but was not limited to, . Notifications: The attending practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition . This Federal tag related to IN00420198. 3.1-41(a)(2)

Based on record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 8 of 8 months reviewed. (April, May, June, July, August, September, October, and November 2023). This had the potential to affect all 73 residents currently residing in the facility. Findings include: The review of the April to November 2023 Licensed Nursing schedule indicated the following days were short of 8 hours consecutive RN coverage: April: Sunday 4/2 = No RN coverage scheduled Sunday 4/9 = No RN coverage scheduled Sunday 4/23 = No RN coverage scheduled Saturday 4/29 = only 6.5-hours RN coverage scheduled Sunday 4/30 = only 6.5-hours RN coverage scheduled May: Sunday 5/7 = No RN coverage scheduled Sunday 5/14 = No RN coverage scheduled Saturday 5/20 = No RN coverage scheduled Sunday 5/21 = No RN coverage scheduled Sunday 5/28 = No RN coverage scheduled June: Sunday 6/4 = No RN coverage scheduled Sunday 6/11 = No RN coverage scheduled Sunday 6/25 = No RN coverage scheduled July: Saturday 7/1 = only 6.5-hours RN coverage scheduled Sunday 7/2 = No RN coverage scheduled Saturday 7/8 = only 6.5-hours RN coverage scheduled Sunday 7/9 = No RN coverage scheduled Saturday 7/15 = only 6.5-hours RN coverage scheduled Sunday 7/16 = only 6.5-hours RN coverage scheduled Saturday 7/22 = only 6.5-hours RN coverage scheduled Sunday 7/23 = only 6.5-hours RN coverage scheduled Sunday 7/29 = only 6.5-hours RN coverage scheduled Sunday 7/30 = No RN coverage scheduled August: Sunday 8/6 = No RN coverage scheduled Saturday 8/12 = only 6.5-hours RN coverage scheduled Sunday 8/13 = only 6.5-hours RN coverage scheduled Sunday 8/20 = No RN coverage scheduled Saturday 8/26 = only 6.5-hours RN coverage scheduled Sunday 8/27 = No RN coverage scheduled September: Sunday 9/24 = No RN coverage scheduled October: Saturday 10/7 = only 6.5-hours RN coverage scheduled November: Saturday 11/4 = No RN coverage scheduled Sunday 11/5 = No RN coverage scheduled The review of the Quality Assessment and Performance Improvement (QAPI) indicated the facility identified staffing challenges due to the lack of staff related to RN coverage for 8 consecutive hours in 5/23. During an interview on 11/2/23 at 11:00 a.m., the Executive Director indicated that management was aware of the RN shortage. In May they added it to QAPI and reviewed the staffing weekly. During an interview on 11/8/23 at 8:30 a.m., LPN (Licensed Practical Nurse) 9 indicated there wasn't always RN coverage on the weekends. Management would come in if there was a call-in and they were unable to replace them but that wasn't a guarantee that would happen. During an interview on 11/8/23 at 11:00 a.m., the Executive Director indicated the DON during the period where the facility was short of RN's did not cover for the shortage. They also had interim DONs until the current DON was hired and she had been at the facility about a month. They had the capability of borrowing from a sister facility. Due to the nursing shortage, it had been a challenge. They did not use agency nurses. During an interview on 11/8/23 at 11:29 a.m., the Executive Director indicated the management team had two RNs on staff for the time period from April to the current date. The most current Facility Assessment Tool policy, included, but was not limited to, .The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required . 3.1-17(b)(3)

Based on record review and interview, the facility failed to ensure appropriate documentation of assessments and monitoring for a change in condition for (Resident 47), and to follow up in obtaining IV (intravenous) infusions as ordered and documentation of assessments for (Resident 226) for 2 of 5 residents reviewed for Quality of Care. Findings include: 1. The record for Resident 47 was reviewed on [DATE] at 10:16 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type II diabetes, COPD (chronic obstructive pulmonary disease), dysphagia, pneumonia, vascular dementia, atherosclerotic heart disease, and anemia. The Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was severely cognitively impaired. The nurse's note, dated [DATE] at 9:39 a.m., indicated therapy was assisting the resident to get in her chair with a Hoyer lift. The resident became unresponsive. Her vitals were obtained, and her blood pressure was ,d+[DATE] mmHg (millimeter of mercury), heart rate was 56, her O2 (oxygen saturation) was 94% on room air, and her respirations were 13. The resident would take 10 normal breaths, and then a couple of very shallow respirations. The NP (Nurse Practitioner) 7 was notified and came to assess the resident. The resident was taken to the nurse's station to be closely monitored. The record lacked documentation indicating the resident was monitored and assessed for signs and symptoms and interventions were implemented. The NP progress note, dated [DATE] at 5:41 p.m., indicated therapy was getting the resident up from the bed in the a.m., and into a chair. She had an episode where she became unresponsive, and her blood pressure dropped. She came to with a sternal rub and her blood pressure came back up to ,d+[DATE] mmHg. However, the nurse asked the NP to see the resident again later in the day due to increased lethargy. The nurse indicated she was having trouble getting the resident to swallow her medication and she wasn't talking as much. When the NP first saw her, she was answering her questions, however after a few minutes she stopped responding and her blood pressure was low again at ,d+[DATE] mmHg. The resident was a full code at that time. The NP also discussed with the resident's significant other about her continually declining status and with the history of a stroke it might be hard for her to fully recover her previous strength. The resident was sent to the hospital due to decreased mental status and unresponsiveness with hypotension. The NP note, dated [DATE] at 5:51 p.m., indicated the resident returned from the hospital. She was admitted to the hospital for altered mental status and UTI (urinary tract infection). She was treated with antibiotic and cefdinir ordered for continuation. The nurse alerted the NP that the resident was very lethargic and complaining of a sore throat. She was having trouble taking her medications but was able to take medications crushed in applesauce. When the NP assessed the resident her 02 (oxygen)saturation was 80%. The 02 was turned up to 5L (liters) and a breathing treatment provided, however her oxygen saturation was only 83%. She was very lethargic and unable to answer all questions. The resident kept stating that her bottom hurt. She was unable to state the year or where she was. The resident was difficult to arouse at times. Due to the resident's increased lethargy and confusion, she was sent to the hospital for evaluation. The NP note, dated [DATE] at 5:35 p.m., indicated the resident was readmitted from the hospital. She was admitted for an elevated troponin and pneumonia which was evident on the CT (Computed Tomography) scan. She was monitored, given IV antibiotics, and steroids. They also started her on Keppra twice a day due to her off and on altered mental status and lethargy. She failed her swallow study while at the hospital and a PEG (percutaneous endoscopic gastrostomy) tube was placed and she was NPO (nothing by mouth) with tube feedings. She was alert, but still significantly confused and unable to identify place, time, or situation. The NP note, dated [DATE] at 5:05 p.m., indicated the resident had a decrease in responsiveness and she was very lethargic and not responding well. She has had several episodes of hypotension and decreased responsiveness recently that results in readmission to the hospital. The NP went to assess the resident and gave a vigorous sternal rub, she moaned in response, but did not open her eyes or speak. Her vital signs were stable. While the NP was talking to the family the nurse rechecked the resident's vital signs about 20 minutes later and her blood pressure was dropping. The NP had an extensive and lengthy conversation with the resident's significant other about advanced care planning and goals of care. The significant other stated she had always wanted to be a DNR (Do Not Resuscitate), however she was currently CPR (cardiopulmonary resuscitation) at the facility due to her inability to make her own decisions, no immediate family member or POA (power of attorney). The NP explained to the resident's significant other the situation and discussed her recent hospitalization s as well as guarded prognosis due declining health and frequent admissions. He voiced understanding, and was very tearful, and stated he only wanted what was best for the resident. They discussed various code status and what each one entailed. 2. The record for Resident 226 was reviewed on [DATE], at 11:44 a.m. The diagnoses included, but were not limited to, cachexia, encephalitis and encephalomyelitis, COPD, type II diabetes, calciphylaxis, other disorders of calcium metabolism, colostomy, severe protein malnutrition, anemia, resistant staphylococcus aureus infection, epilepsy and epileptic syndromes, hypotension, and stage 3 chronic kidney disease. The Admission MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact. The record lacked documentation indicating the resident was monitored and assessed for signs and symptoms and interventions were implemented. The NP note, dated [DATE] at 1:51 p.m., indicated that she spoke to the resident's family, and they were concerned if the NA (Sodium) Thiosulfate infusions needed restarted or not. She contacted the physician, and family wanted another physician to be consulted first. Staff were to call and get a follow up appointment with that office as soon as possible and ask if the infusions could be restarted before the appointment or if he wanted to see her first. The record lacked documentation indicating the physician was notified about the NA Thiosulfate infusion, and any attempts to make appointment for the resident to see the physician. The physician's order, dated [DATE], indicated that the September order was now documented. The nurse's note, dated [DATE] at 8:15 p.m., indicated the EMS (Emergency Medical Services transported the resident to the hospital. The resident's family were made aware of the resident's change in condition and transfer to the hospital. The nurses note, dated [DATE] at 10:26 p.m., indicated the resident was sent to the hospital for possible seizure. The nurses note, dated [DATE] at 11:46 a.m., indicated the resident was intubated in the emergency room and transferred to another larger hospital and admitted into ICU (Intensive Care Unit) on a ventilator. During an interview on [DATE] at 8:45 a.m., the DON (Director of Nursing) indicated when there was a change in the resident's condition there should be documentation in the nurse's notes and an assessment completed. During an interview on [DATE] at 9:35 a.m., Regional Director of Clinical Operations indicated the SBAR (Situation Background Assessment and Recommendation) was documentation the resident had a change in condition. There should be documentation in the nurse's notes indicating the resident's symptoms and what interventions did the nurse provide. During an interview on [DATE] at 10:29 a.m., the DON indicated someone dropped the ball when the NP documented she wanted the physician called about the NA Thiosulfate infusion being restarted and to make an appointment with the physician as soon as possible. She indicated the order was put in on Monday [DATE] and she was waiting for the physician's office to respond. The most current Clinical Documentation Standards policy, included, but was not limited to, .b. The nurse is expected to: i. Document accurately and truthfully to the best of his/her knowledge, what is heard or seen during assessments or encounters that concern the resident . iii. Document entries during the work shift and complete all entries before leaving the facility for that tour/shift iv. Document the status of the resident including changes . 3XXX,d+[DATE](a)

Based on record review and interview, the facility failed to include the resident in the care plan meetings when developing her plan of care (Resident 51), and to revise a resident's plan of care when the discharge plan changed (Resident 59) for 2 of 34 residents care plans reviewed. Findings include: 1. During an interview with Resident 51 on 11/2/23 at 10:23 a.m., she indicated she had been in the facility for two years and thought her last care plan meeting was maybe a year ago. This was about the time the Social Worker started and she hadn't had one since. The day she was finally able to get out of bed and up into her power chair after recuperating from surgery, the Social Worker came and told her there was going to be a care plan meeting. The meeting only dealt with her weight and never discussed any other issues, such as her desire to discharge from the facility. Her family had not been involved in the meeting either and she could not remember having any other meetings after this one. She did not feel like this was a true care plan meeting. The record for Resident 51 was reviewed on 11/3/23 at 12:40 p.m. The diagnoses included, but were not limited to, personal history of traumatic brain injury, unspecified intracranial injury with loss of consciousness of unspecified duration, morbid obesity, post-traumatic stress disorder, paraplegia, and adjustment disorder with mixed anxiety and depressed mood. The Quarterly Minimum Data Set (MDS) assessments, dated 2/22/23, 3/6/23, 6/15/23, 9/15/23 and 9/22/23, and the Annual MDS assessment, dated 5/19/23, indicated the resident was alert and oriented. During an interview on 11/6/23 at 8:30 a.m., the Executive Director (ED) indicated the Social Worker was responsible for sending out care plan letters to the residents and families and took the notes. Everyone was responsible for making their own changes to the care plans as needed. During an interview on 11/6/23 at 9:55 a.m., the Social Worker indicated the former Director of Nursing (DON) was the one who insisted on doing the documentation for the care plan meetings in August and September. On 11/6/23 at 10:12 a.m., the Regional Director of Clinical Operations (RDCO) presented a letter, dated 2/6/23, given to the resident, in which the resident was invited to her care plan meeting. The IDT (Interdisciplinary Team) notes, dated 2/21/23, indicated the resident was present for this meeting. The record was lacking documentation of any additional care plan meeting invitations to the resident or her family or IDT notes of what was discussed in the meetings or if the resident attended any further meetings. 