Every finding on record at Harrison's Crossing Health Campus

Based on record review and interview, the facility failed to ensure documented physician rationale for a declination of pharmacy recommendations and failed to ensure the physician signed and dated the pharmacy recommendations for 3 of 5 residents reviewed for unnecessary medication (Residents 19, 56, and 8). Findings include: 1. Resident 19's record was reviewed on 4/15/26 at 2:13 p.m. The profile indicated that the resident's diagnoses included, but were not limited to, unspecified dementia (a clinical term for cognitive decline that prevents a definitive diagnosis of a specific type), unspecified severity with anxiety (a diagnosis for significant anxiety, panic, or fear that causes distress or functional impairment but does not fully meet the specific criteria for other, more defined anxiety disorders), and depression unspecified (a diagnosis used when symptoms of depression cause significant distress or impairment but do not meet the full criteria for a specific depressive disorder). An annual Minimum Data Set (MDS) assessment, dated 3/20/26, indicated the resident had severe cognitive impairment and was on an anti-psychotic medication. A pharmacy recommendation, dated 11/25/25, recommended a reduction of aripiprazole (anti-psychotic medication) 5 milligrams (mg) daily. There should be documentation related to clinically contraindicating a gradual dose reduction including specific and individualized rationale for why the medication was medically necessary at the current dose. The pharmacy recommendation was marked as denied and the form lacked a documented rationale as to why the physician denied the recommendation. The electronic health record lacked documentation of a physician rationale for a declination of the pharmacy recommendation. During an interview, on 4/17/26 at 2:30 p.m., the Regional Clinical Support Nurse indicated she was unable to provide a documented rationale from the physician for his denial of the gradual dose reduction of the aripiprazole medication. She further acknowledged the physician should have documented a rationale for declination of the pharmacy recommendation. 2. Resident 56's record was reviewed on 4/15/26 at 10:40 a.m. The profile indicated the resident's diagnoses included, but were not limited to, insomnia unspecified (a general diagnosis for consistent difficulty falling asleep, staying asleep, or getting quality sleep that causes daytime impairment, but lacks a specific, clearly defined underlying cause) and Alzheimer's disease unspecified (a medical diagnosis for progressive brain decline that causes dementia, applied when the specific stage or age of onset has not been documented). A quarterly Minimum Data Set (MDS) assessment, dated 3/14/26, indicated the resident had severe cognitive deficit. A physician's order, dated 3/10/25, indicated to administer two 25 milligram (mg) tablets (50 mg) of trazodone (medication to treat insomnia), at bedtime. A pharmacy recommendation, dated 9/15/25, indicated the resident's trazodone order had been in place since, March 2025 and recommended to consider changing the dose to 25 mg at bedtime as needed (PRN) times 14 days and re-evaluate the need for the medication. The physician declined the recommendation. The recommendation form lacked documentation of the justification for the physician declination. On 4/16/26 at 9:10 a.m., the Regional Clinical Support provided a document titled, Psychiatry Progress Note, with a date of service on, 9/22/25. The document lacked documentation that the resident had indicated he was not sleeping well. The document indicated, .He believed that he eats and sleeps well. He denied any current concerns at this point in time. On 4/16/26 at 9:10 a.m., the Regional Clinical Support provided a document titled, BH Progress Note, with a date of service on 9/26/25. The document lacked documentation that the resident had indicated he was not sleeping well. The document indicated, .Resident denies issues with sleeping at this time. Consulted with staff whom reported the resident is stable and functioning at baseline. During an interview, on 4/16/26 at 9:10 a.m., the Regional Clinical Support indicated the expectation was that the physician or nurse practitioner would provide documented justification for any declinations of pharmacy recommendations. 3. Resident 8's record was reviewed on 4/15/26 at 2:24 p.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia with psychotic disturbance (a diagnosis for a person with significant memory loss and cognitive decline that is accompanied by hallucinations [seeing, hearing, smelling, tasting, or feeling things that are not actually there, yet feel completely real] or delusions [a firm, fixed belief that is clearly false, irrational, or not based on reality, which a person holds onto despite overwhelming evidence to the contrary], where the exact cause is not yet determined). An annual Minimum Data Set (MDS) assessment, dated 4/3/26, indicated the resident had severe cognitive deficit and received antipsychotic (medications to treat psychosis, such as hallucinations or delusions) and antianxiety medication. A physician's order, dated 10/24/24, indicated to administer 0.25 milligrams (mg) of alprazolam (antianxiety medication) three times a day. A historical review of the resident's medication regimen indicated that the resident had received 100 mg quetiapine (antipsychotic medication) twice daily, since April 2025. A physician's order, dated 2/12/26, indicated to administer 50 mg of quetiapine one time a day. A physician's order, dated 2/12/26, indicated to administer 100 mg of quetiapine at bedtime. A pharmacy recommendation, dated 7/17/25, indicated to consider a dose reduction of quetiapine 100 mg twice daily to 50 mg every morning and 100 mg at bedtime. The physician declined the recommendation and document that the resident was on hospice (end of life care) services. The form lacked any further justification for the physician's decision to decline the recommendation. Additionally, the form lacked documentation of the physician's signature and date. A pharmacy recommendation, dated 9/15/25, indicated to consider a dose reduction of the resident's Xanax (alprazolam) 0.25 mg three times daily to 0.25 mg two times daily. The physician declined the recommendation. The form lacked documentation of the physician's signature and date. Review of behavior tracking reports from September 2025 and forward, indicated the resident had experienced anxiety related behaviors. During an interview, on 4/16/26 at 9:10 a.m., the Regional Clinical Support indicated the expectation was that the physician or nurse practitioner would provide documented justification for any declinations of pharmacy recommendations and sign and date the document when it was completed. On 4/16/26 at 9:10 a.m., the Regional Clinical Support provided a document, with a revision date of January 2018, titled, Consultant Pharmacist Reports, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures.E. Recommendations are acted upon and documented by the facility personnel and/or prescriber. 1) Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. 410 IAC (Indiana Administrative Code) 16.2-3.1-3(w)

Based on interview and record review, the facility failed to assess or provide valid medical justification from the attending physician to determine if continued use or removal of a urinary catheter was clinically warranted for 1 of 1 residents reviewed for catheter use (Resident 41).Findings include:On 4/14/26 at 1:41 p.m., during an interview, Resident 41's husband indicated the resident had an indwelling foley catheter (a thin, flexible catheter used especially to drain urine from the bladder). He indicated the catheter was placed in the hospital and she had no issues with urination prior to being in the hospital and did not know why she still had a catheter. He had requested it be removed. The husband indicated he had not been informed of the reason for the catheter.On 4/15/26 at 11:00 a.m., the medical record of Resident 41 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, surgical aftercare following surgery on the nervous system clot evacuation (removal of blood clot in the brain), hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength) following nontraumatic intracerebral hemorrhage (bleeding in the brain), neuromuscular dysfunction of bladder, unspecified (a condition where a person loses bladder control due to nerve damage or diseases of the nervous system).A physician order, dated 11/19/25, indicated use of an Indwelling Urinary Catheter, Medical reason: neurogenic bladder (a dysfunction of the bladder caused by damage to the nerves that control urination).A care plan, dated 11/19/25, indicated resident used a foley catheter. Interventions included, but were not limited to, provide assistance with catheter care and change foley catheter per physician orders. Review of the hospital discharge and discharge summary records from admission to the facility on [DATE] lacked a diagnosis of neurogenic bladder. The records indicated the catheter was placed due to an unstageable wound (a wound where the base is completely covered by dead tissue). The wound was on the coccyx (a small, triangular area located at the very bottom of the spinal column).Resident 41's current medical record lacked clarification or justification by the physician for foley catheter use.A quarterly Minimum Data Set (MDS) assessment, dated 2/26/26, indicated the resident was cognitively impaired and had an indwelling foley catheter during the assessment period.On 4/17/26 at 10:30 a.m., during an interview the resident indicated she could not remember if she had any issues with urinating prior to hospitalization but since then she had some confusion. She indicated she could not remember if the staff had discussed the catheter with her.On 4/17/26 at 11:00 a.m., during an interview the Regional Nurse Consultant indicated the justification for the foley catheter was because the resident has a wound on her bottom and if the catheter was removed the wound would be contaminated creating an increased risk of infection. She acknowledged the facility did not have an assessment from the physician indicating the clinical reason for maintaining an indwelling catheter.On 4/17/26 at 1:26 p.m., the Director of Nursing provided a document, titled, Guidelines for the use of Indwelling Catheter, dated 5/11/16, and indicated it was the policy currently being used by the facility. The policy indicated, .An indwelling catheter is not used unless there is a valid medical justification.1.Urinary catheters are deemed medically necessary for the following reasons and must have a supporting diagnosis for its use).other conditions as deemed valid by the attending physician and or urologist with supporting documentation.2. Resident/Representative has the right to decline the use of an indwelling catheter. If resident/representative declines, information and education should be provided indicating the risks and benefits. 3. Resident/Representative should be informed of the risks and the benefits of indwelling catheter use.410 Indiana Administrative Code (IAC) 3.1 3.1-41(a)(2)

