Every finding on record at Heritage Healthcare

Based on observation, interview, and record review, the facility failed to ensure narcotic medications were free from theft of an employee for 1 of 3 residents reviewed for misappropriation of property. (Resident B) The deficient practice was corrected on 2/10/2026, prior to the start of the survey, and was therefore past noncompliance.Findings include:During an interview, on 2/26/26 at 1:10 p.m., the Director of Nursing (DON) indicated, on the morning of 2/3/26, RN 2 informed her Resident B was missing a narcotic medication. RN 2 had completed a narcotic count with RN 3, on 2/2/26 at 10:00 p.m., and Resident B had two (2) narcotic cards for oxycodone (a medication used for pain). The next morning at 6:00 a.m., RN 2 returned to the facility for another shift and realized Resident B no longer had two (2) medication cards. RN 3 had indicated to RN 2 that Resident B had been given pain medication during the night, but RN 3 was not aware of a missing narcotic card. RN 3 then left the facility. The DON then reviewed the medication card with RN 2 and found the medication card and the documentation sheet for the narcotic medication was missing. The top of the narcotic card was found in the medication disposal box, but no medications were found. The narcotic log sheet was not found. The pharmacy was notified and had indicated Resident B was missing a card of narcotic medications with five (5) pills.During an interview, on 2/18/26 at 12:08 p.m., Resident B indicated he was not aware of the missing medications and did not remember receiving a pain pill on 2/3/26 at 2:00 a.m.The clinical record for Resident B was reviewed on 2/16/26 at 4:10 p.m. The diagnoses included, but were not limited to, diabetes mellitus, fracture of the lower end of the left femur, chronic kidney disease, and non-traumatic subarachnoid hemorrhage.A physician's order, dated 1/27/26, indicated to administer oxycodone hydrochloride (HCL) immediate release (IR) 5 milligrams (mg) as needed every 6 hours for pain. During an interview, on 2/16/26 at 2:32 p.m., RN 2 indicated she completed a narcotic count, on 2/2/26 at 10:00 p.m., with RN 3. There were two (2) narcotics cards and log sheets for Resident B during the count. When she came back to work, on 2/3/26 at 6:00 a.m., she completed the narcotic count again with RN 3. She discovered a narcotic card and log sheet for Resident B was missing. RN 3 had indicated Resident B had required pain medication throughout the night and then left the facility without signing to indicate the narcotic count was completed and accurate. RN 2 immediately notified the DON, and the DON completed a recount with her. Resident B was missing a narcotic medication card and log sheet.During an interview, on 2/26/26 at 1:10 p.m., the Director of Nursing (DON) indicated after it was discovered a narcotic medication was missing, all medication carts in the facility were checked and no additional discrepancies were found. RN 2 and 3 were suspended pending the investigation. RN 2 was cleared and returned to work. RN 3 denied taking the medication and quit after being questioned. The facility then terminated RN 3. All staff were educated on the policies for abuse and routine reconciliation of controlled substances on 2/3/26. The facility audits of the medication carts are ongoing. A pharmacy review was scheduled for 2/18/26. The missing medications for Resident B were replaced by the facility. A current facility policy, titled Abuse- Identification of Types, dated as last reviewed 5/6/25 and provided by the Executive Director on 2/16/26 at 4:00 p.m., indicated .Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent This deficient practice was corrected by 2/10/26 after the facility implemented a systemic plan that included the following actions: all narcotic sheets were audited, residents were interviewed, RN 3 was terminated and deemed ineligible for rehire, all nurses were re-educated on abuse and the management of controlled substances, and the pharmacy was scheduled to completed a house wide audit of narcotic medications.This citation relates to Intake 2734631.3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure food items were labeled with the date received, the reach-in refrigerator was maintained at a safe temperature, and temperature logs were up to date. This deficient practice had the potential to affect 68 of 69 residents who received food from the