2. On 11/1/23 at 11:01 a.m., Resident 59 indicated he still wanted to return home once he got his medical issues resolved and that was his plan since admission on 2/1/23. The record for Resident 59 was reviewed on 11/6/23 at 3:20 p.m. The diagnoses included, but were not limited to, immobility syndrome (paraplegic), muscle weakness, diabetes mellitus due to underlying condition with unspecified complications, other symptoms and signs involving the musculoskeletal system, and muscle wasting and atrophy. The Quarterly MDS assessments, dated 3/14/23, 6/7/23 and 9/7/23, indicated the resident was alert and oriented. The Quarterly MDS assessment, dated 3/14/23, indicated the active discharge planning was occurring for the resident to return to the community. The Social Worker, Physician/NP (Nurse Practitioner), and therapy notes initially indicated the resident planned to return home after the completion of therapy. The Quarterly MDS assessments, dated 6/7/23 and 9/7/23, indicated there was no active discharge planning occurring and the resident was not going to be returning to the community. The Social Worker notes, dated 2/28/23, 6/7/23 and 9/12/23 subsequently indicated the plan was for the resident was to remain in the long term facility. During an interview with the Social Worker on 11/8/23 at 9:15 a.m., she indicated the resident no longer had a home to be discharged to nor would any Assisted Living facility accept him due to the amount of care he needed. The resident's family member was very involved in the resident's care and helped the resident make a decision to remain in the facility long term. During an interview with PT (Physical Therapist) 13 on 11/8/23 at 9:20 a.m., she indicated the resident was going to remain in the facility for long term due to his care needs and that his family member gently reminded the resident why he could not return to home. A care plan, dated 3/14/23, indicated the resident wished to be discharged to home. The goal was for the resident to be be discharged to an appropriate location based upon physical and cognitive status. The approaches included: discuss the feelings and concerns of the resident, and resident representative, with impending discharge; notify the medical provider of discharge plans; provide contact numbers for all community referrals; provide education to resident and resident representative regarding equipment, treatments, and medication; and determine gaps in abilities that will affect discharge. The record lacked documentation of the resident's care plan being updated since being implemented on 3/14/23 to reflect the resident's need for long term care. On 11/6/23 at 2:17 p.m., the Regional Director of Clinical Operations (RDCO) presented a copy of the facility's current policy titled Plan of Care Overview. This policy included, but was not limited to, Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs of the residents .The purpose of the policy is to provide guidance to the facility to support the inclusion of the residents or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to their daily routines and goals to potentially return to a community setting. Procedure: 1. General Care Planning (PoC) Goals and Guidelines: .b. Resident/representatives will be offered opportunities to voice their views .c. Resident/representatives will have the right to participate in the development and implementation of his/her own PoC including but not limited to: .ii. Right to identify individuals or roles to be included in the planning process .iv. Right to participate inn goal establishment and outcomes .d. The facility will: .iii. Review care plans quarterly and or with significant changes in care . During an interview with the Executive Director (ED) on 11/8/23 at 1:00 p.m., he indicated the facility created a Quality Assurance and Performance Improvement plan on 10/1/23 to address care plans not being documented per company policy due to lack of information to be sent out for scheduling, lack of accountability to attend meetings and that people forgot and did not attend the meetings. The plan had a column for the current percentage (QM - Quality Measures) - number of care plans documented correctly which was blank. The Preintervention column - the current QM percentage, amount to be completed, number of residents that trigger, etc. was also left blank. The First, Second, and Final Re-measurement - what the goal would be for the next percentage for each item identified were blank and only gave a date as to when they would assess the issues. The ED indicated they did do an audit of just how many residents were affected and had care plans not updated or not being invited to their care plan meetings but was unable to provide that number or when the next review would be for each of the residents affected. The care plans would be updated with documentation of attendance by the residents only when they came up for their next review. 3.1-35(c)(2)(C) 3.1-35(d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure appropriate oversight of medication administration during 2 of 3 random observations. (Residents 6 and 38) Findings include: 1. During an observation on 11/5/23 at 12:24 p.m., there was a medication cup sitting on Resident 6's bedside table. The cup contained the following: a white round tablet, which was imprinted with gc 422; a yellow round tablet, imprinted with an e; a small pink round tablet, imprinted with PH 034; a small orange round tablet, imprinted with 5729; a small white round tablet, imprinted with c73; and a blue capsule, imprinted with t026 120. The resident indicated she had no idea how long the medications had been there. No staff were present in the resdient's room. During an interview on 11/1/23 at 8:50 a.m., LPN (Licensed Practical Nurse) 6 indicated she took the medications in about 20 minutes prior the resident's breakfast tray arriving. She was not supposed to leave the medications and never would again. The resident usually took her pills herself, one at a time, in applesauce and she disliked staff doing it for her. She reviewed the resident's MAR (Medication Administration Record), and her pill packets, and identified the medications as the resident's Colace, cardizem, Pepcid, metoprolol, aspirin, and iron. The record for Resident 6 was reviewed on 11/1/23 at 10:00 a.m. The resident's diagnoses included, but were not limited to, atrial fibrillation, irritable bowel syndrome without diarrhea, hypertension, traumatic subdural hemorrhage without loss of consciousness, and gastro-esophageal reflux disease without esophagitis. The Quarterly MDS (minimum data set) assessment, dated 8/28/23, indicated the resident was moderately cognitively impaired. The physician's orders indicated the resident was currently receiving Cardizem extended release 24 hour 12 mg (milligrams) every morning for hypertension, Pepcid 40 mg every morning for GERD, ferrous sulfate (iron) extended release tablet 150 mg every morning for anemia, metoprolol tartrate 25 mg every morning and bedtime for hypertension, and Colace 100 mg 1 tablet twice daily for constipation. The MAR (medication administration record) indicated all of the medications had been documented as administered on 11/1/23 during the morning medication pass by LPN 6. The resident's record lacked documentation of any orders, care plan, or assessments for self-administration of medications. 2. During an observation on 11/1/23 at 9:00 a.m., Resident 38 was resting in bed. He had a medication cup on his bedside table. The cup contained 13 tablets of various shapes, colors, and sizes. The resident indicated his nurse left them there that morning, and they did not usually do that. He then took the medications. No staff was present in the resident's room. During an interview on 11/1/23 at 9:10 a.m., LPN 6 indicated she thought the resident had taken the medications. She thought she saw him move the cup towards his mouth. She identified the medications she'd administered that morning as the colace 100 mg, gabapentin 300 mg, vitamin D 50 mcg (micrograms), vitamin C, aspirin 81 mg, clonidine 0.1 mg, ferrous sulfate 325 mg, lasix 20 mg, metformin 1000 mg, lopressor 25 mg, protonix 40 mg, zoloft 25 mg, and xarelto 20 mg. She had brought them in around 7:45 a.m. The record for Resident 38 was reviewed on 11/1/23 at 10:30 a.m. The resident's diagnoses included, but were not limited to, diabetes mellitus type 2, hypertension, atrial fibrillation, and iron deficiency anemia. The physician's orders indicated the resident was currently receiving the following medications: aspirin 81 mg in the morning, clonidine 0.1 mg in the morning for hypertension, colace 100 mg twice daily for constipation, ferrous sulfate 325 mg every morning and bedtime for iron deficiency anemia, gabapentin 300 mg in the morning for pain, lasix 20 mg in the morning for edema,, metformin 1000 mg in the morning for diabetes mellitus type 2, metoprolol succinate 25 mg every morning for hypertension, protonix 20 mg every morning for GERD (gastro-esophageal reflux disease), xarelto 20 mg every morning for atrial fibrillation, vitamin C 500 mg every morning and bedtime for iron deficiency anemia, vitamin D 50 mcg tablet daily for vitamin D deficiency, and zoloft 25 mg every morning for depression. The MAR indicated the resident's morning medications had been last administered on 11/1/23 by LPN 6. The resident's record lacked documentation of any orders, care plan, or assessments for self-administration of medications. The most current Medication Administration Policy included, but was not limited to, . Procedure . bb. Remain with resident until the medication is swallowed . cc. Do not leave medication at bedside . 3.1-11(a)

Based on record review and interview, the facility failed to ensure the safety of a resident during an assisted transfer, which resulted in the resident falling backwards and developing a subdural hematoma and laceration to the back of her head for 1 of 3 resident reviewed for falls. (Resident E) Findings include: The record for Resident E was reviewed on 9/19/23 at 12:15 p.m. The diagnoses included, but were not limited to, cervical disc disorder with myelopathy of the cervicothoracic region, cognitive communication deficit, need for assistance with personal care, muscle weakness, and obesity. The care plan, dated 11/4/22 and last revised on 8/23/23, indicated the resident was at risk for falls, gait and balance problems, medications, weakness with an actual fall on 8/23/23. The interventions, dated 8/23/23, included, but were not limited to, apply anti-tippers to the wheelchair and send the resident to the ER (emergency room ) as needed per MD (medical doctor) order. The nurse's note, dated 8/23/23 at 1:29 p.m., indicated the resident was getting ready to be put back into her bed after dialysis. The aides reclined her wheelchair to position her for the full body lift transfer. The resident's wheelchair tipped backwards, and the resident slid out. She received a hematoma and a small laceration to the back of her head on the left side. The nurse practitioner was called and came to assess the resident. The nurse on the hall indicated the resident took Eliquis. The nurse practitioner gave an order to send the resident to the ER for evaluation. The nurse's note, dated 8/23/23 at 1:35 p.m., indicated at 12:15 p.m., the nurse was called to the resident's room by the CNA (Certified Nurse Aide). The resident was assessed by the nurse. There was no change in LOC (level of consciousness). Her legs were equal in length, with no turn in or turn out. There was no pain when her BLE (bilateral lower extremities) were assessed. Her pulses were equal and bilateral. The resident had hit her head on the floor. The resident sustained a 0.5 cm (centimeter) cut on her head with bleeding. The resident was assisted to bed. At 12:20 p.m., the NP was on site and assessed the resident. A new order was received to send the resident to a local hospital for evaluation and treatment. At 12:45 p.m., EMS (emergency medical service) was on site to transport the resident. The Skin Grid Non-Pressure assessment, dated 8/23/23 at 12:15 p.m., indicated the laceration to the back of the head measured 0.75 cm long. The nurse's note, dated 8/23/23 at 6:05 p.m., indicated the resident was transferred from a local hospital to another hospital to confirm her injury. The nurse practitioner and representative were notified. The CT (computerized tomography) scan results on 8/23/23 at 11:04 p.m., indicated the hematoma measured 5.8 mm (millimeters) in greatest thickness, which had decreased in size since the prior examination. The CT showed a SDH (subdural hematoma) with midline shift. The left midline shift measured 7.3 mm with effacement of the right lateral ventricle. The midline shift was 9.5 mm on the prior examination. No fracture was observed. The resident complaint of a headache since the fall, which had not improved. The nurse's note, dated 8/27/23 at 5:18 p.m., indicated the resident arrived at the facility at 5:17 p.m., via transport on a stretcher. During an interview on 9/19/23 at 1:01 p.m., CNA (Certified Nurse Aide) 4 indicated two CNAs were using the lift to seat the resident in her wheelchair. They made sure she was positioned in the wheelchair correctly before seating her in it. The resident liked the wheelchair tilted back slightly when using the full body lift. The wheelchair tipped back. The wheelchair did not have anti-tippers at the time of the fall but did now. She was unsure why the chair didn't have anti-tippers before the fall. The resident was assisted down as best they could. The resident hit her head on the floor. There was a lot of blood. The nurse and the Unit Manager came into the room to assess the resident. She was then assisted into her bed. The resident was sent out to the hospital the same day. The anti-tippers made it better to transfer the resident now. During an interview on 9/19/23 at 1:09 p.m., CNA 3 indicated they were getting the resident up. The resident's weight shifted in the chair. The high back chair made her tip. Her chair was supposed to have a spreader bar (The Seating Dynamics Spreader Bar head support mount was width and depth adjustable and may also be used to position the head support off-center. The Spreader Bar provides tremendous flexibility in adjustment and unparalleled rigidity on it for easy storage) and it didn't latch properly for some reason. When her chair was inspected, it was found that the spreader bar was not latched and altered her weight. The resident fell and busted her head. There was bleeding. They were going to get her vitals, but the nurse was called in and assessed the resident. She couldn't get the bleeding to stop. The resident hit her head on something, but she wasn't sure what. The high back chair was taller than the resident, but the resident had slid up the high back, above the top of the chair back. The resident was sent out to the hospital. The current Mechanical Lifts and Transfer policy, included, but was not limited to, . The use of mechanical lifts requires a competent and skilled user and requires the use of two (2) employees safely, for both resident and employees .VIII. Transferring to a Wheelchair .c. Move the wheelchair into position. d. Engage the rear wheel locks of the wheelchair to prevent movement of the wheelchair . This Federal tag relates to Complaint IN00417434 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure the physician was notified when a resident (Resident B) complained of bilateral shoulder pain and malfunctioning of his automatic implantable cardioverter defibrillator for 1 of 3 residents reviewed for physician notification. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility staff failed to notify the physician of a resident's complaint of bilateral shoulder pain and malfunctioning of the residents' automatic implantable cardioverter defibrillator. The resident was found unresponsive on [DATE] and died . The Executive Director (ED) and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 4:35 p.m. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The clinical record for Resident B was reviewed on [DATE] at 11:11 a.m. The diagnoses included, but were not limited to, hypertension and presence of automatic (implanted) cardiac defibrillator. The quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident's cognition was intact. The care plan, dated [DATE], indicated the resident had an AICD (automatic implantable cardioverter defibrillator) related to a complete atrioventricular block. The interventions included, but were not limited to, defibrillator checks as ordered and follow up with cardiology as ordered. The progress note, dated [DATE] at 1:28 p.m., indicated the resident refused to go to his appointment for his AICD check due to complaints of not feeling well. The resident requested his oxygenation be checked and complained of nausea. The resident's oxygenation was 90% on 2 liters of oxygen and he was administered 4 mg (milligrams) of Zofran (antiemetic) as ordered by the physician on [DATE]. The progress note, dated [DATE] at 4:44 p.m., indicated the resident complained of bilateral shoulder pain and pacemaker complications. The resident was assessed with the following findings: apical heart rate of 67 after one minute of auscultation, temperature was 97.8, respirations were 18, and blood pressure was ,d+[DATE]. The resident was educated that he would be discharged tomorrow. The resident asked to be sent to the hospital. Upon education that he was to be discharged tomorrow, the resident decided to contact his spouse prior to his decision to be sent to the hospital. The progress note, dated [DATE] at 1:21 p.m., indicated the resident complained of nausea at times and his as needed Zofran was administered as prescribed. Review of the [DATE] medication administration record (MAR) indicated the resident received Zofran 4 mg at 8:34 a.m. and 5:49 p.m. for nausea and meclizine (medication for dizziness) 12.5 mg at 8:34 a.m., per standing order, on [DATE]. Between [DATE] and [DATE], the resident's MAR indicated [DATE] was the first time the resident had requested 2 doses of the Zofran and the first time the resident had requested the meclizine. The progress note, dated [DATE] at 9:30 p.m., indicated the resident was found unresponsive lying in his bed. There were no respirations and no pulse. CPR (Cardiopulmonary Resuscitation) and defibrillating was initiated and 911 called. CPR was continued until 9:09 p.m. when EMT's (emergency medical technicians) arrived. The paramedics were unable to resuscitate the resident and time of death was called at 9:29 p.m. The clinical record lacked documentation of the physician's notification related to Resident B's bilateral shoulder pain and complaints of the malfunctioning AICD or any resident education on refusing to go for his AICD check. During an interview on [DATE] at 11:43 a.m., LPN (Licensed Practical Nurse) 3 indicated he did not notify the physician of the resident's complaints of shoulder pain and possible AICD malfunctioning. He was unaware he had to do so and thought that the physician was to be notified when the resident was sent out. The resident had not made that decision at that point. It was towards the end of his shift, and he passed the information on the LPN 4 during shift change. At 12:55 p.m., LPN 3 clarified malfunctions as the resident reported to him that his heartbeat felt irregular and his AICD was malfunctioning. During an interview on [DATE] at 11:57 a.m., LPN 4 indicated she was not told anything about the resident complaining of bilateral shoulder pain or malfunctioning AICD. The only thing she was told was that the resident was going to be discharged on Monday and the resident had been coming up with all kinds of excuses not to go home. LPN 3 told her he had checked everything, and the resident was fine. LPN 4 passed medication to the resident between 7:00 p.m. and 7:30 p.m. on [DATE]. There was no documented nursing assessment related to the resident's prior complaints of bilateral shoulder pain or complaints of AICD malfunctions during LPN 4's shift. On [DATE] at 2:43 p.m., the Executive Director provided a current undated copy of the document titled Notification of Change in Condition. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care that meets the .needs .concerns of the residents. The safety of residents .is of primary importance .The Centers for Medicaid and Medicare Services (CMS) requires that processes be in place for notifications of acute changes such as cardio .The center must inform the resident, consult with the resident's physician .when there is a change requiring such notification .Significant change in the residents physical condition .including but not limited to .life-threatening condition .clinical complications .Notifications .The attending practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition The Immediate Jeopardy, that began on [DATE], was removed on [DATE], when the facility conducted the following: The DON/Designee reviewed all residents with a change of condition for the last 14 days to ensure physician notification, family notification, and follow-up was completed as appropriate. The DON/Designee reviewed all residents with an AICD and implemented daily monitoring orders for completion by licensed nurses to ensure compliance with daily monitoring to include no symptoms of malfunction/failure, slowed or irregular heartbeat, pain with potential to related to cardiac concern, shortness of breath, faintness/dizziness, unexplained falls, and unexplained weakness. An audit was conducted for all resident appointments for the last 30 days to ensure all appointments were completed as ordered and if resident refused appointment, including AICD follow-up appointments, education would be provided on the risk for potential adverse outcomes and physician notified of refusals. All licensed nurses were educated on the facility's policy for notification of COC to MD/NP and family, internal devices/pacemaker and follow-up appointments to include refusal of appointments and cardiac signs and symptoms, potential negative outcomes of missed AICD follow-up appointments to include device failure, cardiac arrest, and potential death, completion of resident education and notification to physician related to missed or refused AICD follow-up appointments, and on the daily monitoring of signs and symptoms of potential problems with AICD. This Federal tag relates to Complaint IN00412084 3XXX,d+[DATE](a)(2)

Based on interview and record review, the facility failed to ensure the physician was notified timely when a resident's (Resident B) oxygen saturation dropped from 96% to between 78% to 79% , which resulted in hospitalization and the need for mechanical ventilation via BiPAP (Positive Pressure Ventilator) machine for 1 of 3 residents reviewed for significant change in condition. Findings include: The clinical record for Resident B was reviewed on 2/22/23 at 11:47 a.m. The diagnoses included, but were not limited to, congestive heart failure, hypertension, and anxiety. The care plan, dated 10/11/22, indicated the resident had an altered cardiovascular status with interventions that included monitoring vital signs, and observe for signs and symptoms of chest pain and shortness of air. The Nurse Practitioner note, dated 12/22/22 at 5:19 p.m., indicated the staff alerted the NP due to the resident vomited and was coughing. The resident was alert and complained of mild shortness of breath and mild chest pain when coughing. The resident's oxygen saturation was 96% on room air. The NP plan included a chest x-ray, prednisone 20 mg (milligrams), and Duoneb 3 ml (milliliters). The progress note, dated 12/23/22 at 5:01 a.m., indicated the resident was sent out to the hospital on 12/22/22 at 10:45 p.m. due to being unresponsive, diaphoretic and an oxygen saturation between 45% to 60% on oxygen at 3 LPM (liters per minute). During an interview on 2/22/23 at 10:35 p.m., LPN (Licensed Practical Nurse) 5 indicated, on 12/22/22, somewhere between 7:00 p.m. and 8:00 p.m., the resident had de-stated (drop in oxygen), and her oxygen saturation was between 78% to 79% at which time she placed oxygen at 3 LPM as a nursing measure. The LPN monitored the resident the entire time and would have documented the oxygen saturation in the vital signs. When LPN 5 placed the oxygen on the resident, the resident was responding, not well, but was responding. LPN 5 did not notify the physician at the time the resident de-stated between 7:00 p.m. to 8:00 p.m., but did notify the physician of what had transpired, during that time frame, when she sent the resident to the emergency department at 10:45 p.m. The clinical record lacked documentation of the significant change in the resident's oxygenation and need for oxygen, physician notification at the time the resident de-stated prior to 10:45 p.m. on 12/22/22, or any monitoring of the resident's vital signs and oxygen saturation between 7:00 p.m. to 10:45 p.m. on 12/22/22 During an interview on 2/23/23 at 3:42 p.m., LPN 6 indicated if a resident had a saturation of 96% on room air and it dropped between 78% to 79%, it would be a significant change in condition, the resident should have been assessed, and the physician should have been notified. The EMS (emergency medical service) report, dated 12/22/22, indicated upon arrival to the facility at 10:44 p.m., the resident was found to be unresponsive to any stimulation, visibly labored breathing, oxygen saturation in the upper 60's, and on oxygen at 5 LPM. The oxygen was changed to a non-rebreather, which raised the oxygen level to 84%. The resident's respirations were assisted via BVM (bag valve mask) with 100% oxygen and transported to the hospital. The EMS pre-hospital assessment indicated the resident was in respiratory distress with vital signs as follows: On 12/22/22 at 10:50 p.m., the resident's blood pressure was 221/103, pulse was 144, respirations were 36, and oxygen saturation was 66%. On 12/22/22 at 11:00 p.m., the resident's blood pressure was 225/167, pulse was 157, respirations were 49, and oxygen saturation was 87%. The Emergency Documentation, dated 12/22/22 at 11:54 p.m., indicated the patient presented with hypoxia, unresponsiveness, diaphoretic, and arrived via EMS in critical condition. Pursued the use of a BMV to increase her oxygen saturation into the upper 90's and she was transitioned to a BiPAP. On 2/23/23 at 1:55 p.m., the interim Director of Nursing provided a current, undated copy of the document titled Notification of Change in Condition. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .The safety of residents .is of primary importance .Changes may include, but are not limited to .changes in overall health status .significant medical changes .Notifications .The attending practitioner is promptly notified of significant changes in condition, and the medical record must reflect the notification, response, and interventions implemented to address the resident's condition This Federal tag relates to Complaint IN00402241 3.1-5(a)(2)

Based on record review and interview, the facility failed to ensure a resident's advanced directive were honored for 1 of 26 residents reviewed for advanced directives. The resident had persistent rib pain, anxiety, and negative emotions related to being revived when he had wanted to be a DNR. (Resident D) The immediate jeopardy began on [DATE], when the facility failed to follow a resident's advance directive of a do not resuscitate. The Executive and Director of Nursing Services were notified of the immediate jeopardy at 2:12 p.m., on [DATE]. The immediate jeopardy was removed on [DATE] at 3:22 p.m., but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings include: During an observation, on [DATE] at 3:00 p.m. Resident D's physical chart had a sign taped to the front of it with a red stop sign on it. The sign indicated in case of hospice crisis, to contact the resident's hospice provider, with the phone number listed on it. Under the condition alert tab, DNR was written in both dark blue marker, and an orange highlighter, with the resident's name, room number, and status as a hospice patient written on it. There was no indication the resident was a full code for CPR to be performed on the chart, or in the first page of the chart. The clinical record for Resident D was reviewed on [DATE] at 1:11 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was cognitively intact, the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months. The POST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The form was signed by the resident and the physician on [DATE]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated [DATE] and last revised on [DATE], indicated the resident had chosen a DNR code status. The goal included the resident's code status would be honored through the next review date. The interventions included, but were not limited to, code status will be established at time of admission or readmission and reviewed quarterly and as needed and verify presence of DNR status post [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated [DATE] at 11:29 a.m., indicated the resident asked for pain medication at 11:00 a.m. The nurse went in and found the resident almost on the floor, sitting half in his wheelchair. There was a small amount of blood and saliva coming out of his mouth. A sweep of his throat was done and nothing was found. The resident had no pulse. He was lowered to the floor and CPR (cardiopulmonary resuscitation) was started. After 2 minutes of CPR a pulse was observed. EMS (Emergency Medical Services) and hospice were notified. EMS arrived and transported the resident to the hospital. The nurse's note, dated [DATE] at 2:52 p.m., indicated the resident would be returning to the facility. Report was received from the local hospital that the resident was COVID-19 negative and the resident had pneumonia and would return with orders for [MEDICATION(S)] 2 mg for two days and [MEDICATION(S)] 300 mg 1 tablet every 12 hours for 7 days. The hospice note, dated [DATE], indicated the hospice nurse received a message from the facility indicating the resident had been found unresponsive, 911 was called, and CPR was started. The resident was a DNR. Before the call was returned the on call hospice nurse called to report the patient was breathing and had a pulse, and was being transported to the local hospital. The hospice nurse instructed the on-call hospice nurse to call the hospital to give report and emphasized the patient was on hospice and was a DNR. The hospice note, dated [DATE], indicated LPN 3 called hospice and reported the resident went unresponsive. EMS was called and CPR was performed before hospice was informed and despite the patients DNR status. The hospice nurse spoke with LPN 4 and informed her the patient was a hospice patient and a DNR. The hospice note, dated [DATE], indicated the resident was at the local hospital. He was complaining of chest pain which was likely related to CPR being performed per hospital staff, but a chest x-ray was performed and the resident had pneumonia. He was given [MEDICATION(S)] to assist with the pain. The hospital summary report, dated [DATE], indicated the resident was brought in from the nursing home with complaints of shortness of breath. He was a DNR but CPR was performed for 3 minutes at the nursing home when he was found unresponsive and not breathing. By the time EMS came he was alert. The patient improved over an hour but his wheezing had not resolved. The hospital recommended admission for continued treatment, however the resident refused and stated he wanted to go back to the nursing home. He had metastatic lung cancer and was a DNR. He would be treated with antibiotics, steroids, and continued nebulizer treatments at the nursing home. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated [DATE], indicated a message was left with hospice regarding a need for a new script for [MEDICATION(S)]. The hospice note, dated [DATE], indicated the resident had shortness of breath on minimal exertion, his lung sounds were diminished throughout all lobes with wheezing in the left lobes. The resident stated he had ribs broken on both sides. The hospice note, dated [DATE], indicated the resident stated he wanted to remain hospice and be a DNR. The hospice nurse told him she would see him the following day for his final decision. A new post form, dated [DATE], indicated the resident had chosen to be a DNR and wanted comfort measures only. The form was signed by the resident and the physician on [DATE]. The hospice note, dated [DATE], indicated the resident was uncomfortable due to pain from broken ribs due to CPR. He told the chaplain there was no part of his body that did not hurt. He shared his experience of passing and being brought back to life. He wanted to be a DNR. The chaplain had a conversation with the resident about not going through the CPR. The resident completed his post form and signed it. The Pain Observation tool, dated [DATE] at 8:23 a.m., indicated the resident was verbalizing or exhibiting non-verbal symptoms of pain. The onset was [DATE]. The location of the pain was the chest and ribs. The pain was worse in the morning, afternoon, evening, and night. The feeling of the pain was described as internal, external, and acute. The resident was able to verbally express his pain level as an 8 on a numerical scale, which indicated 0 was no hurt, and 10 hurt the worst. A numerical 8 on the scale meant the pain hurts a whole lot. The pain was described as feeling like a sharp, throbbing, stab feeling. The pain affected the resident's ability to sleep or rest, toilet self or maintain continence, bath himself, perform personal hygiene, and dress himself. The pain resulted in a change in his appetite, participation in activities, and his ability to concentrate or focus. The pain was caused by CPR, and was increased by movement. The resident received routine dilauded which was effective, and also used [MEDICATION(S)] as needed. The nurse's note, dated [DATE] at 7:57 p.m., indicated a new order to give [MEDICATION(S)] 100 mg per 5 ml 0.75 mL every 1 hour as needed for pain until [MEDICATION(S)] arrived, then delete and go back to original order. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated [DATE] 9:50 a.m., indicated the pharmacy said they did not have a script from the doctor. Hospice was notified and they indicated they would reorder again. At 11:00 a.m. the pharmacy was contacted and they still did not have the prescription. Hospice was contacted and indicated they would send it again. The pharmacy was contacted and indicated the medication would arrive at 3:00 p.m. and 4:00 p.m. The facility was awaiting the medication, the resident was upset and requesting [MEDICATION(S)] every hour. The hospice note, dated [DATE], indicated the resident told the chaplain he could not get over his experience of bring revived. His ribs were still sore and he was not happy. The nurse's note, dated [DATE] 2:25 p.m., indicated the hospice nurse was in to check on the patient's pain medications. The resident indicated he was feeling more anxious than normal. The hospice nurse advised the resident's [MEDICATION(S)] was changed from every six hours as needed to every 4 hours as needed. The hospice note, dated [DATE], indicated the resident stated he was in pain and sore since his hospital visit when they did CPR. The social worker informed the facility the patient said he was sore from breaking ribs when they did CPR. The facility nurse indicated the patient had routine and as needed pain medication and she did not know how he could have such high amounts without sleeping. The social worker encouraged making the resident comfortable and hospice mindset, and that the patient might have a high tolerance and to call hospice with concerns. The hospice note, dated [DATE], indicated the resident vented frustrations to the chaplain. He felt ignored and neglected by his team of caregivers. The nurse's note, dated [DATE] 1:27 p.m., indicated the resident's liquid [MEDICATION(S)] was changed to [MEDICATION(S)] 20 mg three times daily and his [MEDICATION(S)] was changed from scheduled to every 4 hours as needed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated [DATE] 6:46 a.m., indicated the resident complained of left lower tooth pain and he thought he may need to see a dentist due to his mouth hurting. He believed it may be going into an abscess. Hospice was notified. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated [DATE] at 2:04 p.m., indicated a new order for [MEDICATION(S)] 30 mg 1 tablet four times daily for pain. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated [DATE] at 6:42 a.m., indicated a new order for [MEDICATION(S)] 20 mg/mL, give one mL every hour as needed for shortness of breath or pain. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on [DATE] at 8:40 a.m., the resident indicated he was upset because he had a DNR order and he had been revived. He died and stopped breathing, and the nurse found him on the floor. She performed CPR and broke his ribs and his sternum. It happened about a month and a half to two months ago. He was still sore from it and it really hurt. The nurse didn't know he was a DNR, a lot of them didn't. He was on Hospice to keep him comfortable because he had cancer. When he revived he indicated he was almost home and then he didn't know how to feel when he woke up in the ER. After a day or two he wished she had never touched him because he was in so much pain. The resident stated, She broke all that stuff inside me and I had to live through it and I wouldn't have had to live through it if she hadn't of done that. I tell everyone now personally I'm a DNR. I don't want it to happen again. During an interview, on [DATE] at 1:45p.m., LPN 4 indicated she performed CPR on Resident D. An aide came and told her that he wanted pain medication. She was discharging a patient and said she would be right there. When she finished her paperwork she went in and the resident was slumped over and he did not have a pulse. She tried to arouse him and he had no pulse. She went out and the other nurse and CNAs were at the nurses station. She went for the crash cart and asked the other nurse to check for his code status and call the DON. When she was coming back she asked the nurse and she said he was a CPR. Another nurse and her went in and started performing CPR and sent him out to the hospital. When he got back she checked the chart and the DNR was marked out and CPR was wrote above it. That was on the first page in his physical chart. She did not check his POST form or his electronic orders. She did not look. The other nurse was looking for her. When it was all done and over she looked at the first page of the chart. She had no idea why it was crossed out. They wondered why it looked like that. She was told after the fact he was a DNR, but she followed what she was told. The other nurse, LPN 3 that confirmed the status. When she first went in and raised him up he had a little bit of saliva coming from his mouth. She did do a sweep because she thought he might have been choking. He did not say anything at all. He was not breathing. She didn't feel any cracking or anything, he's a larger man. She had cared for him since that time. He had complained several times. He said I can't believe your 100 pounds self-hurt my ribs. It made my ribs hurt. The last couple of times she'd had him he had not said anything related to his ribs. She indicated he had thanked her for saving his life. He had told her about the pain a few times, he had described it on more than one occasion. She did not ask him to rate the pain or describe it. She was not aware of anyone notifying the doctor of the pain or obtaining any imaging. She was not aware if they had a policy to check the electronic chart for code status orders. They had let hospice know he had talked about his ribs hurting. During an interview, on [DATE], at 8:20 a.m., the ED indicated she had completed a timeline the night prior. Some of her staff members told her the resident had been thankful they had performed CPR on him. They found a POST form for the resident, dated [DATE] that indicated the resident was a full code. They had just seen the hospice notes for the first time that the resident complained of his ribs being cracked but did not see that mentioned on his chest x-ray from the hospital. The hospital told them he wanted to return as a full code because he wanted to keep going. On [DATE] the hospice nurse documented that he wanted to remain with hospice and remain a DNR. She told him she would revisit on [DATE] for his final decision. On [DATE] that post form with a DNR was signed. At that time the order was placed and the care plan with the DNR status was placed. It was concerning to her they just got the notes from hospice, she didn't know why they didn't send them after their visit. During an interview, on [DATE] at 8:22 a.m., the Administrator in Training indicated what he knew of their process was that hospice was to print the notes and put them in the binder. They had a DNR form for the resident that was prepared on [DATE] which was before he was on service with them and was signed by the physician. He did not come on service with them until [DATE]. He was a transfer from another hospice provider. They had an additional post form after he came back from the hospital again that was on [DATE] that they obtained after the incident, which indicated he was a DNR again. His DNR status was confirmed with him upon his admission. It was in their admission documentation. There was a conversation between the admission nurse and the patient. In their electronic system he was flagged as a DNR. He did momentarily decide to be full code at the hospital after he had been revived, but she was told he ultimately stayed DNR. They were not contacted she believed until after he was sent out to the hospital. During an interview, on [DATE] at 9:22 a.m., Hospice RN 6 indicated she saw the resident personally twice weekly. He was in a high rate of pain. He came on service with the hospice service in July, and she had seen him regularly since then. He had always been a DNR. They had a POST form signed from the previous hospice group he was with, and that was dated a year before they got him as a patient. When they got him in July of 2022 he verified he wanted to be a DNR the day they admitted him. The only time she was aware of him not wanting to be a DNR, was after they coded him. There was approximately 48 hours where he wanted to be a full code, but all she had heard after that time was that he wanted to be a DNR and he should have always been a DNR. He had a tendency to agree with who was in front of him. She took her time to make sure his decisions were completely his own. He expressed that he shouldn't be alive and he was. His ribs were hurting for weeks afterwards which constantly reminded him that he was revived and how much pain that caused and how he never wanted to go through that again. Probably until the first of September he would ask her, I'm a DNR right? She always asked the nurses to reiterate that he was a DNR. She would say, if she could localize one of his pains, he had back pain, mouth pain, rib pain, lung issues that cause pain. Discerning between which one hurt the most would be difficult. He absolutely expressed how bad his ribs were hurting. For a couple of weeks it was all he spoke of. It was his main point of pain. He should not have had CPR, he was a DNR. It did hurt his ribs and it added to his pain. It reaffirmed the DNR for him. He was his own person, he was capable of making his own choices. His thought processes were not inaccurate. During an interview, on [DATE] at 10:57 a.m., LPN 3 indicated She did recall the incident. LPN 4 came and hollered we needed everybody on deck. They were trying to figure out if he was a full code or a DNR. So I looked on the computer, the computer said he was a DNR, some of the aides said in the book we had was CPR, so I looked in the book and that's what it said. I called hospice to get clarification. I was waiting for a reply back from them. During that waiting period we initiated CPR and called 911. Hospice called me back but by the time I got that call back everything was taken care of. The electronic health record said he was a DNR. She did not check his orders. Usually the code status is right at the top. She did check the physical chart. It said CPR. She thought it had said DNR and had been marked out and changed. She did not know if they were supposed to use the physical chart or the electronic chart. All she knew was to call hospice for clarification. The paper chart is the quickest to reach. The paper chart and electronic chart should reflect one another. She did indicate the resident expressed to her upon his return he was grateful they saved his life. The Initiate CPR policy and procedure, last reviewed [DATE], provided on [DATE] at 3:15 p.m. by the ED, included, but was not limited to, . Procedure . 3) Residents found unresponsive, not breathing or without a pulse, will have staff immediately locate the Code Status and communicate this to the team . 4) If CPR is indicated, staff will begin CPR and call [DATE] with these exceptions: a. There is a valid DNR order in place . The General Code Status policy and procedure, last reviewed [DATE], provided on [DATE] at 3:15 p.m., included but was not limited to, . It is the intent of this facility to honor the residents wishes and rigts of the resident/representative to make the determination of what, if any, resuscitative measures will be implemented in the event the resident's respirations and/or pulse cease either by natural or unnatural causes . The purpose of this policy is to guide clinical staff to quickly and accurately identify residents in the facility that do and do not request CPR as a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . An efficient and accurate method of determining the code status of a resident during a medical emergency is needed. The use of an electronic health record (EHR) provides for fast retrieval to identify and how to appropriately respond to respiratory and cardiac arrested based upon the resident/representative wishes . Procedures . I . c. Code Status is found in the electronic health record and will be used by the nurse to validate Code Status before initiating CPR . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the DON completed an audit of all residents to ensure accuracy of their Advanced Directives to include the validation of the POST form, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate jeopardy was removed on [DATE] but remained at the lower scope and severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy, because the facility still needed to conduct further education to include expectations of notification to contracted companies involved in care of mutual residents, ensure social services involvement for psychosocial support during the decision making process, ensure psychiatric and social services were offered related to advanced directives decisions for residents, communication to contracted companies would include a copy of the POST form, or any form utilized to identify the residents' advanced directives, code blue drills on random shifts and audits would need to be conducted. This Federal tag relates to Complaint IN 039 3.,d+[DATE](a)