Based on observation and record review, the facility failed to ensure a resident was treated in a dignified manner during 1 of 1 random meal service observation (Resident 8). Findings include: On 2/14/25 at 10:05 a.m., Resident 8 was observed eating a meal at the nurses' station table with several other residents who were not eating. The resident was observed spilling food over their clothing. Certified Nurse Aide (CNA) 20 was standing next to the resident and talking to him. On 2/14/25 at 10:07 a.m., during an interview, CNA 20 acknowledged the resident should have a clothing protector, but she forgot to put one on because he was in the hall. The employee did not obtain a clothing protector, and the resident continued to spill food over himself. On 2/14/25 at 10:10 a.m., during an interview, CNA 13, indicated the resident did need a clothing protector. She obtained a washcloth and cleaned the resident's clothing and applied a clothing protector. The resident repeatedly told the employee he was sorry he had spilled his food. The employee reassured him it was okay, and the resident thanked her. On 2/14/25 at 10:30 a.m., the medical record of Resident 8 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) without dyskinesia (uncontrolled, involuntary muscle movements ranging from shakes, tics and tremors to full-body movements), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and dysphagia (difficulty swallowing). A quarterly Minimum Data Set (MDS) assessment, dated 12/6/24, indicated the resident required assistance of one person for eating and was not cognitively intact. A care plan, dated 8/15/19, indicated the resident had diagnosis of Parkinson's disease requiring assist with activities of daily living (ADL) care. Interventions included, but were not limited to, provide assistance during ADL care to include but not limited to eating, toileting, bed mobility, transfers, wheelchair mobility, ambulation. On 2/14/2025 at 11:32 a.m., the Clinical Nurse Consultant provided a document, titled, Resident Rights, dated 12/17/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose .To ensure resident rights are respected and protected and provide an environment in which they can be exercised .2. Our residents have the right to .a. Be treated with dignity and respect 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure a resident was provided showers as preferred for 1 of 26 residents reviewed for choices (Resident 2). Findings include: During an interview, on 2/10/25 at 11:34 a.m., Resident 2 indicated it had been almost 2 weeks since she last had a shower. She was scheduled to receive 3 showers a week, on Monday, Wednesday, and Friday. She further indicated the shower in her room was too cold and she was waiting for it to be fixed by the maintenance worker. Resident 2's record was reviewed on 2/12/25 at 11:52 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 11/22/24, indicated the resident was cognitively intact and required two-person physical assist with transfers. A care plan, dated 4/19/22, indicated profile care guide. Interventions included, but were not limited to, perform transfers 2 assist with gait belt and showers on Monday, Wednesday, and Friday on the evening shift. Review of point of care documentation, dated January 13 through February 12, 2025, indicated Resident 2 did not receive a shower on 1/29/25, 1/31/25, 2/3/25, 2/5/25, 2/7/25, 2/10/25. Review of shower sheets, dated 2/5/25, indicated Resident 2 had refused her shower because the water in her room was still too cold. The shower sheet lacked documentation that staff had offered the resident an alternative shower to use. Review of shower sheet, dated 2/7/25, indicated Resident 2 had refused her shower because it was too cold. The shower sheet lacked documentation that staff had offered the resident an alternative shower to use. During an interview, on 2/12/25 at 11:24 a.m., Resident 2 indicated the shower was now fixed and was hoping to get back on her regular schedule of shower days, she indicated the staff never offered her an alternative shower to use when the water in her room was too cold. During an interview, on 2/12/25 at 2:18 p.m., the Clinical Support Nurse indicated the resident should have been offered an alternative shower if hers was too cold. During an interview, on 2/12/25 at 2:20 p.m., the Director of Health Services (DHS) indicated they had a spa area where the resident could have used a shower or in an unoccupied room. During an interview, on 2/13/25 at 9:30 a.m., the Administrator indicated the facility did have a spa that residents could use for showers, but the room was cold, and most residents did not like to use it. Staff should have offered the resident an alternative shower to use. On 2/13/25 at 11:43 a.m., the Clinical Support Nurse provided a document, with a revised date of 5/11/17, titled, Resident Rights Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To ensure resident rights are respected and protected and provide an environment in which they can be exercised .2. Our residents have a right to: a. Be treated with dignity and respect 3.1-3(u)(3)

Based on record review and interview, the facility failed to notify the physician of significant weight loss for 1 of 6 residents reviewed (Resident 15). Findings include: On 2/12/25 at 10:19 a.m., the medical record of Resident 15 was reviewed. The resident was admitted to the facility on [DATE]. Admission diagnosis included, but was not limited to, fracture of the right femur (fracture of the long thigh bone of the leg), cardiomyopathy (a disease of heart muscle. It causes the heart to have a harder time pumping blood to the rest of the body), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Lymphedema (swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), edema (swelling caused by too much fluid trapped in the body's tissues). An admission Minimum Data Set Assessment (MDS) dated [DATE], indicated the resident was administered a diuretic (medication to reduce extra fluid in the body) and was short of breath during the assessment period. A care plan, dated 1/23/25, indicated the resident was receiving high risk medications, received diuretic medication. Intervention included, but were not limited to, observe and report effectiveness as needed. A physician order, dated 1/25/25, indicated to adminster Lasix 40 mg (milligrams) one tablet by mouth two times per day. A review of the resident's weight record indicated the resident had 19.5 % weight loss, 37.5 pounds in less than 30 days. Admission weight on 1/24/25 was recorded as 192.3 pounds. On 2/4/25 recorded weight was 163 pounds. On 2/12/25 recorded weight was 154.8 pounds. A physician order, dated 2/6/25, indicated to adminster Lasix 40 mg, one tablet by mouth one time per day for diagnosis of edema. On 2/11/25 a nutrition progress note indicated the root cause of weight loss was due to decreased swelling of bilateral lower extremities with diuretic treatment and compression wraps. A nurse progress note, on 12/6/25, indicated the resident was seen by the Nurse Practitioner (NP). Lasix was decreased to 40 mg daily from 40 mg twice daily. Compression wraps were ordered on 2/3/25. The record lacked documentation of physician notification of the increased and continual weight loss. NP visit notes did not indicate a plan of treatment had been in place for reduction of edema, a review of current weight loss status or continuation of weight loss plan. The NP note lacked notification to the attending physician of the weight loss. On 2/14/25 at 2:10 p.m., during an interview with the residents physician and the Director of Health Services (DHS) the physician indicated the weight loss was due to administration of Lasix to decrease massive abdominal edema. He acknowledged he had not reviewed the residents weight loss until 2/14/25. The physician acknowledged the medical record lacked documentation of notification of the weight loss, though the NP had seen the resident on 2/6/25 and decreased the Lasix to 40 mg daily. The physician acknowledged the record lacked notification of significant weight loss or of continual plan to reduce edema. On 2/18/2025 at 1:37 p.m., the Clinical Nurse Consultant provided a document titled, Physician Provider Notification Guidelines, dated12/17/24, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose .ensure the resident's physician or practitioner (may include NP, PA or clinical nurse specialist) is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care .11. Attempts to notify the physician/provider and their response should be documented in the resident electronic health record 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident's urostomy (a surgical opening in the belly that re-directs urine away from a bladder that's diseased, had been injured, or isn't working as it should) catheter bag (a bag that collects urine) was kept from coming in contact with the floor for 1 of 2 residents reviewed for catheters (Resident 4). Findings include: During a meal service observation, on 2/10/25 at 11:51 a.m., Resident 4's urinary catheter bag was observed to be in contact with the floor. During a random observation, on 2/10/25 at 12:49 p.m., Resident 4 was propelling herself in her wheelchair out of the dining room. Her urinary catheter bag was in contact with the floor and dragging underneath her wheelchair. During a random observation, on 2/11/25 at 9:29 a.m., Resident 4 was in the therapy room. Her urinary catheter bag was in contact with the floor. During a random observation, on 2/11/25 at 10:46 a.m., Resident 4 was being assisted in her wheelchair by a staff person down the hallway to participate in an activity. The resident's urinary catheter bag was dragging on the floor under her wheelchair. Resident 4's record was reviewed on 2/12/24 at 2:28 p.m. The profile indicated the resident's diagnoses included, but were not limited to, personal history of urinary tract infections (UTI-an infection in any part of the urinary system), and disorder of the kidney and ureter (a blockage where the ureter and kidney meet which may cause the kidney to swell and eventually stop working). An admission Minimum Data Set (MDS) assessment, dated 12/30/24, indicated the resident had no cognitive deficit and had a urostomy. A care plan, dated 12/27/24, indicated the resident had an ostomy to divert her urine. The care plan lacked documentation to maintain the catheter bag and/or tubing from coming contact with the floor. An event document, dated 1/13/25, indicated the resident had developed a UTI that was not present upon admission. During an interview, on 2/13/25 at 10:06 a.m., Certified Resident Care Assistant (CRCA) 9 indicated urinary catheter bag and/or tubing should not come into contact with the floor. During an interview, on 2/13/25 at 11:44 a.m., the Clinical Support nurse indicated the resident's urinary catheter bag should not have been in contact with the floor. On 2/12/25 at 10:01 a.m., the Executive Director (ED) provided a document, with a review date of 12/16/24, titled, Preserving Dignity with Indwelling Catheter, and indicated it was the policy currently being used by the facility. The policy indicated, .SOP (Standards of Practice) Details: 1 .e. Urinary drainage bags and catheter tubing should be kept from touching the floor surface 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure proper administration of scheduled medication by nursing staff and failed to ensure competent nursing staff removed a PICC line (a thin, flexible tube that's inserted into a vein in the arm and ends in a large vein near the heart) for 2 of 5 residents reviewed for unnecessary medications (Resident 14 and 20). Findings include: 1. Resident 14's record was reviewed on 2/11/25 at 2:00 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A quarterly Minimum Data Set (MDS) assessment, dated 1/31/25, indicated the resident had moderate cognitive impairment and was on an anti-anxiety medication. A care plan, dated 5/3/22, indicated the resident has a diagnosis of anxiety disorder. Interventions included, but were not limited to, medications per order and psych services as needed. A physician order, dated 12/30/24, indicated to administer alprazolam (anti-anxiety medication) 0.5mg (milligrams) by mouth four times a day. Administration hours were 7 to 9:00 a.m., 1 to 1:30 p.m., 4 to 5 p.m., and 8 to 10 p.m. Review of December 2024 Medication Administration Record (MAR) indicated the following: a. On 12/6/24, Licensed Practical Nurse (LPN) 21 documented that he administered Resident 14's alprazolam medication at 6:35 p.m. and the medication was not due until 8 to 10:00 p.m. b. On 12/12/24, LPN 21 documented that he administered the resident's alprazolam mediation at 6:35 p.m. and the medication was not due until 8 to 10:00 p.m. Review of January 2025 MAR indicated the following: a. On 1/4/25 LPN 21 documented that he administered the resident's alprazolam mediation at 6:56 p.m. and the medication was not due until 8 to 10:00 p.m. b. On 1/17/25 LPN 21 documented that he administered the resident's alprazolam mediation at 6:25 p.m. and the medication was not due until 8 to 10:00 p.m. c. On 1/24/25 LPN 21 documented that he administered the resident's alprazolam mediation at 6:28 p.m. and the medication