kitchen.Findings include:1. During the initial kitchen tour with [NAME] 2, on 7/30/25 at 10:21 a.m., the following pre-packaged food items were found to be not labeled with the date received:a. six (6) packages of gravy mixb. three (3) containers of cream of wheatc. eight (8) bags of brown sugard. four (4) packages of brownie mixe. one can of sauerkrautf. one can of peasg. one can of marinara sauceh. one can of cheddar cheese sauce During an interview, on 7/30/25 at 10:43 a.m., [NAME] 2 indicated he dated items with the date received when he put away new food items and then labeled them with the date opened when the item was opened.During an interview, on 7/31/25 at 9:58 a.m., the Dietary Manager indicated the pre-packaged food items should have been labeled with the date received at the time they were taken out of the shipping box and placed on the shelves.2. During the initial kitchen tour with [NAME] 2, on 7/30/25 at 10:25 a.m., the reach-in refrigerator had a temperature of 60 degrees Fahrenheit.During a follow-up visit to the kitchen, on 7/30/25 at 12:30 p.m., the reach-in refrigerator had a temperature of 60 degrees Fahrenheit.During an interview, on 7/30/25 at 12:30 p.m., [NAME] 2 indicated the refrigerator temperature should not be 60 degrees Fahrenheit, and he called for maintenance.During an interview, on 7/31/25 at 9:30 a.m., the Dietary Manager indicated the refrigerator should not have been 60 degrees Fahrenheit the previous day. He was unsure of the length of time the refrigerator had been at an elevated temperature, but the temperature logs indicated it had been less than 12 hours.3. The temperature logs for the reach-in refrigerator did not have entries for the day shift on the following dates: 7/2, 7/3, 7/4, 7/5, 7/6, 7/8, 7/9, 7/10, 7/11, 7/12, 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/22, 7/23, 7/24, 7/25, 7/26, 7/29 and 7/30/25.The temperature logs for the reach-in refrigerator did not have entries for the evening shift on the following dates: 7/3 and 7/20/25.During an interview, on 7/31/25 at 9:30 a.m., the Dietary Manager indicated the temperature logs should have been completed twice a day on each shift.The refrigerator/freezer temperature log, labeled 3-door Reach-in and dated July 2025, indicated .the refrigerator temperature should be at or below 41 F. If the temperatures are not within these ranges, notify the Director of Food and Nutrition Services or Maintenance immediately.A current facility policy, titled Food Safety, dated 5/1/25 and received from the Executive Director on 8/1/25 at 9:23 a.m., indicated .Pre-packaged food.container is labeled with the name of the contents and date.Food is labeled with the date received.Ambient temperatures in refrigerators/coolers are to remain at or below 41 F to significantly slow growth of microorganisms.Temperatures are recorded at least twice daily on the Refrigerator/Freezer Temperature Log.any problems will be reported immediately to the Director of Food and Nutrition Services/Maintenance.3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure pureed foods were prepared according to the recipe to ensure the nutritive value, flavor, and appearance were conserved for 5 of 5 residents reviewed for a pureed diet.Findings include:During an observation, on 7/30/25 at 10:48 a.m., [NAME] 2 was observed to add 5 cooked and seasoned hamburger patties to a food processor. He added an unmeasured amount of water, turned on the processor, and mixed until a pudding consistency was obtained. He did not refer to a recipe during the observation.During an interview, on 7/30/25 at 10:48 a.m., [NAME] 2 indicated he was unsure if there was a recipe for purees. He did not know where it was and thought it may have been in with the regular recipes. He usually thinned things with broth or water. He indicated he had already prepared the peas by adding 5 servings of peas to the blender and used milk to thin the peas to get the desired consistency.During an interview, on 7/31/25 at 9:30 a.m., the Dietary Manager indicated the puree recipes were stored in the regular recipe book and the recipes should have been followed.The recipe, titled PU Beef Patty 2 oz SPD, labeled recipe #364, indicated:1. Prepare according to regular recipe.2. Place food in processor, process until smooth.3. Reheat to a minimum temperature of 165F for 15 seconds. Hold at minimum required temperature or higher for service. Follow hot-holding temperature of 135F or 140F