Based on observation, record review, and interview, the facility failed to ensure appropriate interventions were developed and implemented to prevent the development and worsening of pressure ulcers resulting in a facility acquired stage 3 pressure ulcer and a deep tissue injury (Resident 84) for 1 of 4 residents reviewed for pressure ulcers. (Resident 84) Findings include: During an observation on 9/27/22 at 8:31 a.m., Resident 84 was lying in bed on her right side. She had no pressure relieving boots in place and was rubbing her left foot on the bed repeatedly. During an observation on 9/29/22 at 10:28 a.m., the resident was lying in bed. There were no heel boots on the resident's feet or observed anywhere in the room. There was a dressing to her left lateral foot, dated 9/28/22. She was moving her left foot back and forth and scooting it on the surface of the bed. There was a scabbed, dry, reddened area to lateral aspect of the base of her right great toe. There was a pillow in place between her legs, however both feet were resting directly on the mattress surface. During an observation on 9/29/22 at 10:34 a.m., CNA (Certified Nurse Aide) 10 indicated the resident had a small open area on her bottom. There was a bordered gauze dressing in place to her sacrum, dated 9/28/22. The CNA indicated the resident always moved her feet in a jerking motion, she had done it ever since she could remember taking care of her. There was not much they could do for her feet. During an observation on 9/29/22 at 2:15 p.m., PT (Physical Therapist) 11 returned the resident to her room in a geri-chair. The resident had a positioning pillow between her knees and heelbo (socks with padding to protect the heel) socks in place to her bilateral feet. The nursing staff had referred the resident to therapy when they noticed a change in her muscle tone on the left side a couple week ago. Her arm had started to curl up and her left leg was drawing completely to her chest. They were trying heelbo socks on her feet for the first time that day. The socks had built in padding to protect the heel because she was rubbing her skin a lot. They were trying to prevent further breakdown. They had been available prior to that day. She did not have heel protection boots that she was aware of. The therapist looked in the room and in the resident's drawers and could not locate any protective heel boots. The clinical record for Resident 84 was reviewed on 9/28/22 at 10:03 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 5/30/22, indicated the resident was cognitively intact, required extensive staff assistance with bed mobility, transfers, toileting, and personal hygiene, was at risk for developing pressure ulcers, and had no pressure ulcers upon admission to the facility. The care plan, initiated on 5/25/22, indicated the resident had impaired skin integrity or was at risk for altered skin integrity. Interventions, dated 5/25/22, indicated to administer treatments as ordered by medical provider, apply a barrier creams post incontinent episodes, complete skin at risk assessment upon admission and readmission, quarterly, and as needed, complete weekly skin checks, ensure residents are turned and repositioned, enhanced barrier precautions when dressing, bathing, showering, transferring, personal hygiene, changing linens, toileting and peri-care, providing care to wound care for skin openings that require a dressing, float heels while abed, nutritional consult on admission, quarterly, and as needed, diet as ordered, and update physician for any signs or symptoms of infection. The admission assessment, dated 5/24/22 7:50 p.m., indicated the resident would remain free of skin breakdown. A pressure reducing mattress was in place. The assessment did not indicate if the resident's skin was intact or not. The skin assessment, dated 7/20/22, indicated the resident had no skin issues. The skin grid non-pressure assessment, dated 7/23/22 at 1:42 p.m., indicated the resident had a new non-pressure area described as a sheering wound in between the resident's buttocks. The size indicated diffuse. The skin loss was partial thickness with red, moist, grainy, optimal granulation. There was no exudate or pain. The treatment recommendations indicated continue current treatment orders. Current treatment orders indicated, keep clean and dry. The clinical record lacked documentation of any orders, new interventions, or physician notification. The skin and wound note, dated 7/27/22 at 2:59 p.m., indicated the resident had been seen by the Wound NP for assessment of a new area first observed on 7/23/22 by the floor nurse. The area was assessed to be a stage 3 pressure ulcer to the sacrum. The resident was post [CONDITION(S)], non-complaint with turn and repositioning, incontinence and had decreased mobility. Her family member indicated he had been dealing with this off and on for years and it was nothing new for her. New treatment orders were given The Wound NP's assessment, dated 7/27/22, indicated the resident had a stage 3 pressure ulcer to the sacrum, which developed in house on 7/23/22. The wound measured 1.32 cm (centimeters) in length by 0.75 cm in width, by 0.1 cm in depth. There was 60% granulation, 40% slough or eschar, and moderate serosanguinous drainage. The treatment included to cleanse with normal saline and apply medical honey and a bordered foam dressing every 3 days and as needed. The wound NP's assessment, dated 8/10/22, indicated the stage 3 to the resident's sacrum was stable, however the measurements had increased to 2.72 cm in length, 2.96 cm in width, and 0.1 cm in depth. The treatment remained the same. The wound NP's assessment, dated 8/17/22, indicated the wound was debrided and was improving with decreased measurements. The skin and wound note, dated 9/12/22 at 3:49 p.m., indicated the Wound NP saw the resident for a report of a new skin issue. Her left medial foot had an evolving deep tissue injury, a blanchable area to her left first digit on the medial and multiple scabbed areas from self-inflicted scratch marks. The resident had a contracture to the left leg and scratched her right leg with her toenails. She was unable to understand importance of elevating her feet related to decreased safety awareness. Staff tried to separate her legs with pillow and the resident removed it with her good hand. Staff encouraged the resident to elevate her right heel without success. On 9/12/22 the care plan was updated to reflect a deep tissue injury to the left medial foot. An intervention of providing off-loading heel boots was added. The wound assessment, dated 9/12/22, indicated the resident had a new SDTI to her left lateral foot, which measured 2.77 cm in length, 1.53 cm in width, and 0 cm in depth. The treatment indicated to skin prep and leave open to air. During an interview on 9/29/22 at 1:56 p.m., the resident's family member indicated the resident had just been gotten up for the first time in 5 months. It was the first time she had been out of her bed for anything other than a shower since she'd been in the facility. She was paralyzed on one side and couldn't stand up. She had bed sores which she got from moving her leg. He had not seen boots on the resident's feet, just the bandages and medication once she got the sores. He had not seen anything on her feet beforehand. She had a sore on her bottom too at the end of her spine. He did not know how she got it. During an interview on 9/30/22 at 2:39 p.m., LPN 3 indicated skin assessments were conducted once a week. If a new area of skin impairment was identified she would chart it on the skin assessment, measure it, clean it, let the wound nurse know, and do the skin grid assessment. Part of the assessment would include the measurements, notification to the physician, and they would also do a nurses note saying if they called the family or the doctor. The wound nurse would be notified if she was in the facility, and they would let the unit manager or DON (Director of Nursing) know. Treatment was started immediately. She would do immediate first aide and get clarification on an order. During an interview on 9/30/22 at 2:42 p.m., the DON indicated skin assessments should be completed at least weekly. If a new area was found it should be written up. Staff should ensure the doctor was called, orders were obtained, and the resident's family was notified. She would expect a new area to be measured. The wound nurse was there on Mondays so the wound identified on 7/23/22 should have been seen on 7/25/22. Notification to the physician would be located in the progress notes. All she could see the nurse charted on was the skin grid assessment on 7/23/22. She did not see any indication of the physician being notified or any treatment orders between 7/23/22 and 7/27/22. The resident was constantly moving. They had tried boots and heel lifts. She wasn't aware of what heelbo socks were or that they existed, or she would have tried them, but she didn't believe they had been tried prior. She thought the resident had a noncompliant care plan but could not locate one in the clinical record. When a resident refused an intervention, they would keep trying new interventions. She would expect to see noncompliance with interventions reflected in the clinical record and the care plan. The Skin Care and Wound Management Overview, dated 5/30/19, was provided on 9/30/22 at 9:30 a.m., by the Regional Nurse. The policy included, but was not limited to, . Skin care and wound management program included, but is not limited to: Analysis of facility pressure ulcer data for quality improvement opportunities. Application of treatment protocols based on clinical 'best practice' standards for promoting wound healing. Daily monitoring of existing wounds. Identification of residents/patients at risk for development of pressure ulcers. Implementation of prevention strategies to decrease the potential for developing pressure ulcers . 3.1-40(a)(1) 3.1-40(a)(2) 3.1-40(a)(3)

Based on interview and record review, the facility failed to ensure a resident (Resident B) received the correct medication, which resulted in hospitalization , for 1 of 3 residents reviewed for significant medication errors. Findings include: The clinical record for Resident B was reviewed on 1/13/22 at 12:57 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The incident report, dated 1/5/22, indicated the resident received the wrong medication. The January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility investigation indicated Resident B also received the following medications on the morning of 1/5/22 without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Acetaminophen ([MEDICATION(S)]) 1,000 mg -[MEDICATION(S)] (supplement) 500 mg -[MEDICATION(S)] (diuretic) 2 mg -[MEDICATION(S)] Silver Tablet (supplement) -[MEDICATION(S)] (allergy medication) 10 mg -[MEDICATION(S)] (supplement) 1,000 mg -[MEDICATION(S)] (hypertensive medication) HCl ([MEDICATION(S)]) ER (extended release) 240 mg -FluticasonePropionate (allergy spray) 50 mcg (micrograms) -[MEDICATION(S)] (medications for chest pain) ER 30 mg -[MEDICATION(S)] (diuretic) 2.5 mg -[MEDICATION(S)] (insulin) 70/30 (70% intermediate acting and 30% short acting) 25 units subcutaneously -Oxybutin Chloride ER (bladder relaxant) 5 mg -Vitamin B-12 (supplement) 1,000 mcg -[MEDICATION(S)] (supplement) 1,000 units -[MEDICATION(S)] (stool softener) 100 mg -[MEDICATION(S)] Sulfate (iron supplement) 325 mg -[MEDICATION(S)] (medication for [CONDITION(S)]) 400 mg -Potassium Chloride ER (supplement) 10 milliequivalents The nurse's note, dated 1/5/22, indicated Resident B was accidentally given Resident C's medication. The nurse practitioner was notified with new orders to monitor blood sugars and vital signs every hour. The nurse practitioner spoke with the residents' facility PCP (primary care physician) who then ordered D5 ([MEDICATION(S)] 5% which was used for low blood sugar) IV (intravenously) at 75 ml (milliliters)/hr (hour). The resident's blood pressure dropped to 84/64 (normal range is 120/80). The nurse practitioner gave an order to send the resident to the emergency department. The hospital history and physical note, dated 1/5/22 at 2:54 p.m., indicated the resident was sent via EMS (emergency medical services) from the facility when the resident accidentally received both his and his roommate's medication. He had a low heart rate and blood sugar. The patient was given 200 ml of D5 in route per EMS due to low blood glucose. Upon arrival, the patients' blood sugar was 85. The patient was also given 0.5 [MEDICATION(S)] in route per EMS due to [CONDITION(S)] (low heart rate) of 42 BPM (beats per minute). His heart rate on arrival is in the 70's. During an interview on 1/13/22 at 1:44 p.m., LPN (Licensed Practical Nurse) 2 indicated she was being orientated on medication pass with LPN 3. LPN 3 prepared the medications and she administered them. There was a misunderstanding and LPN 2 thought the medications and insulin were for Resident B. LPN 3 had asked her a question, which she could not remember, and that was when she realized she had given the resident the incorrect medications. The clinical record for Resident C was reviewed on 1/13/22 at 1:15 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The incident report, dated 1/5/22, indicated Resident C's morning medications were inadvertently given to Resident B. On 1/13/22 at 2:56 p.m., the AIT (Administrator in Training) provided a current copy of the document titled Medication Administration dated 12/14/2017. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care that meets the .physical .needs .of the residents. Safety of residents .is a top priority of care .Procedure .Administer medication only as prescribed by the provider .Observe the five rights in giving medication .the right resident .the right medicine .Do not administer medications prepared by others The past noncompliance began on 1/5/22 and was removed and the deficient practice corrected by 1/7/22 after the facility implemented the following action: All licensed nursing staff were educated on medication administration, which included the six rights of medication administration and the proper procedure for medication administration was observed. This Federal tag relates to Complaint IN 472 3.1-48(c)(2)