was not due until 8 to 10:00 p.m. d. On 1/31/25 LPN 21 documented that he administered the resident's alprazolam mediation at 6:44 p.m. and the medication was not due until 8 to 10:00 p.m. Review of February 2025 MAR indicated the following: a. On 2/1/25 LPN 21 documented that he administered the resident's alprazolam mediation at 6:30 p.m. and the medication was not due until 8 to 10:00 p.m. b. On 2/6/25 LPN 21 documented that he administered the resident's alprazolam mediation at 6:32 p.m. and the medication was not due until 8 to 10:00 p.m. Resident 14's record lacked documentation that the physician was ever notified that the resident was requesting her medication to be administered early. During an interview, on 2/11/25 at 3:01 p.m., Registered Nurse (RN) 4 indicated she wasn't sure if they could administer medication outside of the timeframe, she would have to check the policy. During an interview, on 2/11/25 at 3:02 p.m., LPN 5 indicated nursing staff may administer medication an hour before or after the medication administration time. During an interview, on 2/12/25 at 9:46 a.m., the Clinical Support Nurse indicated nursing staff may administer medication an hour before or after the medication administration times. Staff should notify the doctor if residents were requesting the medication earlier. Medications should be administered as ordered by physicians. The facility was not aware that the LPN was administering medications outside of the hour window. On 2/12/25 at 10:19 a.m., the Clinical Support Nurse provided a document, dated 12/1/21, titled, Medication Administration Times Procedural Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, . To ensure mediation is administered in resident centered fashion and documented in medical record .f. The nurse shall give the resident options of administration to ensure appropriate spacing of administration 48226 2. On 2/11/25 at 1:59 p.m., the record of Resident 20 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, Surgical amputation right foot toes, (removal of the toes on the right foot due to disease), (MRSA) methicillin resistant staphylococcus aureus infection (a bacterial infection that is resistant to some antibiotic treatments), osteomyelitis (inflammation or swelling that occurs in the bone from an infection somewhere else in the body that has spread to the bone), gangrene the death of body tissue due to a lack of blood flow or a serious bacterial infection) of the foot, proteus mirabilis (bacteria causing serious infection in the body) as the cause of diseases classified elsewhere, pseudomonas (bacterial causing serious infection in the body) as the cause of diseases. On 2/3/25 an admission Minimum Data Set Assessment (MDS) assessment indicated the resident was cognitively intact. A care plan, dated 1/31/25, indicated the resident required IV medication related to infection/osteomyelitis, cellulitis (a deep infection of the skin caused by bacteria), and MRSA. Interventions included but were not limited to: administer IV as ordered, IV site care as ordered. Upon admission to the facility a peripherally inserted central venous catheter PICC/Central Line (a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart called the superior vena cava) was inserted into the residents arm. The IV (intravenous) was used to administer antibiotic medication to treat bacterial infections. A physician order, dated 1/31/25, administer piperacillin-tazobactam reconstituted (mixed with sterile water solution) administer 4.5 gram in100 mL (milliliters) over 30 minutes through intravenous administration (medications administered into a vein) every 6 hours for diagnosis of MRSA. A physician order, dated 1/31/25, indicated to administer vancomycin reconstituted solution 1,000 mg (milligrams) administer 1 gram in 250 mL (sterile water solution) over 1 hour through intravenous administration every 12 hours to be administered at 10:30 a.m., and 10:30 p.m. for diagnosis of MRSA. A physician order, dated 1/31/25, with a designated implementation date of 3/5/25, indicated dressing covering PICC/CL IV was to be changed every 5 days and to measure external IV catheter (the length of the IV catheter outside of the body), and enter the measurement into the medication note. The Treatment Administration Record (TAR) indicated the dressing was changed on 2/4/25 when a new PICC/CL IV was placed and changed again on 2/6/25. Review of the TAR lacked documentation indicating the PICC/CL IV had been measured since admission as ordered by the physician. Nurse progress note, dated 2/6/2025 at 10:14 a.m., entered by Licensed Practical Nurse (LPN) 14 indicated the following: resident showered this shift. When resident was getting out of shower he took the PICC line drsg (dressing) off, when he removed drsg it pulled PICC out and inch and was visibly bleeding when i arrived in resident room. PICC was removed access RN was called promptly to replace line . bleeding was stopped . no c/o [complaints of] from patient at this time. On 2/10/25 at 2:20 p.m. an entry was made in the medical record by LPN 23. The documentation indicated LPN 23 drew blood from the PICC/CL for lab testing. The medical record lacked documentation of physician order to draw blood from the PICC/CL IV or documentation that a licensed Registered Nurse (RN) completed the blood draw. The medical record lacked documentation of an assessment by an RN prior to and after blood draw from the PICC/CL line. On 2/13/25 at 9:31 a.m., observed PICC/CL dressing. The dressing was soiled and edges starting to roll. The dressing was dated 2/6/25. On 2/13/25 at 9:50 a.m., during an interview with the Director of Health Services (DHS) she indicated the implementation date was a data entry error, and the dressing should have been changed on 2/11/25. On 2/14/25 at 10:10a.m., during an interview Licensed Practical Nurse (LPN) 14 indicated on 2/6/25 Resident 20 was in the shower and the resident attempted to remove the dressing over the PICC/CL IV and pulled on the IV. She indicated the PICC/CL IV was pulled out approximately one inch from the arm and was bleeding slightly. The LPN applied pressure to the arm for a minute to ensure it was no longer bleeding. She notified the DHS of the incident. She returned to the resident's room with another LPN and removed the PICC/CL from the residents arm and notified the Registered Nurse (RN) who would replace the PICC/CL IV. The LPN acknowledged she did not notify the physician of the incident and did not obtain an order to remove the PICC/CL IV. The employee indicated the DHS was in the facility and the DHS had notified the physician and obtained an order to remove the IV. The medical record lacked documentation of physician notification and order to remove the PICC/CL IV. The medical record lacked documentation of the length of the PICC/CL IV after removal, of pressure being applied to the area for a specific amount of time after removal, or an assessment of the IV site by a licensed RN before and after removal of the IV. On 2/14/25 at 10:40 a.m., during interview with the Registered Nurse Clinical Consultant (RNCC) and Director of Health Services (DHS), the DHS failed to verify she notified the physician for an order to remove the IV or of an assessment being completed by an RN before or after removal. The RNCC indicated an LPN was not licensed or permitted to remove a PICC/CL or draw blood from a PICC/CL IV. The RNCC acknowledged a central line IV catheter must be assessed by an licensed RN and only removed by a qualified licensed RN trained specifically in PICC/CL IV insertion and removal. On 2/14/2025 at 11:32 p.m., the RNCC provided a document titled, Catheter Insertion and Care , dated 12/15, and indicated it was the policy currently being used by the facility. The policy indicated, .General Guidelines .1, A prescriber must write an order for a CVAD or midline to be removed .7. The nurse or practitioner removing the catheter must have proven competency in this procedure Procedure .1. The procedure for removing CVAD and midlines is different for each catheter. 2. This procedure must be performed by a person who is certified in the removal procedure and demonstrates clinical competency in removing catheter .D. Peripherally Inserted Central Catheter (PICC) .4. Catheter can be placed or removed at the bedside or in the hospital setting by a Certified Specialty Nurse (Verify with the State Nurse Practice Act) .6. Catheter length is measured for baseline comparison upon removal. Catheter measurements are compared to baseline to verify that all of catheter has been removed .11. No blood pressure or phlebotomy should be done on arm that contains PICC 3.1-14(i)

Based on record review and interview, the facility failed to ensure justification for the long-term use of antibiotics for 1 of 26 residents reviewed for antibiotic use (Resident 1). Findings include: Resident 1's record was reviewed, on 2/12/25 at 2:44 p.m. The profile indicated that the resident's diagnoses included, but were not limited to, urinary tract infection (UTI - an illness in any part of the urinary tract the system of organs that make urine) and chronic kidney disease stage 3 (a person has moderate damage to their kidneys, with a noticeable decline in kidney function). A quarterly Minimum Data Set (MDS) assessment, dated 11/15/24, indicated the resident had moderate cognitive impairment and was always incontinent with bowel and urine. A physician order, dated 6/12/23 with no discontinue date, indicated to administer doxycycline hyclate (antibiotic) 100 mg (milligrams) by mouth once daily for UTI prophylaxis (tending to prevent or ward off, preventive). Review of Resident 1's notes indicated the last documented UTI was on 12/20/24 per a nursing progress note. During an interview, on 2/14/25 at 9:29 a.m., the Clinical Support Nurse indicated the Medical Director had prescribed the prophylactic antibiotic back in 2023 for the resident and was no longer Resident 1's primary care doctor. She was unable to provide documentation that the physician had documented a justification for the long-term antibiotic use. During an interview, on 2/14/25 at 2:10 p.m., the Medical Director indicated that he had not been informed of the best practice regarding antibiotic stewardship and the use of prophylactic antibiotic treatment. Review of a typed statement, dated 2/14/25, indicated the Medical Director had prescribed the antibiotic for UTI prophylaxis due to the resident being prone to UTI's. The resident had since changed doctors, and the new physician continued with the medication. During an interview, on 2/17/25 at 8:55 a.m., the Clinical Support Nurse indicated they had not been able to get a hold of Resident 1's primary care doctor regarding prophylactic antibiotic use, and to obtain a justification for the use of it. On 2/11/25 at 3:00 p.m., the Administrator provided a document, dated 11/10/17, titled, Antibiotic Stewardship Guideline, and indicated it was the current policy being used by the facility. The policy indicated, .Purpose: Optimize the treatment of infections by ensuring the residents who require an antibiotic, are prescribed the appropriate antibiotic. Reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use .6. Pharmacy provider will assist in review of all antibiotic usage for appropriateness. 7. Antibiotic use will be calculated on monthly basis for QAPI purposes 3.1-48(a)(2) 3.1-48(a)(4)