based on facility policy. The recipe, titled [NAME] Peas Fzn, labeled recipe #488, indicated:1. Prepare according to regular recipe.2. Drain green peas and place the peas in food processor.3. Process until smooth and product reaches an applesauce consistency.4. Reheat to a minimum temperature of 165F or higher for 15 seconds. Hold at minimum required temperature or higher for service. Follow hot-holding temperature of 135F or 140F based on facility policy. A current facility policy, titled Food Preparation, dated as revised 4/29/25 and provided by the Executive Director on 8/1/25 at 9:23 a.m., indicated .Recipes are provided by the Director of Food and Nutrition Services and followed by the food service associates.3.1-20(i)(4)3.1-21(a)(1)

Based on observation, interview and record review, the facility failed to ensure the facility and resident rooms were maintained for 8 of 33 rooms reviewed for environment. (room [ROOM NUMBER], 16, 23, 18, 21, 32, 36, 103).Findings include: During an observation, on 7/30/25 beginning at 12:21 p.m., the following were observed.1. In room [ROOM NUMBER], the wall under the window had a large area with no paint. 2. In room [ROOM NUMBER], the wall had paint peeled off under the window and on the right side by the bathroom door.3. In room [ROOM NUMBER], the wall had black scuff marks and missing paint on the lower portion of the wall.4. In room [ROOM NUMBER], the bottom of the door had black scuff marks.5. In room [ROOM NUMBER], the lower part of the door had scuff marks and chipped paint on the door trim.6. The eye washing station door trim had peeling paint.7. The soiled utility room door trim had peeling paint.8. In room [ROOM NUMBER], the door had chipped paint and scuff marks on the trim.9. In room [ROOM NUMBER], the door had chipped paint on the trim. 10. In room [ROOM NUMBER], there were several small holes on the wall above the dresser. During an environmental tour, on 8/5/25 at 2:09 p.m., the Executive Director (ED) indicated there was peeling paint, holes, and scuff marks on the walls. During an interview, on 8/4/25 at 11:45 a.m., the Certified Nursing Assistant (CNA) 2 indicated the walls in room [ROOM NUMBER] had been messed up for over a year. During an interview, on 8/4/25 at 12:31 p.m., the resident in room [ROOM NUMBER] indicated someone had just patched some holes. A current facility policy, titled Plant Operations - General Policy, dated as last reviewed on 5/15/25 and received from the ED on 8/5/25 at 2:43 p.m., indicated .A safe, clean, and structurally sound environment shall be achieved in the facility through the development and implementation of the Plant Operation Program, the development and training of personnel, and the evaluation of goals in the department of assure correlation with the goals of the facility 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure the resident and resident's representative received notification in writing of the facility's bed hold policy and the reason for the resident's transfer and discharge to the hospital for 1 of 2 residents reviewed for hospitalization. (Resident 3) Findings include:The clinical record for Resident 3 was reviewed on 8/1/25 at 11:45 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, chronic kidney disease, diabetes mellitus, cerebral infarction, cognitive communication deficit and gastrostomy. A nursing progress note, dated 7/28/25 at 10:20 a.m., indicated the hospital called and informed the facility Resident 3 was admitted to the Intensive Care Unit with aspiration pneumonia.There was no documentation in the electronic medical record to indicate the resident and resident's representative was provided information in writing regarding the reason for the resident's transfer to the hospital and the facility's bed hold policy. During an interview, on 8/1/25 at 2:27 p.m., the Executive Director (ED) indicated the bed hold policy, and the transfer and discharge summary were provided to the Emergency Medical Team and not the resident or the resident's representative. A current facility policy, titled Transfer and Discharges, dated as last updated 4/22/25 and received from the ED on 8/1/25 at 2:39 p.m., indicated .The facility will follow the limited conditions under which CMS has outlined how the facility may initiate transfer or discharge of the resident, the documentation that must be included in the medical record, and who is responsible for making the documentation. The facility