Based on observation, interview and record review, the facility failed to ensure adequate supervision was in place when three (3) residents (Resident B, C, and D) with dementia, exited the facility without supervision for 3 of 4 residents reviewed for supervision. Resident B ambulated 0.8 miles away from the facility, Resident C was found 0.5 miles from the facility in his electric wheelchair, and Resident D was found in the parking lot. The Immediate Jeopardy began on 10/24/21 when three (3) residents with dementia exited the facility without supervision. Resident D was found in the facility parking lot. Resident B exited the side exit door by the breakroom to the parking lot. The route was undetermined, however, there are 3 possibilities all with road and terrain dangers. Resident C exited through the front doors and was found 0.5 miles from the facility. The road taken by Resident C was observed to have multiple small inclines and declines with no sidewalk. The Regional Director of Operations/Acting Administrator, Regional Director of Clinical Operations, and Interim Director of Nursing were notified of the Immediate Jeopardy on 10/27/21 at 4:25 p.m. The Immediate Jeopardy was removed and the deficient practice corrected on 10-25-2021 prior to the start date of the survey and was therefore past Non Compliance. Findings include: 1. The clinical record for Resident B was reviewed on 10/26/21 at 12:50 p.m. Diagnosis included, but were not limited to, dementia. The MDS (Minimum Data Set) admission assessment, dated 7/19/21, indicated severely impaired cognition and wandering behavior occurred 1-3 days. The Wandering Assessment Tool, dated 10/14/21, indicated the resident had risk factors for elopement or unsafe wandering. The care plan, dated 7/14/21, indicated the resident was at risk for wandering. Interventions included to assess for hunger, thirst, ambulation, and toileting needs, notify staff of wandering risk, provide diversionary tactics, and to provide structured activities at times of increased wandering. The progress note, dated 10/21/21 at 2:29 p.m., indicated the resident refused her shower and told staff she would take her shower at home. Another head count was completed and the resident was not found. A Code W (missing resident) was called and the resident was found. The Nurse Practitioner note, dated 10/25/21 at 4:49 p.m. indicated the resident had increased confusion/wandering, walked out of the building yesterday, and had been wandering around the building since she admitted . During an interview on 10/26/21 at at 1:25 p.m., the Interim DON (Director of Nursing) indicated staff had asked the resident to take a shower, the resident said no, and that she would take one at home. At approximately 3:30 p.m., the exit door alarm by the breakroom was sounding. She went to the door, looked out, did not see anyone, and turned the alarm off. She went back to her office and then asked the staff to do another head count as she just felt something was not right. She was told Resident B was missing, they called a Code W, and staff began to search outside for the resident. The resident was found by her ex-husband walking by the fairgrounds. The resident exited the building by pushing on the door until it opened and was gone approximately 30 - 40 minutes. The fairground is located 0.8 miles from the facility. During an interview on 10/26/21 at 1:50 p.m., CNA (Certified Nursing Assistant) 3 indicated on 10/24/21, she was sitting in the office with the Interim DON when she heard the door alarm at around 2:45 p.m. The Interim DON got up, turned off the door alarm, came back to her office, and asked the Unit Manager to have staff do another head count. At 3:40 p.m., LPN (Licensed Practical Nurse) 6 came back to the office and said they could not find Resident B. CNA 3 and CNA 7 went out side and checked the perimeter of the building and could not find the resident. Both CNA's got in the car and drove down the road to look for her. During the search, the facility notified them that the resident's ex-husband had found the resident at the fairgrounds. During an interview on 10/27/21 at 11:23 a.m., the Interim DON when she interviewed the staff, they told her they did not hear the door alarms when Resident C and Resident B exited because they were in resident rooms providing care. On 10/27/21 at 3:35 p.m., the Regional Director of Operations provided a current copy of the document titled Elopement Prevention dated 7/1/16. It included, but was not limited to, Elopement is defined as when a resident/patient leaves the premises or a safe area without authorization and/or any necessary supervision and places the resident/patient at harm or injury .Policy .The facility strives to prevent resident/patient elopement 2. The clinical record for Resident C was reviewed on 10/26/21 at 1:15 p.m. Diagnoses included, but were not limited to, vascular dementia and right sided [CONDITION(S)]. The quarterly MDS assessment, dated 3/16/21, indicated moderately impaired cognition. The progress note, dated 10/24/21 at 9:28 a.m., indicated the resident became upset when he asked the nurse for pain medication and was asked to wait until she administered the medication she had prepared for another resident. She was informed by CNA 4 that the resident had exited the building in his power wheel chair. Staff visualized the resident within a minute, followed the resident, and then the resident was brought back to the building. The BIMS (Brief Interview of Mental Status) assessment, dated 10/25/21, indicated severely impaired cognition. During an interview on 10/26/21 at 1:23 p.m., the Interim DON indicated the resident requested pain medication from the nurse. The nurse was in the middle of gathering another resident's medication and told him he would have to wait until she finished the medications she was working on. The resident became agitated and at approximately 9:28 a.m., the resident, in his electric wheelchair, exited through the first set of front entrance doors. He then pulled on the right, second exit door and pulled it off the track and exited the building. CNA 3 saw him at the edge of the parking lot. She called the building to see if he was in the building, he was not, CNA 3 followed him to the top of the hill and brought him back in the building. During an interview on 10/26/21 at 1:50 p.m., CNA 3 indicated she had taken the breakfast cart to the kitchen. CNA 7 was coming in and CNA 3 went out for morning her break. She looked to the left and saw a resident. She called CNA 4 to have her look and and see if Resident C was in the building and he was not. He was riding in his electric wheel chair on the main street. As she started to go after him, he crossed the road and at the split, went left. She continued to go after him and found him in the high school parking lot. She asked him what he was doing and he told her getting the hell out of here. He kept going and told her he was mad because the nurse would not give him his pain medication. He wad finally convinced him to come back to the building. She did not see him exit the building and there was only a short where she did not have eyes on him. The resident was wearing a cut off t-shirt, shorts and did no have shoes or socks on. During an interview on 10/26/21 at 2:35 p.m., CNA 4 indicated at 9:28 a.m., she received a call from CNA 3 who asked her to check and see if Resident C was in his room. He was not there and she told the nurse. She went to the front door, the alarm was sounding, and the right last exit door was open. She, CNA 3 and CNA 7 took off looking for the resident and found him in the high school parking lot. He started going again after that and would not stop as he was mad because the nurse would not give him his pain medicine. They Finally convinced him to come back to the building. The distance from the building to the high school parking lot was 0.5 miles and the temperature was between 70 and 81 degrees between 6:00 a.m. and 6:00 p.m. with a partly cloudy sky. 3. The clinical record for Resident D was reviewed on 10/26/21 at 3:42 p.m. Diagnosis included, but was not limited to, dementia. The admission MDS assessment, dated 9/7/21, indicated severely impaired cognition. There was not a wandering tool observation completed on admission. The IDT (interdisciplinary team) note, dated 10/25/21 at 9:49 a.m., indicated the resident had exited the facility when another family was leaving. Staff observed the resident in the parking lot from the window and escorted him back into the building. During an interview on 10/26/21 at 1:25 p.m., the Interim DON indicated the resident exited the facility with 2 family members between 11:00 a.m. and 11:05 a.m. Another family member, who was coming in reported that he was out in the parking lot. Staff found him in the parking lot and brought him back on the building. During an interview on 10/26/21 at 2:35 p.m , CNA 4 indicated she was in the break room and getting ready to sit down. She looked out the window and saw the Resident D, went to the parking lot, and escorted him back in the building. The written statement from a family member indicated on 10/24/21 at 11:00 a.m., she arrived at facility for a visit. As she was walked around the corner, she saw 2 women and a man exit the building through the front door. At first she thought they were together, but after they exited, the man walked away for the women. One of the women flagged her down and asked if she could inform the staff that he had left the building. About 3 minutes later, the staff escorted him back into the building. The Past noncompliance Immediate Jeopardy began on 10/24/21. The Immediate Jeopardy was removed and the deficient practice corrected by 10/25/21 after the facility implemented a systemic plan that included the following actions: The facility completed staff education on the elopement policy and elopement drills on 10/25/21, elopement drills initiated 10/25/21, all doors were checked for proper functioning and secured on 10/24/21, wandering/elopement risk assessments were completed on 10/25/21 to identify those at risk for elopement, the care plans and elopement books were updated on 10/25/21, and a brief interview of mental status was completed 10/25/21 on all residents to ensure accuracy. This Federal tag relates to Complaint IN 732 3.1-45(a)(2) -+-

Based on observations,interview, and record review, the facility failed to ensure interventions were implemented for a resident (Resident B) when he refused to turn and reposition, which resulted in a stage 3 (full thickness skin loss potentially extending into the subcutaneous tissue) pressure ulcer to the coccyx and SDTI (suspected deep tissue injury is damage to underlying soft tissue as a result of pressure) area to the right heel; and failed to ensure appropriate interventions were in place for an at risk resident (Resident G) which resulted in a stage 3 pressure ulcer to the coccyx for 2 of 3 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident B was reviewed on 6/17/21 at 1:47 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (Minimum Data Set) assessment, dated 3/17/21, indicated the resident had moderately impaired cognition and required an extensive two person physical assistance with bed mobility. The Braden Scale for Pressure Risk assessment, dated 3/11/21, indicated the resident was at a moderate risk related to slightly limited sensory perception, was occasionally moist, was chairfast, had very limited mobility, probably inadequate food intake, and a problem with friction and shearing. Moderate risk with potential interventions of an actual turning schedule, wedge support for 30 degree side positioning, pressure reduction support surface, and protect heels. The care plan, dated 3/11/21, indicated a self-care deficit and the resident required an extensive two-person physical assistance with bed mobility. The care plan, dated 3/12/21, indicated a potential for impaired skin integrity and to complete weekly skin checks and a skin risk assessment upon admission, quarterly, and as needed. The 3/11/21 admission skin evaluation indicated the resident refuses care at times and refuses to be turned at times. admitted with a stage 1(sheering) to the left buttock which measured 4.3 cm (centimeters) x (by) 3.4 x 0.1 (area healed) The weekly skin assessment, dated 3/18/21, indicated the resident had no new impaired areas. The nurse's note, dated 3/19/21 at 5:38 a.m., indicated the resident had shearing to the coccyx which measured 3 cm in length, 2 cm in width with no depth. A [MEDICATION(S)] treatment was placed and the resident was encouraged to turn every 2 hours with assistance. Review of the weekly Skin Grid Pressure sheets, completed by the wound nurse, indicated the following area with measurements to the coccyx: 3/19/21 at 3:19 p.m. - 5 cm in length, 3.5 cm in width with a depth of 0.2 cm - Stage III 3/26/21 - 6 cm in length, 2 cm in width with a depth of 0.3 cm 4/1/21 - 3 cm in length, 2 cm in width with a depth of 0.1 cm; low air loss mattress added 4/7/21 - 2.5 cm in length, 1.5 cm in width with a depth of 0.1 cm 4/13/21 - 2.3 cm in length, 1.2 width with a depth of 0.1 cm 4/20/21 - 2 cm in length, 1.5 cm in width with a depth of 0.1 cm 4/29/21 - 2.7 cm in length, 1.6 cm in width with a depth of 1.6 cm 5/05/21 - 2.5 cm in length, 2.3 cm in width with a depth of 1.6 cm 5/13/21 - 3.1 cm in length, 1.8 cm in width with a depth of 1.5 cm 5/20/21 - 2.5 cm in length, 1.9 cm in width with a depth of 2.0 cm 5/27/21 - 2.1 cm in length, 2.1 cm in width with a depth of 2.0 cm 6/3/21 - 2.4 cm in length, 1.6 cm in width with a depth of 1.7 cm 6/10/21 - 2.0 cm in length, 1.9 cm in width with a depth of 2.5 cm Review of the weekly Skin Grid Pressure sheets indicated the following area with measurements to the right heel: 3/19/21 - 4 cm x 4 cm with no depth - deep tissue injury 3/26/21 - 4 cm x 4 cm with no depth. 