Based on record review and interview, the facility failed to ensure abnormal involuntary movement scale (AIMS) assessments (a 12-item clinician-rated scale to assess severity of involuntary movements of the mouth, face, extremities, and trunk in residents taking neuroleptic [psychiatric drugs that treat mental health symptoms] medications) were conducted for 3 of 5 residents reviewed for unnecessary medications (Residents 31, 5, and 15). Findings include: 1. Resident 31's record was reviewed on 2/11/23 at 2:03 p.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia with psychotic disturbance (a condition where a person with dementia [a group of brain conditions that cause memory loss, thinking problems, and difficulty doing daily tasks] experiences a range of behavioral changes. A quarterly Minimum Data Set (MDS) assessment, dated 1/17/25, indicated the resident had severe cognitive deficit and received antipsychotic medication (drugs used to treat symptoms of psychosis [hallucinations: sights, sounds, smells, tastes, or touches that a person believes to be real but are not real, delusions: false beliefs], and dementia) on a routine basis. A care plan, dated 7/17/24, indicated the resident had been admitted on an antipsychotic medication. Interventions included, but were not limited to, monitor for side effects of the medication. A physician's order, dated 7/12/24, indicated to administer a 100 milligram (mg) tablet of quetiapine (antipsychotic medication) two times a day. A pharmacy recommendation, dated July 2024, recommended to complete an AIMS assessment on the resident. The record lacked documentation that an AIMS assessment had been completed. During an interview, on 2/11/25 at 3:40 p.m., the Clinical Support nurse indicated the facility was unable to produce AIMS assessments for the resident. The AIMS assessment had not been completed. 2. Resident 5's record was reviewed on 2/11/25 at 3:22 p.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia with psychotic disturbance (a condition where a person with dementia [a group of brain conditions that cause memory loss, thinking problems, and difficulty doing daily tasks] experiences a range of behavioral changes). An admission Minimum Data Set (MDS) assessment, dated 1/21/25, indicated the resident had severe cognitive deficit and received antipsychotic medication (drugs used to treat symptoms of psychosis [hallucinations: sights, sounds, smells, tastes, or touches that a person believes to be real but are not real, delusions: false beliefs], and dementia) on a routine basis. A care plan, dated 1/20/25, indicated the resident had a diagnosis of dementia with behaviors and was treated with antipsychotic medication. Intervention included, but were not limited to, observe for adverse side effects of medication. A physician order, dated 1/18/25, indicated to administer a 50 milligram (mg) tablet of Seroquel XR (extended-release antipsychotic medication) one time a day for diagnosis of unspecified dementia with other behavioral disturbance. The record lacked documentation that an AIMS assessment had been completed. During an interview, on 2/11/25 at 3:40 p.m., the Clinical Support nurse indicated the facility was unable to produce AIMS assessments for the resident. The AIMS assessment had not been completed. 3. Resident 15's record was reviewed on 2/11/25 at 3:27 p.m. The profile indicated the resident's diagnoses included, but were not limited to, dementia with agitation (a resident with the loss of cognitive functioning who becomes restless and worried and experienced the inability to settle down) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). An admission Minimum Data Set (MDS) assessment, dated 1/27/25, indicated the resident had no cognitive deficit and received antipsychotic medication (drugs used to treat symptoms of psychosis [hallucinations: sights, sounds, smells, tastes, or touches that a person believes to be real but are not real, delusions: false beliefs], and dementia) on a routine basis. A care plan, dated 1/27/25, indicated the resident had come from the hospital with an antipsychotic medication due to post operative (after surgery) hallucinations. Interventions included, but were not limited to, observe for adverse side effects of the medication. A physician's order, dated 2/6/25, indicated to administer a 25 milligram (mg) tablet of Seroquel (antipsychotic medication) with Special Instructions: To be given with a 50 mg tablet, for a total of 75 mg, two times a day. A physician's order, dated 2/6/25, indicated to administer a 50 mg tablet of Seroquel with Special Instructions: To be given with a 25 mg tablet, for a total of 75 mg, two times a day. The record lacked documentation that an AIMS assessment had been completed. During an interview, on 2/11/25 at 3:40 p.m., the Clinical Support nurse indicated the facility was unable to produce AIMS assessments for the resident. The AIMS assessment had not been completed. On 2/12/25 at 10:21 a.m., the Clinical Support nurse provided a document, with a review date of 12/17/24, titled, Guidelines for: Abnormal Involuntary Movement Scale (AIMS), and indicated it was the policy currently being used by the facility. The policy indicated, .Procedures: 1. A licensed nurse will complete an AIMS scale assessment on all residents on antipsychotic medications .3. The AIMS assessment will be repeated for residents taking antipsychotic medications every six (6) months or as needed for displaying symptoms 3.1-48(a)(3) 3.1-48(a)(5)

Based on observation and interview, the facility failed to ensure employees were sanitizing hands while providing meal service during 1 of 2 dining observations, and the facility failed to ensure sanitary measures were maintained while obtaining temperature readings of prepared food with a food temperature measuring device during 1of 2 dietary food service observations. Findings include: 1. On 2/10/25 at 12:06 p.m. observed Dietary Assistant 18 assist a resident by repositioning her wheelchair and moving the chair closer to the table. The employee then obtained food for another resident and failed to sanitize his hands between residents. Observed several employees entering kitchen by touching the door handle and did not sanitize their hands before serving residents their meal. Observed Certified Nurse Aide (CNA) 19, serve food to residents and did not sanitize hands between residents. Observed CNA 19 entering the kitchen multiple times pushing on the door handle and did not sanitize hands before serving food to residents. Hand sanitizer was available in the dining area. Hand washing sink was available inside of the kitchen service area for employees to use. On 2/11/25 at 11:30 a.m., during interview the Clinical Nurse Consultant acknowledged the employs did not need to touch the kitchen door to open it as it had a push bar on the door and employees should sanitize between residents while serving food. On 2/13/2025 at 11:43 a.m., the Clinical Nurse Consultant provided a document titled, Guideline for Handwashing/Hand Hygiene, dated 2/9/17, and indicated it was the policy currently being used by the facility. The policy indicated, .1. All healthcare workers shall utilize hand hygiene frequently and appropriately .b. Before/after preparing/serving meals, drinks 2. On 2/18/25 at 11:36 a.m., during observation of food temperature testing with Dietary [NAME] (22), the employee tested the temperature of the meat and then tested the temperature of the other food items on the steam table and the cold food with a food temperature measuring device then wiped the device on a napkin. The employee failed to disinfect the temperature device between each food item. On 2/18/25 at 11:45 a.m., during interview employee 22, acknowledged she had not sanitized the temperature device between each food item. She acknowledged she should have sanitized the device and indicated she did not have any wipes available. On 2/18/25 at 11:47 a.m. during interview the Dietary Manager acknowledged the cook should have wiped the food temperature measuring device between each food item and wipes were available in the main kitchen. On 2/18/2025 at 1:29 p.m., the Clinical Nurse Consultant provided an undated document, titled, guidelines, and indicated it was the policy currently being used by the facility. The document indicated, .Equipment food-contact surfaces and utensils shall be cleaned as follows .3. Between uses with raw fruits and vegetables and with potentially hazardous food. 4. Before using or storing a food temperature measuring device 3.1-21(i)(1) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure the laundry staff properly stored and handled clean and soiled linens within the clean and soiled laundry areas for 1 of 1 observation of the laundry area. This deficient practice had the potential to spread infectious agents throughout the facility and increase the possibility of infection for residents residing within the facility. Findings include: During a tour of the laundry area with the Director of Health Services (DHS), who was the Infection Preventionist, on 1/8/24 at 2:00 p.m., the following was observed: clean laundry laying on the floor, personal items and gowns in bags laying on the floor with unbagged clean laundry on top of and on the floor next to the bags, clean gowns and lift pads partially on top of the bags on the floor and partially lying on the floor, and the soiled laundry area contained several barrels of soiled linen with none of the barrels covered. Laundry Staff 17 was observed transferring bagged soiled linen without gloves on and laid the soiled linen on the floor in front of the washer. During an interview on 1/8/24 at 2:06 p.m., Laundry Staff 18 indicated items were clean that were in the clean laundry area and indicated the lift pads might need to be labeled and then washed. During an interview on 1/8/24 at 2:08 p.m., Laundry staff 17 indicated they were new and was not sure of duties. The staff acknowledged the soiled area with barrels did contain soiled linen. The DHS acknowledged this was not correct procedure for handling clean and soiled linen. On 9/20/23 at 3:19 p.m., the Executive Director (ED) provided a document titled, Laundry Operations, dated 2/5/2018, and indicated it was the policy currently being used by the facility. The policy indicated, .PROCEDURES .Pick up soiled laundry from soiled linen rooms. PPE's (personal protective equipment) are to be worn. The carts are to be covered at all times .Sort laundry and place in washers with like material. PPE's are to be worn A policy for handling clean linen was not provided by the facility. 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 1 of 6 residents reviewed for care plan meetings (Resident 37). Finding includes: During an interview, on 1/2/24 at 11:04 a.m., Resident 37 indicated she did not remember being invited to or attending a care plan meeting recently. She could not recall when the last one was. Resident 37's record was reviewed on 1/5/24 at 11:19 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 8/8/23, indicated the resident had moderate cognitive impairment. Census information indicated the resident was admitted to the facility on [DATE]. A Social Service Director (SSD) note, dated 7/12/23 at 11:42 a.m., indicated a care plan meeting was conducted on this day for Resident 37. An SSD note, dated 12/20/22 indicated a care plan meeting was conducted on this day for Resident 37. Resident 37's record lacked documentation of a quarterly care plan meeting being conducted between the months of December 2022 - July 2023, and July 2023 - January 2024. During an interview, on 1/5/24 at 2:50 p.m., the SSD indicated Resident 37's daughter had attended the last care plan meeting that was conducted on 7/12/23. The resident was not in attendance per request of the daughter. The SSD indicated she had missed some quarterly care plan meetings with Resident 37. The SSD indicated the residents should have a care plan meeting within 5-7 days of admission and then quarterly thereafter. Resident 37 did not have quarterly care plan meetings as she should have. During an interview, on 1/5/24 at 3:22 p.m., the Executive Director (ED) indicated he was aware that some of the residents had missed their quarterly care plan meetings. He indicated the SSD had been helping in other buildings and some care plan meetings were missed on the schedule for the facility. On 1/5/24 at 3:39 p.m., the ED provided and identified an undated document as a current facility policy titled, Resident's First Meeting Guidelines. The policy indicated, .2. Subsequent meeting for non-Medicare residents should be conducted at a minimum of quarterly and with a significant change 3.1-35(e)