will also provide transfer/discharge notice to the resident/responsible party in accordance with federal regulations A current facility policy, titled Bed-Hold Policy, dated as last updated 4/22/25 and received from the ED on 8/1/25 at 2:39 p.m., indicated .The Bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence. The facility will provide written information to the resident or resident representative the nursing facility policy on bed-hold periods and the residents return to the facility to ensure that residents are made aware of the facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility .Before a nursing facility transfers a resident to a hospital .the nursing facility must provide written information to the resident or resident representative 3.1-12(a)(6)(A)(i)3.1-12(a)(6)(A)(ii)3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level I was completed on or prior to admission for 1 of 3 residents reviewed for PASARR. (Resident 10)Findings include:The clinical record for Resident 10 was reviewed on 8/1/25 at 2:56 p.m. The diagnoses included, but were not limited to, mild intellectual disabilities, dementia, depression, post-traumatic stress disorder (PTSD), anxiety, and bipolar disorder. Resident 10 was admitted to the facility on [DATE].A physician's order, dated 1/15/25, indicated to administer duloxetine (an antidepressant medication) 30 milligrams (mg) once a day. An initial PASARR Level I was not completed until 6/26/25.During an interview, on 8/5/25 at 11:30 a.m., the Executive Director (ED) indicated the PASARR was not completed in the correct time frame. A current facility policy, titled Pre-admission Screening and Resident Review (PASARR), dated 10/2022 and received by the ED on 8/5/25 at 1:03 p.m., indicated .the facility will ensure that potential admissions are to be screened for possible serious mental disorders .the initial pre-screening is referred to as PASARR Level 1, and is completed prior to admission to a nursing facility 3.1-16(d)(1)(A)3.1-16(d)(1)(B)3.1-16(d)(2)(A)3.1-16(d)(2)(B)

Based on interview and record review, the facility failed to ensure physician's orders were followed related to medications hold parameters for 1 of 5 residents reviewed for quality of care. (Resident 5)Findings include:The clinical record for Resident 5 was reviewed on 8/1/25 at 9:52 a.m. The diagnoses included, but were not limited to, atrial fibrillation, atherosclerotic heart disease, presence of a coronary angioplasty implant and graft, and occlusion and stenosis of the carotid artery.A care plan, dated 6/6/19, indicated Resident 5 had altered cardiovascular status related to coronary artery disease, atrial fibrillation, hypertension, and a history of myocardial infarction. Interventions included, but were not limited to, administer medications as ordered. A physician's order, dated 4/15/25, indicated to administer carvedilol (a medication used to treat high blood pressure and heart failure) 6.25 milligram (mg) by mouth twice a day and to hold the medication for a systolic blood pressure less than 100 or a heart rate less than 60.A physician's order, dated 5/23/25, indicated to administer diltiazem extended release (a medication used to treat high blood pressure and chest pain) 180 mg by mouth twice a day and to hold the medication for a systolic blood pressure less than 100 or a heart rate less than 60.A Medication Administration Record (MAR), dated 5/1/25 through 5/31/25, indicated the following:a. Diltiazem was administered on the evening of 5/23/25 with a heart rate of 58.b. Carvedilol was administered on the morning of 5/23/25 with a heart rate of 59. A MAR, dated 6/1/25 through 6/30/25, indicated the following:a. Diltiazem was administered on the evening of 6/10/25 with a heart rate of 59, on 6/19/25 with a heart rate of 43, and on 6/29/25 with a heart rate of 56.b. Carvedilol was administered on the evening of 6/9/25 with a heart rate of 58, on 6/10/25 with a heart rate of 43, on 6/19/25 with a heart rate of 43, and on 6/29/25 with a heart rate of 59.During an interview, on 8/4/25 at 3:21 p.m., Registered Nurse 2 indicated medications should not have been given outside of physician's ordered parameters. If a resident's blood pressure was outside of the parameter, she would hold the medication and notify the physician.During an interview, on 8/4/25 at 3:30 p.m., the Director of Nursing indicated Resident 5's carvedilol and diltiazem should not have been administered outside of the physician's ordered parameters.A current facility policy, titled Administration of Medications, dated as reviewed on 9/16/24 and received from the Executive Director on 8/5/25 at 9:28 a.m., indicated .Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration.Right Assessment. Note the resident's history and any parameters around drug administration.3.1-37(a)