4/1/21 - 2.8 cm x 1.2 cm x 0.1 cm 4/7/21 - 1 cm x 0.5 cm with no depth 4/13/21 - healed at this time 4/20/21 - 2 cm x 1.5 cm with no depth 4/29/21 - 1.4 cm x 2.3 cm with no depth 5/5/21 - 0.5 cm x 1.3 cm with no depth 5/13/21 - 0.6 cm x 1.1 cm with no depth 5/20/21 - 0.6 cm x 1.3 cm with no depth Area healed The care plan, dated 4/20/21 indicated the resident had an alteration in skin integrity. Interventions included, float heels while [NAME], keep skin clean, dry, and odor free, treatments as ordered, turn and reposition every 2 hours, and update the physician with signs or symptoms of infection as needed. The clinical record lacked documentation of any interventions implemented related to the resident's refusal of care prior to the acquisition of the wounds. During an interview, on 6/17/21 at 4:45 p.m., the Director of Nursing indicated the resident acquired the wounds due to his refusal to turn and reposition. On 6/18/21 at 11:07 a.m., there were no specific interventions implemented related to the resident's refusal of care until 4/30/21. The current policy titled Skin Care & Wound Management Overview dated 7/2016 included, but was not limited to, A pressure ulcer is defined as localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction .Policy .The facility strives to prevent resident .skin impairment .Skin care and wound management program includes .Implementation of prevention strategies to decrease the potential for developing pressure ulcers .Develop a care plan with individualized interventions .Modify .interventions as needed 2. The clinical record for Resident G was reviewed on 6/18/21 at 12:12 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment, dated 5/16/21, indicated the resident's cognition was moderately impaired cognition, no walking activity, and required an extensive two person physical assistance with bed mobility. On 6/21/21 at 4:00 p.m., the resident's coccyx wound was observed with LPN (Licensed Practical Nurse) 5. There was no treatment observed in place and the wound measured 0.7 cm in length, 0.3 cm in width with a depth of 0.2 cm. The Braden Scale for Pressure Ulcer assessment, dated 4/19/21, indicated the resident was a low risk for pressure ulcers due to slightly limited sensory perception, occasionally moist, chairfast, slightly limited mobility, and a problem with friction and shearing. Low at risk interventions included frequent turning, protect heels, and manage moisture. The care plan, dated 11/10/20, with a revision date of 5/7/21, indicated the resident had actual skin impairment of a stage 3 pressure ulcer to the coccyx. Interventions included wound specialist to follow, dietary consult as needed, treatments as ordered, and to notify the physician of signs and symptoms of infection. The care plan, dated 5/6/21, indicated the resident was at risk for impaired skin integrity. Interventions included consult the dietician per order, evaluate skin integrity, monitor bony prominences for redness, and to apply a barrier product as needed. The weekly skin assessment, dated 4/15/21, indicated the resident's skin was intact. The nurse's note, 4/19/21 at 12:23 p.m., indicated the resident had a new area to the coccyx. The area was assessed and found to be a fissure which measured 1 cm in length, 0.3 cm in width, with a depth of 0.2 cm. The nurse's note, dated 4/22/21 at 12:16 p.m., indicated the wound nurse practitioner was in to see the resident and classified the area as a stage 3 pressure ulcer. Review of the clinical record lacked documentation of a turning and repositioning schedule prior to 6/18/21. During an interview on 6/21/21 at 4:53 p.m., the Director of Nursing indicated the resident's area started as a fissure and classified as a stage 3 by the wound specialist, all residents should be turned/repositioned every 2 hours, and heels should be floated as the residents would allow. This Federal tag relates to Complaint IN 205 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure a resident's wishes for resuscitation were followed. This resulted in the resident not receiving continuous life saving measures and emergency medical services not being called, for 1 of 3 residents reviewed for full code status. (Resident B) The Immediate Jeopardy began on [DATE], when staff failed to continue Cardiopulmonary Resuscitation (CPR) on a resident (Resident B) with an active full code status. The Executive Director, and Regional Director of Clinical Operations were notified of the Immediate Jeopardy on [DATE] at 2:20 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, on [DATE], prior to the start of the survey and was there fore Past Noncompliance. Findings include: The clinical record for Resident B was reviewed on [DATE] at 12:14 p.m. [DIAGNOSES REDACTED]. The care plan, dated [DATE], indicated the resident was a full code and the code status would be honored. The POST (Indiana Physician order [REDACTED]. The progress note, dated [DATE] at 4:30 a.m., indicated the resident was found lying at the bottom of the bed unresponsive and cold to touch. The resident's fingers and lips were blue. The resident was placed on the floor and CPR initiated by LPN 2. RN 3 called off CPR at 4:38 a.m. after no pulse was received. The resident's time of death was 4:38 a.m. The incident report, dated [DATE] at 5:47 p.m., indicated LPN (Licensed Practical Nurse) 2 found Resident B unresponsive and began CPR. RN (Registered Nurse) 3 was summoned to assist with CPR. RN 3 stated Resident B was obviously deceased and EMS (Emergency Medical Services) was not contacted. CPR was discontinued by RN 3 after several rounds of CPR over the course of 20 minutes and no shock indicated per the AED (Automatic External Defibrillator). During an interview on [DATE] at 12:45 p.m., LPN 2 indicated she entered the resident's room at 4:10 a.m. to administer the resident's medication. He was lying at the bottom of the bed, unresponsive, with no pulse or respiration. She pressed the call light for the aide, placed the resident on floor, and initiated CPR by herself for 15 minutes until the aide came and she instructed the aide to get RN 3. EMS was not called as there was no one to call since both nurses were providing CPR and aides cannot do that. They worked on him for 38 minutes at which time the RN 3 said to stop. LPN 2 indicated their policy was to call 911, however, they are supposed to get an order before they do anything. The MD notification system did call back at 4:45 a.m., however, CPR had ceased at that time. Per the facility policy, an RN cannot make the decision to stop CPR, however, she stopped because the LPN worked under the RN. During an interview on [DATE] at 1:06 p.m., RN 3 indicated she was called to Resident B's room and when she entered the room, the resident was blue and his nail beds were discolored. She took over CPR and had LPN 2 call the physician notification system and the family. Upon the LPN's return, she said she could not reach anyone. She and LPN 2 continued CPR and she told LPN 2 to stop because there was obviously no way it would change anything. With the limited staff in the building, she made a judgement call against policy. She should have called 911. During an interview on [DATE] at 12:52 p.m., the Executive Director indicated, per facility policy, a registered nurse cannot call off CPR. At 12:05 p.m. she indicated there were no other medical emergencies at the time of the incident in the facility. Any staff member can call 911 it did not have to be a nurse. On [DATE] at 12:20 p.m., the Executive Director provided a current copy of the document titled General Code Status dated [DATE]. It included, but was not limited to, Advanced Directive .a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves .Policy .It is the policy of this facility to provide resident centered care that meets the .physical needs .of the residents .It is the intent of this facility to honor the wishes and rights of the resident .to make the determination of what .resuscitative measures will be implemented in the event the resident's respirations and/or pulse cease either by natural or unnatural causes .Residents receiving CPR will be transferred to acute care .The exception is when CPR is unsuccessful and the resident is pronounced by a physician or other authorized person at the scene On [DATE] at 12:20 p.m., the Executive Director provided a current copy of the document titled INDIANA Abuse & Neglect & Misappropriation of Property dated [DATE]. It included, but was not limited to, Neglect .In Indiana, neglect is defined as failure to provide goods and services necessary to avoid physical harm The past noncompliance Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included: staff education on the CPR process/Code Policy and neglect, clarification of Code Status with regards to CPR versus Full Code, an audit of resident code status to validate the POST form, orders and care plan coincide, and an audit of all the crash carts to ensure all appropriate supplies are available. This Federal tag relates to Complaint IN 175 3XXX,[DATE](4)(f)(7)

Based on observation, interview, and record review, the facility failed to ensure appropriate interventions were in place for a resident (Resident C) who was at a high risk for acquiring pressure ulcers, which resulted in a stage 3 pressure ulcer to the sacrum and an unstageable pressure ulcer to the left and right heel for 1 of 3 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident C was reviewed on 10/5/20 at 2:07 p.m. The resident's [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated 8/2/20, indicated the resident required an extensive two physical staff assistance with bed mobility. The Braden Observation Tool (used to determine pressure ulcer risk), dated 3/22/20 at 11:55 a.m., indicated the resident had very limited sensory perception, very moist skin, was chairfast, and completely immobile with a problem related to friction and shearing. The care plan, dated 3/16/19, indicated the resident was at risk for impairment to the skin with inventions to avoid friction and shearing, daily skin inspections during care, encourage good hydration and nutrition, the use of a pressure relieving mattress to the bed, and a pressure relieving cushion on the wheelchair. The current activities of daily living care plan indicated the resident required the physical assistance of two staff to reposition and turn in bed. Review of the skin grid pressure sheets for the sacrum wound, first observed on 6/4/20, indicated the following measurements: -6/04/20 - stage 2 pressure ulcer which measured 1.5 cm in length, 0.3 cm in width with a depth of 0.2 cm -7/08/20 - stage 3 pressure ulcer which measured 3.7 cm in length, 2.5 cm in width with a depth of 0.2 cm -8/10/20 - stage 3 pressure ulcer which measured 7.3 cm in length, 5.1 cm in width with a depth of 0.2 cm - On 6/04/20 - stage 2 pressure ulcer (partial thickness skin loss into but no deeper than the dermis) which measured 1.5 cm in length, 0.3 cm in width with a depth of 0.2 cm - On 6/24/20 - stage 3 pressure ulcer (full thickness skin loss potentially extending into the subcutaneous tissue layer) which measured 4.0 cm in length, 1.5 cm in width with a depth of 0.3 cm - On 7/08/20 - stage 3 pressure ulcer which measured 3.7 cm in length, 2.5 cm in width with a depth of 0.2 cm - On 8/10/20 - stage 3 pressure ulcer which measured 7.3 cm in length, 5.1 cm in width with a depth of 0.2 cm a. The physician's orders [REDACTED]. The July 2020 and August 2020 TAR indicated the resident's treatment to his coccyx was not completed on the following days and shifts: - Day shift 7/5/20, 7/23/20, 8/2/20, 8/7/20, 8/15/20, 8/16/20, 8/21/20, 8/25/20, and 8/28/20 - Night shift 8/2/20, 8/6/20, 8/15/20, and 8/16/20 The resident was sent to an acute care hospital on [DATE]. Review of the skin grid pressure sheets for the sacrum wound after readmission to the facility on [DATE] indicated the following measurements: - On 9/10/20 at 3:00 p.m., stage 3 pressure ulcer which measured 6.0 cm in length, 3.4 cm in width with a depth of 0.8 cm - On 9/18/20 at 7:45 a.m., stage 3 pressure ulcer which measured 5.5 cm in length, 4.0 cm in width with a depth of 0.1 cm - On 10/2/20 at 11:00 a.m., stage 3 pressure ulcer which measured 5.5 cm in length, 4.0 cm in width with a depth of 0.5 cm The readmission order, dated 9/8/20, indicated to clean the coccyx wound with normal saline, pat the wound dry, apply a Dakin's 1/4 strength soaked gauze to the wound bed then cover with an opti foam dressing twice daily. The September 2020 and October 2020 TAR indicated the resident's treatment to his coccyx was not completed on the following days and shifts: - Day shift 9/12/20, 9/23/20, 9/28/20, 10/1/20, and 10/2/20 - Night shift 9/17/20, 9/18/20, 9/19/20, 9/20/20, and 9/27/20 During an observation with LPN (Licensed Practical Nurse) 3, on 10/6/20 at 11:40 a.m., the resident's sacral wound measured 6.0 cm in length, 4.8 cm in width, with a depth of 0.5 cm. The wound bed was observed to be covered with slough (yellowish white substance). The resident's clinical record lacked documentation of the staff floating the resident's heels or turning and repositioning the resident prior to acquiring the wounds. During an interview on 10/6/20 at 4:30 p.m., RN 4 indicated the TAR would be signed in order to show a treatment had been completed. During an interview on 10/6/20 at 5:21 p.m., LPN 3 indicated the resident's sacral wound could have been caused by decreased appetite, fidgeting while up in the chair (which could cause friction), and the resident's non-compliance with turning or repositioning. The clinical record lacked documentation of the resident fidgeting while up in his chair, non-compliance with turning and repositioning, or staff turning and repositioning the resident. Care plan for Actual skin impairment to skin integrity of bilateral heels, unstageable wounds, dated 6/2/20 indicated the intervention included, but were not limited to, .heel boots to both heels, skin prep heels BID until resolved .monitor/document location, size and treatment of [REDACTED].pressure relieving boots, hip abduction wedge between thighs when in Broda chair . dated 7/22/20, recommend Juven BID, mvi/min/vitamin c for wound healing. Care plan, dated 6/12/20, indicated the resident removes his pressure relief boots. The interventions included, but were not limited to, .assure pressure relief boots to heels in place . Review of the skin grid pressure sheets for the unstageable wound (localized area of tissue necrosis which develops when soft tissue was compressed for extended periods of time) to the left heel, first observed on 5/24/20, indicated the following measurements: - On 5/27/20 at 6:00 a.m., 4.8 cm (centimeters) in length and 3.5 cm in width. - On 6/26/20 at 7:37 a.m., 2.3 cm in length, 3.0 cm in width with a depth of 0.1 cm - On 7/15/20 at 4:30 p.m., 4.8 cm in length with a width of 3.5 - On 8/19/20 at 7:30 a.m., 4.7 cm in length with a width of 3.5 Review of the skin grid pressure sheets for the unstageable wound to the right heel, first observed on 6/1/20, indicated the following measurements: -6/02/20 at 9:25 a.m., 1.0 cm in length with a width of 1.4 cm -7/8/20 at 8:24 a.m., 1.8 cm in length, 2.3 cm in width with a depth of 0.1 cm. -8/19/20 at 7:30 a.m., 4.6 cm in length with a depth of 3.5 cm b. The physician's orders [REDACTED]. Review of the July 2020 and August 2020 TAR (Treatment Administration Record) indicated the treatment was not completed on 7/5/20, 7/19/20, 7/23/20, 8/2/20, 8/6/20, 8/7/20, 8/15/20, 8/16/20, and 8/25/20. The clinical record lacked documentation of the resident's non-compliance with turning and repositioning, staff turning and repositioning the resident, or staff floating the resident's heels prior to the resident acquiring the pressure ulcers. Review of the document titled Skin Care & Wound Management Overview dated 5/30/19 included, but was not limited to, Policy .The facility staff strives to prevent resident/patient skin impairment .Procedure .Complete the Braden Scale on admission .Develop a care plan with individualized interventions This Federal tag relates to Complaint IN 057 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident's (Resident B) wheel chair brakes were locked prior to the wheel chair rolling unattended, which resulted in a fall with a [MEDICAL CONDITION] humerus; and to provide incontinence care with the assistance of two physical staff members for a resident ( Resident C) who required the assistance