Based on observation, interview, and record review, the facility failed to prevent or decrease contracture related to decreased range of motion and mobility for 1 of 2 residents reviewed for mobility (Resident 4). Findings include: On 1/2/24 at 11:57 a.m., the resident was observed sitting up in a Broda chair (a type of wheelchair) with legs extended and lying against the vinyl of the footrest. The resident was not wearing socks or shoes. No anticontracture measures were in place to prevent the downward flexion of the bilateral feet. On 1/4/24 at 10:39 a.m., during an interview with Licensed Practical Nurse (LPN) 4, the nurse indicated the resident would not allow the staff to put shoes or socks on her and would not allow anticontracture devices to her feet the nurse acknowledged the resident had contracture of bilateral feet. On 1/4/24 at 10:59 a.m., the resident was observed lying in bed, covered with blanket. Bilateral feet were elevated on a pillow feet were flexed downward. There were no anticontracture measures in place to prevent the downward flexion of the bilateral feet. On 1/4/24 at 1:00 p.m., Resident 4's medical record was reviewed. Diagnoses on the resident's profile included, but were not limited to, Hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body and hemiparesis (a relatively mild loss of strength) following other cerebrovascular disease affecting left non-dominant side, Venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart) (chronic) (peripheral) (long term, located near a periphery or surface part (as of the body), Thrombophilia (blood has an increased tendency to form clots), Posterior reversible encephalopathy syndrome (a syndrome characterized by a headache, seizures, altered mental status and visual loss), and muscle weakness. Physician's orders included but were not limited to, Compression stockings on while resident sitting up with legs in dependent position Three Times A Day, OT (occupational therapy) (the use of meaningful activities with specific goals to help people of all ages prevent, lessen, or adapt to disabilities), POC (plan of care) established for 12 sessions x 60 days which may include thera exercises, thera activities and w/c (wheelchair) positioning as indicated, PT (physical therapy) to eval and treat 3 days a week for ROM (range of motion) (the extent or limit to which a part of the body can be moved around a joint or a fixed point), endurance, muscle stretching with a Goal to improve mobility and decrease stiffness. A Quarterly Minimum Data Set, (MDS) a standardized assessment tool that measures health status in nursing home residents, dated 11/16/23, indicated the resident was cognitively impaired. In section GG, mobility the MDS indicated the resident was dependent for bilateral lower extremities and in section O, the MDS indicated ROM was not performed by physical therapy during the look back period. On 1/5/24 at 12:30 p.m., during an interview with the DHS she acknowledged the staff should notify the physician if a resident refuses treatments and the care plan should be implemented for prevention of contractures. The medical record lacked documentation of refusal of care for application of anticontracture and including preventive measures. On 1/9/24 at 3:32 p.m., the Executive Director (ED) provided a document, titled, Policy .Guidelines for selection of Therapeutic Support Surfaces, dated 3/16/22, 5/22/18, and indicated it was the policy currently being used by the facility. The policy indicated, PURPOSE .To provide an appropriate therapeutic surface when determined to be medically necessary by the interdisciplinary team and/or the physician for prevention and healing of skin impairment .PROCEDURES .7. A resident with severe flexion contracture also may require special attention to effectively reduce pressure on bony prominences or prevent breakdown from skin-to-skin contact .a. Use pillows to prevent skin touching skin .b. bolsters may be useful as positioning devices 3.1-42(a)(1) 3.1-42(a)(2) 3.1-42(a)(3)

Based on observation, interview, and record review, the facility failed to ensure proper storage of a Continuous Positive Airway Pressure (CPAP) mask (machine used to supply a constant flow of air at a set pressure into the airway to ensure that the airway stays open) for 1 of 4 residents reviewed for respiratory care (Resident 34). Findings include: On 1/2/24 at 12:59 p.m., Resident 34's CPAP mask and tubing was observed unbagged and hanging over the top and inside the resident's lamp shade. On 1/2/24 at 2:55 p.m., Resident 34's CPAP mask and tubing was observed unbagged and hanging over the top and inside the resident's lamp shade. On 1/3/24 at 9:21 a.m., Resident 34's CPAP mask and tubing was observed unbagged in the partially opened nightstand drawer. On 1/3/24 at 11:08 a.m., Resident 34's CPAP mask and tubing was observed unbagged in the partially opened nightstand drawer. On 1/5/24 at 9:02 a.m., Resident 34's CPAP mask and tubing was observed unbagged in the partially opened nightstand drawer. On 1/5/24 at 9:23 a.m., Licensed Practical Nurse (LPN) 5 observed the unbagged CPAP mask and tubing in the partially opened nightstand drawer and indicated, the CPAP mask and tubing should be stored in a dated bag and should not ever be placed inside the lamp shade. Resident 34's record was reviewed, on 1/5/24 at 9:39 a.m. Diagnoses included, but were not limited to, obstructive sleep apnea (OSA) (breathing disorder when the windpipe is blocked while asleep) and pulmonary hypertension (type of high blood pressure that affects the arteries in the lungs and the right side of the heart). A quarterly Minimum Data Set (MDS) assessment, dated 12/20/23, indicated the resident was cognitively intact, experienced shortness of breath when lying flat, and received oxygen therapy. A care plan, dated 2/8/22 and revised on 9/28/23, indicated the resident had the potential for shortness of breath (SOB) while lying flat related to the diagnoses of OSA and pulmonary hypertension. An intervention on the care plan included, but was not limited to, CPAP machine, with the long-term goal of the resident will be free of complications from SOB. A physician's order, dated 9/11/23, indicated to encourage resident to wear CPAP at night from 10 p.m. to 6 a.m. On 1/5/24 at 12:08 p.m., the Regional Nurse Consultant (RN) 3 indicated the facility policy did not specify the storage of a CPAP mask, but the CPAP mask, like all respiratory equipment, should be bagged when not in use. At that time, RN 3 provided and identified a document as a current facility policy titled, Respiratory Equipment, dated 12/31/22. The policy indicated, .To provide infection control guidelines to help prevent infections associated with respiratory therapy equipment and to prevent transmission of infections to residents .j. Keep oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use 3.1-47(a)(4) 3.1-47(a)(5) 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a physician's order was administered as ordered and the facility failed to ensure monitoring of a resident who was on opioid medication for 1 of 2 residents reviewed for pain management (Resident 44). Findings include: Resident 44's record was reviewed on 1/4/24 at 9:03 a.m. The profile indicated the resident's diagnoses included, but were not limited to, low back pain, spinal stenosis (a narrowing of the spinal canal), intervertebral disc degeneration, lumbar region (a syndrome in which age-related wear and tear on a spinal disc causes low back pain), and spastic hemiplegia affecting right dominant side (causes muscle tightness and involuntary contractions in the limbs and extremities on one side of the body). An admission Minimum Data Set (MDS) assessment, dated 12/15/23, indicated the resident was cognitively intact and he had a pain intensity numeric scale of 8 out of 10. A care plan, dated 12/11/23, indicated the resident was at risk for pain related to decreased mobility and weakness, chronic pain. Intervention included but were not limited to, administer medications as ordered and notify doctor of any side effects observed or lack of effectiveness. The record lacked documentation of monitoring a resident for side effects associated with opioid medication use. A physician order, dated 12/11/23, indicated to administer morphine (opioid analgesic medication used to treat severe pain) 15 mg (milligrams), 1 tablet every 12 hours. A physician order, dated 12/12/23, indicated to administer morphine 15 mg, 1 tablet every 8 hours as needed for pain. Review of the resident's December 2023 medication administration record (MAR) indicated Resident 44 was given a 15 mg morphine tablet on the following dates: a. 12/16/23 at 2:16 p.m. and then again at 8:15 p.m. (less than the 8-hour time interval as ordered) b. 12/22/23 at 5:19 a.m., and then again at 12:57 p.m. (less than the 8-hour time interval as ordered) c. 12/29/23 at 12:57 p.m. and then again at 7:21 p.m. (less than the 8-hour time interval as ordered) d. 12/30/23 at 1:37 p.m. and then again at 7:52 p.m. (less than the 8-hour time interval as ordered) Review of the resident's January 2024 MAR indicated Resident 44 was given a 15 mg morphine tablet on the following dates: e. 1/1/24 at 1:16 p.m. and then again at 7:46 p.m. (less than the 8-hour time interval as ordered) f. 1/2/24 at 7:30 p.m. and then again at 7:51 p.m. (routine medication was given and 20 minutes later a prn (as needed) medication was given) During an interview on 1/4/24 at 11:01 a.m., Licensed Practical Nurse (LPN) 8 indicated as needed medication should only be given at the exact time intervals they were ordered. During an interview on 1/4/24 at 11:10 a.m., Director of Health Services (DHS) indicated prn (as needed) medication should be administered as ordered and not given early. She indicated staff had not followed the physician's order for Resident's 44's pain medication. During an interview on 1/4/24 at 2:40 p.m., DHS indicated side effects of opioid medication use should have been monitored on Resident 44. It should have been on his MAR due to the morphine medication use. On 1/4/24 at 1:30 p.m., the Executive Director (ED) provided a document, with a revised date of 11/18, titled, Preparation and General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .2) Medications are administered in accordance with written orders of the prescriber On 1/5/24 at 11:10 a.m., the ED provided a document, with a revised date of 5/23/17, titled, Guidelines for Pain Observation and Management, and indicated it was the policy currently being used by the facility. The policy indicated, .Purpose: To Ensure each resident's pain including its origin, location, severity, alleviating and exacerbating factors, current treatment and response to treatment will be observed and documented according to the needs of each individual 3.1-37(a)