Based on record review and interview, the facility failed to ensure smoking evaluations were completed quarterly to evaluate the resident's capabilities and deficits for 1 of 6 residents reviewed for accident hazards. (Resident 23) Findings include:The clinical record for Resident 23 was reviewed on 8/1/25 at 2:05 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, atrial fibrillation, anxiety disorder, major depressive disorder, right above the knee amputation, hypertension, and vascular dementia.A care plan, dated 4/13/23, indicated the resident was non-compliant with the smoking policy, smoked in his room and/or pocketed his cigarette butts. Interventions included, but were not limited to, instruct Resident 23 of the smoking risks and the facility policy on smoking and to make certain cigarette butts were disposed of properly in cigarette butt receptacle.The electronic medical record did not contain smoking safety evaluations for 2024. The last documented smoking evaluation was 1/2023.A quarterly smoking safety evaluation was completed on 8/1/25 after the start of the survey. The evaluation indicated Resident 23 had not demonstrated the ability to safely smoke without supervision and had exhibited poor safety awareness when smoking. During an interview, on 8/5/25 at 2:15 p.m., the Executive Director (ED) indicated the facility had not noticed the smoking safety evaluations were not completed quarterly and they should have been. The last smoking evaluation was completed on 1/2023. A current facility policy, titled Smoking Facility, last updated 5/27/25 and received from the ED on 8/1/25 at 2:43 p.m., indicated .The facility will provide a safe environment for residents who smoke tobacco products .The facility will provide supervision to all residents who smoke tobacco products, as determined by their smoking assessment and identified in their care plan interventions .Smoking emergency drills will be conducted annually and as indicated thereafter .All residents who smoke will have a smoking assessment completed with appropriate care plan interventions documented .Residents who currently smoke will have a smoking assessment completed upon admission, readmission, with significant change, and quarterly by a licensed nurse 3.1-45(a)(1)3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident who did not experience a change in payor source was given the choice/opportunity to remain in his room for 1 of 1 resident reviewed for room transfers. (Resident C) Findings includes: The clinical record for Resident C was reviewed on 9/10/24 at 2:10 p.m. The diagnoses included, but were not limited to, traumatic brain injury, muscle weakness, abnormalities of gait and mobility and spastic hemiplegia affecting the left nondominant side. The resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated he was cognitively intact. The resident was admitted to the facility in room [ROOM NUMBER] during his rehabilitation therapy timeframe. When the resident's therapy was competed, the resident was moved to another room without giving him the option to remain in his current room. The new room the resident was provided, did not provide the resident with an adequate bathroom and space for living. During an interview, on 9/6/24 at 4:20 p.m., Resident C indicated the room he was currently in was too small for him to use the bathroom. He was given a bedside commode to use. He did not know why he had to leave room [ROOM NUMBER] which accommodated his needs. During an interview, on 9/10/24 at 3:05 p.m., the Executive Director (ED) indicated the resident was moved on 8/22/24 from room [ROOM NUMBER] to room [ROOM NUMBER]. The resident was moved because he was no longer receiving therapy services and was not considered a short-term resident. His payor source did not change. The resident was not given the choice to remain in room [ROOM NUMBER]. During an interview, on 9/11/24 at 2:51 p.m., Staff Member 2 indicated the resident was upset he had to leave room [ROOM NUMBER] for a smaller room. The resident was not given a choice to stay in room [ROOM NUMBER]. The resident was no longer on the therapy program. He was now on a long-term care restorative program. During an interview, on 9/11/24 at 1:05 p.m., the ED indicated the resident should have been given the choice to remain in room [ROOM NUMBER] or be moved to a different room in the facility. This citation relates to Complaint IN00442214. 3.1-12(a)(14)(A) 3.1-12(a)(14)(B)