of two physical staff members for incontinent care, which resulted in a fall from bed with a [MEDICAL CONDITION] great toe for 2 of 3 residents reviewed for accidents. Findings include: 1. The clinical record for Resident B was reviewed on 5/28/19 at 10:38 a.m. [DIAGNOSES REDACTED]. On 5/28/19 at 12:15 p.m., the resident was observed sitting up in the hall across from the nurses' station with a sling to the right arm. The incident report, dated 5/13/19, indicated Facility Bus Driver 4 was taking Resident B to an appointment at approximately 7:30 a.m. Prior to loading Resident B on the bus, Resident B started to have [MEDICAL CONDITION] activity. Facility Bus Driver 4 tried to secure Resident B in the wheel chair, the wheel chair began to roll down the parking lot. Facility Bus Driver 4 got in front of the wheel chair which then flipped onto the right side on the pavement and Facility Bus Drive 4 fell on top of Resident B. The progress note, dated 5/13/19 at 7:30 a.m., indicated Facility Bus Driver 4 notified staff that while trying to load Resident B on the bus, the resident started to have [MEDICAL CONDITION] activity. The wheel chair began to roll down the parking lot and the wheel chair flipped onto Facility Bus Driver 4 and Resident B fell on the pavement and on top of bus driver. Resident B was noted to have hematoma to right side of the forehead; an abrasion to the right shoulder; hollered out that his right arm was hurting; and a skin tear to the left hand, bilateral toes, and right knee. The addendum progress note, dated 5/13/19 at 12:34 p.m., indicated Facility Bus Driver 4 was on the left side of the wheel chair, attempting to lock the other brake when Resident B started to have [MEDICAL CONDITION] activity and the wheel chair started to roll. When Resident B fell the Facility Bus Driver 4 fell on top of him. On 5/28/19 at 4:40 p.m., review of the facility video from 5/13/19 at 6:56 a.m., Facility Bus Driver 4 was observed to transport Resident B through the first set of doors at the front entrance, she entered the door code and exited the building, at which time Facility Bus Driver 4 let go of the wheel chair. Facility Bus Driver 4 walked to the right of the van to let down the lift, Resident B's wheel chair began to propel forward down the concrete porch decline, the wheel chair picked up speed, rolled to the left of the bus, and out of view. Facility Bus Driver 4 did not lock the resident's wheel chair brakes. The hospital radiology report, dated 5/13/19 at 10:00 a.m., indicated the resident had a displaced [MEDICAL CONDITION] proximal humeral shaft. During an interview on 5/28/19 at 3:40 p.m., the Director of Nursing indicated Facility Bus Driver 4 should have locked the wheel chair brakes but did not. 2. The clinical record for Resident C was reviewed on 5/28/19 at 11:50 a.m. [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated 2/18/19, indicated the resident required a two person physical assistance with toileting at the time of the fall. The ADL (activities of daily living) care plan, which was revised on 2/26/19, indicated the resident required the physical assistance of two staff members for toileting and incontinent care. The incident report, dated 3/30/19, indicated CNA (Certified Nursing Aide) 5 was providing incontinent care to Resident C. The CNA rolled the resident on her left side, the resident's right leg fell off the bed, and the resident rolled off the bed and onto the floor. The progress note, dated 3/30/19 at 5:53 a.m., indicated that while CNA 5 was changing the resident, she rolled the resident on her left side, at which time Resident B's right leg fell off the bed, and the resident rolled out of the bed and landed face down. The resident had bruising to the right knee; the right ear was bruised and swollen with a small skin tear to the back of the ear; and the left ring finger had a 2 cm (centimeter) skin tear. The hospital radiology report, dated 3/30/19, indicated the resident had a mildly displaced [MEDICAL CONDITION] proximal diaphysis (the shaft or central part of the long bone) of the first proximal phalanx (great toe). During an interview on 5/28/19 at 3:40 p.m., the Director of Nursing indicated Resident C was definitely required two person assistance with incontinent care and she was unsure as to why CNA 5 did not ask for assistance while providing incontinent care. This Federal tag relates to Complaint IN 184 3.1-45(a) 3.1-45(a)(1)

Based on interview and record review, the facility failed to follow a resident's wishes (Advance Directives) to not be resuscitated (Do Not Resuscitate) (DNR) and failed to ensure staff accurately documented specific facts in the clinical record for 1 of 7 residents reviewed for advance directives. (Resident #C) This resulted in a resident receiving life saving measures when respirations ceased, including intubation and administration of intraosseous (process of injecting directly into the bone marrow) medications. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 7:40 a.m. when staff initiated Cardiopulmonary Resuscitation (CPR) on a resident (Resident #C) with an active DNR status. The Executive Director of a sister facility and District Director of Clinical Operations (DDCO) were notified of the Immediate Jeopardy on [DATE] at 5:00 p.m. The Immediate Jeopardy was removed on [DATE] at 2:50 p.m., but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: Resident #C's clinical record was reviewed on [DATE] at 3:20 p.m. [DIAGNOSES REDACTED]. The document titled, INDIANA PHYSICIAN ORDERS [REDACTED].Cardiopulmonary Resuscitation (CPR) .(box with a check mark) Do Not Attempt Resuscitation (DNR) .Do not intubate .Avoid intensive care The Care Plan for Resident #C included, but was not limited to, the following: .Advance Directives: has POST form indicating DNR .Date Initiated: [DATE] .Goals .(resident first name) healthcare wishes will be honored .Interventions .No CPR The document titled, physician's orders [REDACTED].CODE STATUS .DO NOT RESUSCITATE The Health Status Note, recorded on [DATE] at 3:20 p.m., effective [DATE] at 9:12 a.m., included, but was not limited to, the following: Res (Resident) noted to be lethargic this morning prior to breakfast. This nurse and CNA (Certified Nursing Assistant) repositioned res (resident) in w/c (wheel chair) and asked res (resident) is (sic) he was feeling ok, (sic) res (resident) stated, Im (sic) fine. Res (Resident) then went to social dining room per norm (normal routine). At approx. (approximately) 0740 (sic) (7:40 a.m.) CNA alerted this nurse that res (resident) was not looking right. Upon examination, res (resident) was nonresponsive to verbal and tactile stimuli, (sic) resp (respirations) noted at 6/min (6 breaths per minute) with shallow breathing noted. unable (sic) to obtain manual b/p (blood pressure). HR 64 (Heart Rate) via (per) manual palpitation. Res (Resident) immediately taken back to room by 2nd nurse and CNA. This nurse called code and notified 911 immediately. Res (Resident) noted to have HR (heart rate) of 62 in room, with resp (respirations) remaining at 6/min (6 breaths per minute). Nursing supervisor checked res (resident) chart at this time and found res (resident) was DNR. EMS (Emergency Medical Services) arrived and was informed of code status. Res (Resident) ceased resp (respirations) and apical pulse was check (sic) x2 (by 2) nurses. No apical found at this time. Res (Resident) time of death verified with MD (Medical Doctor) as 0824 (sic) (8:24 a.m.) The document titled, (name of company) EMS, dated [DATE], included, but was not limited to, the following: .(patient name) . RESPONSE INFO (Information) .Pt (Patient) .In bed .TIME .Dispatch: 07:59 [DATE] .En route: 7:59 [DATE] .At scene: 08:04 [DATE] .Primary Impression: .PT (Patient) WAS DOA (Dead on Arrival) .VITAL SIGNS .Time XXX[DATE] 8:06 .Pulse .0, Absent .Respiratory .0, Absent .Time XXX[DATE] 8:20 .Pulse .100, weak .Respiratory .20 Assisted, Regular .Time XXX[DATE] 8:26 .Pulse .0, Absent .Respiratory .0, Absent .TREATMENT SUMMARY .Time 08:07 .Treatment .Cardiac Monitor .Time 8:08 .Treatment .Intubation .Time .8:09 .Treatment .Oxygen .LPM (Liters Per Minute)=12 LPM .Time 8:09 .Treatment .IO (intraosseous) .Fluid Infused=NaCL (Sodium Chloride) .Amount Infused=300ML (milliliters) .Time .08:13 .Treatment .Blood Drawn .Site=Finger Stick .Comment .177 mg/dl (milligram per deciliter) .Type=Glucose Check only .Time .08:14 .Treatment .EPI ([MEDICATION NAME]) 1:10,000 .Dosage=1.0 mg (milligram) .Comments .NO CHANGE .Time .08:15 .Treatment .[MEDICATION NAME] .Dosage=2 mg (milligram) .Indication=Unconscious .Time .08:17 .Treatment .Sodium [MEDICATION NAME] .Dosage=80 mEq (milliequivalents) .Indication .[MEDICAL CONDITION] .Time .08:18 .Treatment .EPI ([MEDICATION NAME]) 1:10,000 .Dosage=1.0 mg (milligram) .Indication=Asystole .NARRATIVE .MEDIC 3 RECEIVED AN IMMEDIATE RESPONSE EMERGENCY DISPATCH FOR A PT (Patient) THAT IS UNRESPONSIVE, NOT BREATHING, FACILITY STAFF HAS STARTED CPR. U/A/F (Upon Arrival at Facility) A (sic) 84 Y/O (year old) MALE PT (patient) LYING SUPINE IN BED, STAFF PERFORMING CPR, VENTILATIONS ARE BEING ASSISTED WITH BVM (Bagged Ventilation Mask). WHEN ASKED IF THE PT (patient) WAS A DNR, STAFF STATED NO HE WAS A FULL CODE. STAFF SAID THE PT (patient) GOT BACK FROM BREAKFAST 15 TO 20 MINUTES PRIOR TO CALL (sic) EMS. EMS & FIRE TOOK OVER CPR AND VENTILATIONS UNTIL A SPONTANEOUS RETURN OF CIRCULATION. HEART MONITOR SHOWING ASYSTOLE. INTUBATED PATIENT USING #8 ET(endotracheal) TUBE, VISUALIZED TUBE GOING THRU (sic) THE CORDS, CONFIRMED WITH (+) (positive) BILATERAL BREATH SOUNDS, (-) (negative) OVER THE ABDOMEN, ALSO CONFIRMED WITH ENTITLE. ENTITLE RATE OF (underline). IO PLACED IN (R) (right) TIBIAL TUBEROSITY, FIRST ATTEMPT WITH SUCCESS. ADMINISTERED 2ea EPI, 1 mg ea, IOP (Intraosseous Push), GIVEN APPROXIMATELY 4 MINUTES APART. NO RESPONSE NOTED AFTER ADMINISTRATION. ADMINISTERED 2 mg [MEDICATION NAME], IOP, NO RESPONSE NOTED. ADMINISTERED 80 mEq SODIUM [MEDICATION NAME]. NOTED A SPONTANEOUS RETURN OF A RHYTHM WITH (+) (positive) PULSES. NURSE CAME INTO THE ROOM AND ADVISED US THAT THEY MADE A MISTAKE, THE PT (patient) HAS AN ACTIVE DNR. STARTED TO PREP (prepare) THE PT (patient) FOR TRANSPORT WHILE MY PARTNER CALLED MEDICAL CONTROL TO ADVISE THEM OF THE SITUATION. WAS ADVISED TO TRANSPORT THE PT (patient) TO (hospital initials) ER. AS WE WERE MOVING THE PT (patient) TO EMS STRETCHER, WE NOTED THE PT (patient) LOST PULSE AND RHYTHM. CONTACTED MEDICAL CONTROL AGAIN TO ADVISED (sic) THEM OF THE CHANGES IN OUR SITUATION. (name of physician) ADVISED US TO DISCONTINUE RESUSCITATIVE MESURES (sic) TO HONOR THE DNR (sic) ADVISED THE NURSING HOME STAFF OF THE SITUATION. PT (patient) CARE TURNED BACK OVER TO THE NURSING HOME STAFF XXX[DATE] 1800hrs (hours) ADDENDUM: I WAS ADVISED BY PARAMEDIC (name) FIRST ON SCENE THE NURSING HOME STAFF ADVISED HIM THAT THEY SHOCKED THE PATIENT 1 TIME PRIOR TO OUR ARRIVAL USING THEIR AED (Automated External Defibrillator) During an interview on [DATE] at 11:15 a.m., Licensed Practical Nurse (LPN) #6 indicated the Director of Nursing (DON) had staff falsify the documentation on Resident #C's clinical record regarding the incident that took place on [DATE] between 7:40 a.m. and 8:24 a.m. During an interview on [DATE] at 2:25 p.m., LPN #1 indicated the DON told her, word for word, what to write in Resident #C's clinical record regarding the incident that took place on [DATE] between 7:40 a.m. and 8:24 a.m. LPN #1 indicated she could not find a POST under the advance directive tab in Resident #C's clinical record or in the computer and assumed Resident #C was a full code. LPN #1 indicated LPN #2 started CPR compressions when LPN #1 called the code. LPN #1 also indicated when she went back to Resident #C's room EMS had already started an I.V. and was attempting to intubate. LPN #1 then indicated LPN #3 entered Resident #C's room and indicated Resident #C was a DNR. During an interview on [DATE] at 2:40 p.m., LPN #2 indicated LPN #1 asked her for help regarding Resident #C on [DATE] at 7:40 a.m. LPN # 2 indicated she attempted to get a blood pressure manually but could not. LPN#2 indicated as she walked away, Resident #C ceased breathing. LPN #2 indicated she asked LPN #1 if Resident #C was a DNR and LPN #1 indicated no. LPN #2 indicated CPR was initiated until EMS arrived and took over resuscitative measures. During an interview on [DATE] at 3:10 p.m., LPN #3 indicated LPN #1 called a Code on Resident #C. LPN #3 indicated LPN #2 retrieved the crash cart and LPN #1 called 911 at that time. LPN #3 indicated life sustaining measures were initiated and EMS took over when they arrived. LPN #3 indicated she went to the chart again and found the POST which indicated Resident #C was a DNR and at that time alerted EMS. During an interview on [DATE] at 3:30 p.m., the DON indicated LPN #1 could not find Resident #C's code status in the chart or in the computer, so CPR was initiated at that time on [DATE] at 7:40 a.m. The DON indicated she consulted with the DDCO after the incident and, in turn, took that information from the DDCO and helped LPN #1 with the documentation that transpired on [DATE] for Resident #C. The DON indicated that she did not want to put directly into the documentation that Resident #C was a DNR and coded by the staff. She indicated that the documentation could have more accurately reflected the events that took place during the incident with Resident #C on [DATE]. During an interview on [DATE] at 4:00 p.m., the DDCO indicated she did assist the DON in the documentation but was unaware that Resident #C had any life saving support measures done by the facility staff on [DATE]. On [DATE] at 10:35 a.m., the DON from a sister facility, provided a copy of the policy and procedure titled, Advance Directives/ Healthcare Decisions, dated [DATE], and indicated as current. The policy included, but was not limited to, the following: . Policy . Patients have the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives . Do No Resuscitate . Instructs the nursing staff not to perform emergency resuscitation on a patient . Criteria for not Starting CPR . The patient has a valid Do Not Resuscitate (DNR) . order . COMPONENTS: .1. Facility determines on admission whether the patient has executed an advance directive or has given other instructions to indicate what care he or she desires in case of subsequent incapacity . 2. If the patient or the patient's legal representative has executed one or more advance directive(s), or executes one upon admission, the facility obtains copies of these, incorporates and consistently maintains them in the same section of the patient's medical record readily retrievable by any facility staff . 3. The facility communicates the patient's wishes to the direct care staff The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility began inservicing all clinical staff on the steps taken to verify a resident's code status prior to initiating CPR and completed an audit of all residents' clinical records to ensure that the resident's advance directive wishes are consistent throughout the entire clinical record. The noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, as all employees had not been inserviced. 3XXX,[DATE](f)(5) 3XXX,[DATE](f)(7)