Based on record review and interview, the facility failed to ensure a pharmacist completed a resident's monthly medication review for 1 of 5 residents reviewed for unnecessary medications (Resident 41), the facility failed to ensure the physician wrote a response or a rationale for a declination of a pharmacist medication recommendation for 1 of 5 residents reviewed for unnecessary medications (Resident 14), and the facility failed to ensure the physician agreed upon pharmacist recommendation was implemented for 1 of 5 residents reviewed for unnecessary medications (Resident 4). Findings include: 1. Resident 41's record was reviewed on 1/4/24 at 9:12 a.m. The resident was admitted to the facility, on 3/13/23, with a diagnosis included, but was not limited to, unspecified dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities. This typically involves problems with memory, thinking, and behavior). Review on the pharmacy monthly medication reviews, lacked documentation a May 2023 medication review had been completed for Resident 41. On 1/4/24 at 2:28 p.m., the Executive Director (ED) indicated the pharmacist reviewed all the residents in the facility monthly and the May 2023 monthly pharmacy review for Resident 41 had just been missed. 49068 2. A pharmacy recommendation, dated 9/26/23, indicated Resident 14 was taking aspirin (a non-steroid anti-inflammatory drug [NSAID] used to decrease pain, fever, swelling, and help thin the blood to slow down how fast it clots) daily for primary prevention of cardiovascular disease (heart disease). The bleeding risk associated with this medication in individuals above seventy years of age may outweigh the benefits of primary prevention of cardiovascular disease. Please consider discontinuation of aspirin. At the bottom of the recommendation, Physician 21 indicated to continue aspirin, signed, and dated for 9/27/23. No rationale was provided. Resident 14's record was reviewed on 1/4/24 at 9:30 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Parkinson's (disease a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves that can cause tremors, stiffness, and slowing of movement) , Alzheimer's (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks.), tremors, repeated falls, unsteadiness on feet, and lack of coordination. A physician's order, dated 6/15/22, indicated aspirin 81 mg (milligrams) delayed release, once a day, for diagnosis of long term (current) drug therapy. Resident 14's record lacked documentation of any rational for continuation of aspirin. During an interview on 1/9/24 at 8:58 a.m., with the Executive Director (ED), he indicated that there was a known issue with the pharmacy recommendations. Before he brought the stack of recommendations in for review, he looked at them and knew they weren't right. They had been prepping the reviews for the Physician 21, but nobody was following through to see if they were done. When they did go through them, they would find unacceptable responses but were not bringing it to his attention before now. Physician 21 also missed the follow ups on the monthly reports where the pharmacy would say there were so many things that needed to be addressed, there would be recommendations but gaps on reasons. 48226 3. On 1/4/24 at 1:00 p.m., Resident 4's medical record was reviewed. Diagnoses on the resident's profile included, but were not limited to, Hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body and hemiparesis (a relatively mild loss of strength) following other cerebrovascular disease affecting left non-dominant side, Hypotension (low blood pressure), Venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart) (chronic) (peripheral) (long term, located near a periphery or surface part (as of the body), Thrombophilia (blood has an increased tendency to form clots), Chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), Posterior reversible encephalopathy syndrome (a syndrome characterized by a headache, seizures, altered mental status and visual loss), Type 2 diabetes mellitus with diabetic neuropathy (a disease that occurs when your blood glucose, also called blood sugar, is too high and a type of nerve damage that can occur if you have diabetes) and muscle weakness. Physician's orders included but were not limited to, Vitamin D3 tablet 25 mcg (1,000unit) 1 tablet once a day ordered 6/08/2022; Ozempic (Semaglutide) pen injector 1mg/dose inject 2 mg subcutaneous once a week on Sunday ordered 11/04/2023; and Rybelsus 7 mg tablet orally once a day ordered 6/9/2022 and discontinued on 1/01/2023. On 1/16/23 a monthly medication review was completed. The pharmacist recommended to increase vitamin D to 2000 units daily. Documentation indicated the physician failed to review the recommendation and the recommendation was not completed. On 3/19/23 the monthly pharmacy medication review indicated a re-[NAME] recommendation was given to increase vitamin D to 2000 units. Documentation indicated the physician failed to review the recommendation and the recommendation was not completed. On 4/20/23 the monthly pharmacy medication review indicated a re-[NAME] recommendation was given to increase vitamin D to 2000 units. The documentation failed to indicate the physician reviewed the recommendation and the recommendation was not completed. On 7/26/23 the monthly pharmacy medication review indicated a recommendation to the physician. The Resident was on Semaglutide and Rybelsus. The recommendation was to discontinue one of the medications. The documentation indicated the physician reviewed and ordered Rybelsus medication to be discontinued. The documentation failed to indicate the medication was discontinued. On 9/26/23 the monthly pharmacy medication review indicated; a re-[NAME] recommendation was given. The resident was on Semaglutide and Rybelsus. The documentation failed to indicate the physician reviewed the recommendation. The medication was not discontinued until 11/1/23. On 1/5/24 at 11:09 a.m., the Executive Director (ED) provided a document titled, Organizational Aspects, dated 11/18, and indicated it was the policy currently being used by the facility. The policy indicated .F. The specific activities that the Consultant Pharmacist and or pharmacy representative perform includes but is not limited to .1. Reviewing the medication regimen (medication regimen review) of each resident at least monthly, or more frequently under certain conditions (e.g., upon admission or with a significant change in condition as notified by the facility), incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication review (See IIIA1: MEDICATION REGIMEN REVIEW), and documenting the review and findings in the resident's medical record or in a readily retrievable format if utilizing electronic documentation On 1/5/24 at 11:09 a.m., the Executive Director (ED) provided a document titled, IIIA1: MEDICATION REGIMEN REVIEW, dated 11/18, and indicated it was the policy currently being used by the facility. The policy indicated, .The Consultant Pharmacist performs a comprehensive review of each resident's medication regimen routinely as required by state or federal regulations. The medication regimen review (MMR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. Findings and recommendations are reported to the Director of Nursing and the prescriber, and if appropriate, the Medical Director and/or the Administrator .Procedures .E. Recommendations are acted upon and documented by the facility personnel and/or the prescriber .1. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing 3.1-25(h) 3.1-25(i)

Based on observation, interview, and record review, the facility failed to ensure the medication refrigerator log was up to date for 1 of 1 medication storage rooms reviewed and the facility failed to ensure expired medications were disposed of for 1 of 3 medication carts reviewed (Resident 20). Findings include: 1. On 1/5/24 at 9:06 a.m., the 200-hall mediation storage room contained a medication refrigerator, and it had a temperature log that was not up to date. The log was not completed for January 3 and 4, 2024. The refrigerator contained miscellaneous medications that needed to be stored in the refrigerator before or during use. During an interview, on 1/5/24 at 9:06 a.m., the Director of Health Services (DHS) indicated the refrigerator log was missing a couple of days of the temperature being checked in January and the log should be completed daily by the day shift nurse. 2. On 1/5/24 at 9:15 a.m., the 100-hall medication cart contained an expired insulin (medication used to lower blood sugar) pen with an open date of 12/1/23 and an expired insulin vial with an open date of 12/1/23. The insulin pen and vial contained labels that indicated they were for Resident 20. During an interview, on 1/5/24 at 09:17 a.m., Licensed Practical Nurse (LPN) 11 indicated she thought insulin was good for 30 days once opened. She indicated the insulin for Resident 20 was expired and should have been disposed of. During an interview, on 1/5/24 at 9:36 a.m., LPN 8 indicated insulin was good for 30 days once it had been opened. Resident 20's record was reviewed on 1/5/24 at 10:30 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Type 2 diabetes mellitus with diabetic polyneuropathy (a chronic condition that affects the way the body process blood sugar and neuropathy can most often damage nerves in the legs and feet). A physician order, dated 11/29/23, indicated to inject 22 units of Lantus (insulin medication) pen 100 unit/ml (milliliter) by subcutaneous (under the skin) injection at bedtime. A physician order, dated 11/20/23, indicated to inject 2 units Humalog (insulin medication) 100 unit/ml by subcutaneous injection before meals. On 1/5/24 at 11:43 a.m., the Executive Director (ED) provided and identified a document as a current facility policy titled, Equipment and Supplies for Administering Medications, with a revised date of 11/18. The policy indicated, .3) A temperature log with acceptable temperature ranges for each area should be maintained at all times On 1/5/24 at 11:10 a.m., The ED provided and identified a document as a current facility policy titled, Vials and Ampules of Injectable Medications, with a revised date of 11/18. The policy indicated, .F. Medications in multiuse vials may be used for the length of time allowed by state law if inspection reveals no problems during that time .guidelines recommend discarding multidose vials at 28 days after opened 3.1-25(m) 3.1-25(o)

Based on observations, interview and record review, the facility failed to develop, implement, and revise a comprehensive care plan to prevent contractures for 1 of 12 residents reviewed for care plans (Resident 4). Findings include: On 1/2/24 at 11:57 a.m., the resident was observed sitting up in a Broda chair (a type of wheelchair) with legs extended and lying against the vinyl of the footrest. The resident was not wearing socks or shoes. No anticontracture measures were in place to prevent the downward flexion of the bilateral feet. On 1/4/24 at 10:39 a.m., during an interview with Licensed Practical Nurse (LPN) 4. The nurse indicated the resident would not allow the staff to put shoes or socks on her and would not allow anticontracture devices to her feet the nurse acknowledged the resident had contracture of bilateral feet. On 1/4/24 at 10:59 a.m., the resident was observed lying in bed, covered with blanket. Bilateral feet were elevated on a pillow feet were flexed downward. There were no anticontracture measures in place to prevent the downward flexion of the bilateral feet. On 1/04/24 at 11:32 a.m., during an interview with Licensed Practical Nurse (LPN) 6, she indicated the MDS nurse updated the care plans and care plans should be discontinued when they were resolved. On 1/04/24 at 11:40 a.m., the Director of Health Services (DHS) indicated the care plans were updated by the MDS nurse. This was done daily and as needed. On 1/04/24 at 11:46 a.m., LPN 6, indicated she updated all care plans. She resolved and updated care plans when the new MDS was due. On 1/4/24 at 1:00 p.m., Resident 4's medical record was reviewed. Diagnoses on the resident's profile included, but were not limited to, Hemiplegia (a loss of strength in the arm, leg, and sometimes face on one side of the body and hemiparesis (a relatively mild loss of strength) following other cerebrovascular disease affecting left non-dominant side, Hypotension (low blood pressure), Venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart) (chronic) (peripheral) (long term, located near a periphery or surface part (as of the body), Thrombophilia (blood has an increased tendency to form clots), Chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), Posterior reversible encephalopathy syndrome (a syndrome characterized by a headache, seizures, altered mental status and visual loss), Type 2 diabetes mellitus with diabetic neuropathy (a disease that occurs when your blood glucose, also called blood sugar, is too high and a type of nerve damage that can occur if you have diabetes) and muscle weakness. Physician's orders included but were not limited to, Compression stockings on while resident sitting up with legs in dependent position Three Times A Day, OT (occupational therapy) (the use of meaningful activities with specific goals to help people of all ages prevent, lessen, or adapt to disabilities), POC (plan of care) established for 12 sessions x 60 days which may include thera exercises, thera activities and w/c (wheelchair) positioning as indicated, PT (physical therapy) OT to eval and treat 3 days a week for ROM (range of motion) (the extent or limit to which a part of the body can be moved around a joint or a fixed point), endurance, muscle stretching. Goal is to improve mobility and decrease stiffness. A quarterly Minimum Data Set, (MDS), dated [DATE], indicated the resident was cognitively impaired. In section GG, mobility the MDS indicated the resident was dependent for bilateral lower extremities and in section O, the MDS indicated ROM was not performed by physical therapy during the look back period. On 1/5/24 at 12:30 p.m., during an interview with the DHS she acknowledged the staff should notify the physician if a resident refused treatments and the care plan should be implemented for prevention of contractures. On 1/9/24 at 3:32 p.m., the Executive Director (ED) provided a document titled, Comprehensive Care Plan Guideline, dated 5/22/18, and indicated it was the policy currently being used by the facility. The policy indicated, .PURPOSE .to ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .PROCEDURES .1 .b. Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident .c. Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan 3.1-35(a) 3.1-35(b)(1)(i)

Based on observation, interview and record review, the facility failed to ensure person-centered fall interventions were in place for a resident, (Resident B) who had a history of falls, which resulted in actual harm when he fell out of bed and sustained multiple rib fractures and hospitalization . The facility failed to ensure a resident, (Resident C) who had a history of falls, also received person-centered interventions as outlined in her plan of care for 2 of 3 residents reviewed for falls. Findings include: 1. On 9/6/23 at 11:32 a.m., a comprehensive record review was completed for Resident B. He was a long-term care resident who received Hospice services. He had diagnoses which included, but were not limited to, Parkinson's disease (a degenerative cognitive disease which affects the body's ability to control muscle movement), hemiplegia (paralyzed on one side of the body), COPD (chronic obstructive pulmonary disease), neurocognitive disorder with Lewy bodies (a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain), psychotic disorder, tremors, history of pulmonary embolism, and anxiety. Resident B had a comprehensive care plan, dated 3/17/22, which indicated he was at risk for falling related to decreased mobility and weakness. The goal of the care plan was to ensure Resident B would remain free from falls with major injury, and on 1/19/23 the IDT intervention for bolsters to the mattress was added. A progress note, dated 6/16/23 at 9:44 p.m., indicated Resident B wanted to get up for breakfast and turned himself and rolled out of bed. He was assessed with no injury noted. His fall was unwitnessed. The IDT (Interdisciplinary Team) met to evaluate Resident B's fall. An intervention was added to place bolsters (support) to the sides of his bed to help serve as bed boundaries. A nursing progress note, dated 8/13/23 at 10:16 a.m., indicated Resident B rolled out of bed. He complained of neck and back pain and was sent to the emergency room . During an interview, on 9/6/23 at 2:28 p.m., Certified Nursing Aide (CNA) 7 indicated Resident B had been upset on 8/13/23 and yelled out. She went to provide him with perineal care. During her resident care with him, she noticed the patch (a dressing to cover wounds) came off his bottom. CNA 7 centered him on his bed which she had raised to waist height to provide care. She left the room to get the nurse, and when she returned, Resident B was found on the floor, as he must have rolled out of bed. CNA 7 called for help and Licensed Practical Nurse (LPN) 5 came to assist. CNA 7 indicated Resident B used a bariatric (wide) bed with quarter grab bars, but no bolsters had been added to the mattress. During an interview, on 9/6/23 at 2:48 p.m., a Registered Nurse (RN) indicated upon review of Resident B's records she did not find a record of bolsters being ordered, received, or added to his mattress. During an interview, on 9/6/23 at 3:00 p.m., LPN 5 indicated Resident B rolled out of his bed a second time, and there were no bolsters on his bed. On 8/14/23 at 12:25 p.m., the facility reported Resident B sustained multiple fractures of his right 4th, 5th and 6th ribs, and a subtle nondisplaced fracture at the base of the 7th rib. A nursing progress note, dated 8/25/23 at 12:42 p.m., indicated Resident B passed away at a local hospital. 2. On 9/6/23 at 11:12 a.m., Resident C was observed with her eyes closed with her upper body on her bed and her feet were resting on the floor. She was observed lying on a regular mattress without bolsters. On 9/6/23 at 2:30 p.m., Resident C was observed with her eyes closed in the same position observed in at 11:12 a.m. Resident C had a regular mattress without bolsters on it. She was a long-term care resident who received Hospice services. She had diagnoses which included, but were not limited to, acute respiratory failure, pericardial effusion (fluid around the heart), neuropathy (nerve pain), dementia, heart failure, hyperlipidemia (high cholesterol), hypothyroidism, muscle weakness, altered mental status, and history of falls. A care plan, dated 4/25/22, indicated resident was at risk for falling related to decreased mobility, weakness, and cognitive status, which included a goal for Resident C would remain safe from falls with major injury. An intervention on the care plan indicated for her to have a mattress with bolsters. An event, dated 6/22/23, indicated Resident C was found on the floor next to her bed. No injury was observed. IDT added an intervention to have hospice order a mattress with bolsters. An event, dated 7/25/23, indicated Resident C had a fall on 7/25/23 at 3:44 p.m. She was found on the floor in her room. No injury was observed. On 7/26/23 at 9:39 a.m., IDT added an intervention to provide meaningful activity prior to meals. A nursing note, dated 8/19/23 at 2:26 p.m., indicated the resident was found on the floor in her room. There was no injury observed. A fall event, dated 8/19/23, indicated IDT to request hospice send a mattress with bolsters. On 9/6/23 at 12:32 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Fall Management Program Guidelines, dated 3/16/22. The policy indicated .Trilogy Health Services (THS) strives to maintain a hazard free environment, mitigate fall risk factors, and implement preventative measures. THS recognizes even the most vigilant efforts may not prevent all falls and injuries. In the cases, intensive efforts will be directed toward minimizing or preventing injury On 9/6/23 at 12:32 p.m., the ED provided a copy a current facility policy titled, Guidelines for Neurological Checks, dated 12/31/22. The policy indicated .Residents having a fall should be evaluated for injury and neuro checks for 24 hours should be completed within the fall event form This Federal tag relates to Complaint IN00416356. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a physician prescribed radiology order had been provided within the indicated time frame for 1 of 3 residents reviewed for radiology services. Findings include: Resident B's closed clinical records were reviewed on May 08, 2023 at 1:40 p.m. Diagnoses included, but were not limited to, fractures and other multiple trauma. The admission Minimum Data Set (MDS) assessment, dated February 07, 2023, indicated Resident B was cognitively intact. When communicating she understood others and others understood her with clear comprehension. She required extensive assistance from nursing staff to meet activities of daily living needs. She had a history of falls, prior to admission within the past 2 to 6 months, which resulted in a fracture that required surgical repair. Resident B's progress notes indicated: - On February 26, 2023 at 5:30 p.m. (Sunday); the resident had been observed on the floor on her buttocks next to her bed. The resident had indicated she was going to the bathroom and had slipped out of bed. Resident B had no complaints of pain and no injury had been assessed. Nursing staff were going to continue to monitor. -On February 26, 2023 at 9:48 p.m., Resident B's left lower leg was assessed to have developed swelling, discoloration, pain, and numbness. The resident's physician was contacted and orders to immediately X-ray the left lower leg were obtained. The radiology order, dated February 26, 2023 (no time indicated), indicated, Lt [left] lower extremity Xray . STAT - Immediately. Resident B's clinical records lacked documentation the X-ray order had been implemented. A progress note, dated February 27, 2023 at 12:04, indicated, Resident had a fall on 2/26/2023 and reports pain to knee post fall. Nurse notified MD/DHS [Medical Doctor/Director of Health Services] and received order to obtain STAT X-RAY . Resident has plans to transfer to ----- [different nursing home/name] for long term placement. Resident left via ---- [different nursing home/name] and report called to ----- [different nursing home/name] for facility to order STAT X-RAY due to ---- [radiology/name] not coming to facility On May 08, 2023 at 2:30 p.m., Resident B's closed clinical records were reviewed at the nursing home she transferred to on February 27, 2023. The records indicated upon her admission the facility had received a report, from the nursing home she had resided, to obtain a STAT X-ray, to rule out an injury from a fall that occurred on February 26, 2023. Upon having received this report, Resident B was transferred to a local hospital emergency room for evaluation. On May 08, 2023 at 4:00 p.m., Resident B's hospital radiology report, dated February 27, 2023 at 7:07 p.m., was reviewed. The report indicated, no broken bones. On May 09, 2023 at 9:15 a.m.; the Administrator was interviewed. During the interview, the Administrator indicated Resident B's STAT radiology order, dated February 26, 2023, had not been implemented prior to her discharge on February 27, 2023 to a different nursing home. On May 09, 2023 at 10:30 a.m., the Administrator provided a copy of the facility's current Policy and Procedure for Telephone orders dated May 11, 2016. The Administrator indicated this would be the policy followed for STAT physician orders. A review of the policy indicated no procedure for implementation of received physician orders nor documentation of time frames for implementation of received physician orders. On May 09, 2023 at 10:45 a.m.; the Administrator provided a copy of the facility's current non-dated Portable Imaging and Diagnostic Testing Services Agreement. A review of the agreement indicated no documentation to provide services outside of normal business hours nor an agreement to implement STAT services. This Federal tag relates to Complaint IN00402772. 3.1-49(g)

Based on interview and record review, the facility failed to follow-up on urine specimen results and obtain an ordered urine specimen in a timely manner to diagnose and treat a Urinary Tract Infection [MEDICAL CONDITION] for 1 of 3 residents reviewed for infections. Resident B had a 26 day delay in treatment for [REDACTED]. Finding includes: Resident B's closed clinical record was reviewed on 12/5/19 at 11:45 a.m. A note, entered on 9/27/19 at 1:43 p.m., indicated the resident had been seen by the Nurse Practitioner (NP) on 9/26/19 and laboratory tests had been ordered that had included a urinalysis. The Director of Nursing Services (DNS) and Executive Director (ED) were interviewed on 12/6/19 at 10:40 a.m. The ED and DNS indicated the NP had reviewed lab results for a CMP (Complete Metabolic Profile) and CBC (complete blood count) and gave new orders. The urinalysis specimen had not been collected at that time. Documentation on the Medication Administration Report (MAR) included an order to obtain a urinalysis dated 9/28/19. Documentation indicated nursing staff were unable to obtain the specimen on 9/28/19 on day, evening and night shifts; on 9/29/19 on evening and night shifts; on 9/30/19 on day, evening and night shifts; and on 10/1/19 on day shifts. No documentation of the physician being notified of inability to obtain a specimen was noted until 10/1/19, when an order was received to obtain a specimen utilizing the straight catheter method. Licensed Practical Nurse (LPN) 3 was interviewed on 12/6/19 at 10:58 a.m. She indicated usually a clean catch specimen could be obtained from the resident when placed on the toilet after meals. The catheter method was traumatic for the resident. Progress notes, dated 10/4/19, 10/5/19 and 10/6/19, indicated the resident continued on an antibiotic for a urinary tract infection. On 12/6/19 at 10:40 a.m., the DNS indicated this had been errors in charting and the resident had not been placed on an antibiotic to treat the infection. She had not been aware of that until a timeline had been reviewed the evening of 12/5/19. A progress note, dated 10/15/19, included documentation that the medical group had been notified that a urinalysis specimen had been unable to be read and a new order received to catheterize the resident for a new specimen. The laboratory report, dated 10/6/19, of a specimen obtained on 9/28/19 indicated an infection of greater than 100,000 Proteus Mirabilis and Escherichia Coli ESBL (Extended spectrum beta-lactamases.) A treatment sensitive report for the organisms had been included. A progress note from the medical group, dated 10/15/19, indicated the Registered Nurse had been called regarding the resident's ongoing burning/rubbing of the perineal genitalia. The resident's representative had requested a urine test be done to rule out an ongoing urinary tract infection. The note included a urinalysis and culture had been done on 9/28/19, and was positive for a urinary tract infection and yeast with culture isolated of more than 100,000 colonies of Proteus Mirabilis and ESBL [NAME] Coli (infectious organisms.) The note indicated it had looked like the resident had not had any treatment for [REDACTED]. The collection time of a new specimen on the laboratory report was dated 10/19/19. The DNS and Clinical Support nurse were interviewed on 12/6/19 at 11:00 a.m. and indicated they had not been able to identify why there had been a delay in obtaining a new specimen. The results had been received on 10/22/19, and new physician's orders [REDACTED]. A progress note, dated 10/22/19 at 10:48 p.m., indicated the medical group had been notified of the resident not taking medications, twitching, and change of condition. Vital signs had been obtained and a voicemail left with the resident's emergency contact. A note, dated 10/22/19 at 11:09 p.m., included the resident's contact had responded about what treatment she had wanted and she had indicated would prefer subcutaneous hydration over sending the resident out to the hospital. A note on 10/22/19 at 11:11 p.m., indicated the medical group had ordered two liters of oxygen for the resident. An edited note, dated 10/23/19 at 6:33 a.m., included the resident had been assessed and physician notified of a change in condition with new orders to start intravenous fluids. It included but was not limited to, the resident continued on antibiotics for a urinary tract infection. Documentation on the MAR indicated [REDACTED]. Documentation on the administration record noted the medication had been placed on hold on 10/23/19. A late entry progress note, dated 10/23/19 at 11:55 p.m., indicated the nurse had been called by other staff nurse to assess the resident. Staff nurse found Resident B unresponsive and not breathing. Both nurses assessed for apical heart rate for over a minute and it had been absent. The DHS had been notified and an order received to release the body. A death certificate for Resident B, dated 10/23/19, obtained from the county Vital Records Department, received on 12/6/19 at 10:10 a.m., signed by the physician on 10/25/19, listed the immediate cause of death of urinary tract infection and other condition leading to the cause of death as Alzheimer's Dementia. A facility's policy titled, Provider Notification Guidelines, with most recent review date 5/23/18, was provided by the DNS on 12/6/19 at 1:37 p.m., included but was not limited to, PURPOSE .To ensure the resident's physician or practitioner .is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care. PR[NAME]EDURES 1. Resident assessments for change in condition .ordered lab and/or other diagnostic tests should be completed in a timely manner A facility's policy titled, Lab Tracking, effective date (MONTH) 9, (YEAR), provided by the DNS on 12/6/19 at 1:37 p.m., included, but was not limited to, PURPOSE: To facilitate a method of tracking laboratory tests ordered and monitor test has been completed in a timely manner to identify and treat infections and/or make medication adjustments. PR[NAME]EDURES 1. When a physician order [REDACTED]. Print lab requisition and place in lab binder 10. Third shift nurse to run every night: 11. If a one time lab complete ancillary order only 13. For an open ended/unable to obtain order, a Lab Order will need to be placed as well as an Ancillary Order (an order to be collected by the campus), a daily progress note will be written until obtained, i.e. stool sample, urine collection, sputum 18. The nursing staff or person designated by the Executive Director or Director of Health Services shall monitor the Ancillary Results Queue under the facility tab to ensure tests have been completed per physician orders [REDACTED]. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure appropriate interventions for pressure ulcers were implemented resulting in harm when a resident's pressure ulcer on the coccyx worsened from a stage III (Full-thickness loss of skin, in which fat is visible in the ulcer) to an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by dead skin tissue) and increased in size, and the resident developed 3 additional pressure ulcers to include an unstageable pressure ulcer to right buttock, an unstageable pressure ulcer to the left ischial tuberosity (a rounded bone that extends from the curved bone that makes up the bottom of your pelvis called the ischium), and a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) pressure ulcer to the right ischial tuberosity for 1 of 6 residents reviewed for pressure ulcers (Resident 10). Findings include: During a random observation, on 8/22/19 at 10:10 a.m., Resident 10 was observed in bed eating breakfast. The resident's wheelchair in his room had a foam cushion in place. At this time, the resident indicated he had brought the cushion from home. During a wound treatment observation, on 8/22/19 at 10:11 a.m., Resident 10 indicated to the Director of Health Services (DHS) he did not want the same treatment that had been applied to his pressure ulcer areas the night before. The DHS cleaned the stage III (Full-thickness loss of skin, in which fat is visible in the ulcer) pressure ulcer to the coccyx and the unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by dead skin tissue) to the right buttock. At this time, two additional pressure ulcers were found, an unstageable to the left ischial tuberosity (a rounded bone that extends from the curved bone that makes up the bottom of your pelvis called the ischium), and a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed) to the right ischial tuberosity. The DHS indicated she would need to call the wound center to address the resident's concerns with his treatment plan for the pressure ulcers, and to report the two newly identified pressure ulcers. She believed the development of the new pressure ulcers was due to the resident being up in his wheelchair so much because he liked to attend activities, he went out 3 times weekly for [MEDICAL TREATMENT], and ate in the dining room most times. The resident had a foam wheelchair cushion in place, and she was unsure if therapy had been notified of any changes to the resident's pressure ulcer or the development of new pressure ulcers. During an interview, on 8/22/19 at 11:28 a.m., Occupational Therapist (OT) 12 indicated the resident's start of care for occupational therapy was 6/22/19. The resident's wheelchair cushion had not been addressed because it was the resident's personal choice to use his foam cushion from home. Therapy had provided the resident with education on repositioning in his wheelchair, but had not provided education in regards to what wheelchair cushion would be more appropriate for wound healing. She had not been made aware of the change of the resident's pressure ulcer to his coccyx in July, and was not aware the resident had developed 3 more pressure ulcers since admission. She did not feel the foam cushion should have been used. A Roho cushion (dry floatation cushion, skin/soft tissue protection and positioning) would have been more appropriate when the resident's pressure ulcer increased in size and to help aide in the prevention of developing new pressure ulcers. There should have been communication from the nursing staff when there was a change with a resident's pressure ulcer or when a new one had been identified. The resident's plan of care before he was discharged from the facility on 5/5/19, included, but was not limited to, a Roho cushion due to the pressure ulcer on coccyx, that treatment plan should have been discussed with the resident when the he admitted back to the facility on [DATE]. Resident 10's record was reviewed on 8/21/19 at 1:17 p.m. The resident's census record indicated he had been discharged from the facility on 5/5/19 to home. The resident was than admitted back to the facility on [DATE]. A skin progress note, dated 6/21/19 at 8:25 p.m., indicated the resident admitted to the facility on [DATE] with a stage III pressure injury to his coccyx. Skin progress notes for Resident 10's coccyx pressure ulcer, dated 6/21/19 to 7/17/19, indicated the following: On 6/21/19: stage III; measured 4.5 centimeters (cm) length by 2.7 cm width by 1.7 cm depth. On 6/28/19: stage III; measured 2.7 cm length by 0.7 cm width by 1 cm depth. The resident continued to go to the wound center. On 7/3/19: stage III; measured 2.7 cm length by 0.6 cm width by 0.4 cm depth. On 7/10/19: stage III; measured 2.7 cm length by 0.5 cm width by 0.3 cm depth. On 7/17/19: stage III; measured 2.7 cm length by 0.6 cm width by 0.2 cm A care plan, created 7/3/19, indicated the resident was at risk for skin breakdown related to decreased mobility and weakness, incontinence, and functional status. Interventions included, but were not limited to, pressure reducing cushion to chair. A skin progress note, dated 7/29/19 at 8:26 p.m., indicated the residents stage III pressure ulcer was now an unstageable and measured 4.1 cm length by 2 cm width by less than (<)0.1 cm depth. Resident 10 had reported discomfort to wound bed. Resident 10 had wheelchair cushion in place at all times. A care plan, created 7/31/19, indicated the resident had a pressure ulcer to coccyx and would heal without complications. A wound note, dated 8/21/19 at 8:11 a.m., indicated the resident developed an unstageable pressure ulcer to right buttock at the facility. The pressure ulcer measured: 4.5 cm length by 0.5 cm width, and 0.1 cm depth. A physician's orders [REDACTED]. The order lacked what type of wheelchair cushion was to be in place. A wound note, dated 8/22/19 at 4:54 p.m., indicated the resident developed an unstageable pressure ulcer to the left tuberosity at the facility. The pressure ulcer measured: 1 cm length by 1 cm width, and depth could not be measured. A wound note, dated 8/22/19 at 4:56 p.m., indicated the resident developed a stage II pressure ulcer to the right tuberosity at the facility. The pressure ulcer measured: 1.8 cm length by 1 cm width, and depth could not be measured. A physician's orders [REDACTED]. An ordering form for position and support for advanced pressure management was provided, on 8/27/19 at 9:21 a.m., from the Therapy Program Director. The form included, but was not limited to, Roho Quadtro select dry floatation cushion. Great for skin/soft tissue protection and positioning. The cushion had interconnected air cell design aids in healing and prevention of up to stage IV(Full-thickness skin and tissue loss with exposed or directly palpable muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcers, facilitated blood flow by fitting and matching the resident's shape. On 8/22/19 at 3:36 p.m., the Clinical Corporate Consultant 5 provided a document, revised 5/10/17, and titled, Guidelines for Wound Rounds, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: Guidelines for wound rounds. Purpose: To ensure treatment approaches and interventions are being followed through by resident care givers. Procedure: 1. The Director of Health Services or designee should make periodic walking rounds to visualize implementation and follow through of individual resident care plan interventions, approaches and physician orders [REDACTED]. 3.1-40(a)(2)