Based on observation, interview and record review, the facility failed to ensure medications administered orally were separated from topical medications and eye drops, to store cleaning supplies separately from medications, correctly label OTC (over the counter) medications, date opened medications, and routinely dispose of medications after the date of expiration for 4 of 4 medication carts reviewed. (medication cart 1, medication cart 2, medication cart 3, and medication cart 4) Findings include: During a medication cart observation with Qualified Medical Assistant (QMA) 6, on [DATE] at 11:06 a.m., medication cart 1 was observed to have the following: a. The top right drawer had two medication cups containing one pill in each cup not labeled with the resident's names or with the medication name. b. The bottom right drawer had an unlabeled nebulizer machine (a device which turned liquid medication into a mist to be inhaled into the lungs through a mask or mouthpiece) c. The top left drawer had Smooth Nighttime eye ointment, dated opened [DATE]. d. A Saline Nose Spray without a date opened. During a medication cart observation with QMA 6, on [DATE] at 11:19 a.m., medication cart 2 was observed to have the following: a. The top left drawer had ear wax removal drops improperly stored next to Ferrocite oral tablets. b. The second left drawer had OTC vitamin C tablets not labeled with the dose of the medication, the administration directions, or the physician's name. c. The bottom left drawer had mupirocin ointment (an ointment put onto the skin to treat a skin infection) stored in the medication cart instead of being stored in a treatment cart. d. The bottom left drawer had sanitizer wipes stored next to oral medications. During an interview, QMA 6 indicated the sanitizer wipes should not be stored next the oral medications and the ointment should have been stored in the treatment cart. During a medication cart observation with QMA 7, on [DATE] at 11:34 a.m., medication cart 3 was observed to have the following: a. The top drawer had oral medications stored next to eye drop medications without a divider between the two medications. b. The second drawer had Refresh Eye Tears (eye drops which help with dry eye) opened, dated [DATE], and more than 30 days past the discard after opening date. c. The second drawer had Polyvinyl alcohol eye drops (eye drops which help with dry eye) opened, dated [DATE], and more than 30 days past the discard after opening date. During an interview, on [DATE] at 11:45 a.m., QMA7 indicated the eye drops were good for 90 days once opened. During a medication cart observation with RN 8, on [DATE] at 11:49 a.m., medication cart 4 was observed to have the following: a. Glucose gel (to treat low blood sugar) unopened and past expiration date of ,d+[DATE]. A current policy, titled .Storage and Expiration Dating of Medications, Biologics, dated as last revised on [DATE] and received from the Administrator on [DATE] at 1:47 p.m., indicated .Topical (external) use medications or other medications should be stored separately from oral medications when infection control issues may be a consideration .Facility should ensure that test reagents, germicides, disinfectants, and other household substances are stored separately from medications .Facility should ensure that medication and biologicals that: (1) have an expired date on the label; (2) have been retained longer tan recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier .Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened .Medications with a manufacturer's expiration date expressed in month and year (e.g. [DATE]) will expire on the last day of the month .When an ophthalmic solution or suspension has a manufacturers shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container .Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station in Facility to assists Facility in complying with its obligations pursuant to Applicable Law relating to the proper storage, labeling, security and accountability of medications and biologicals . 3XXX,d+[DATE](j) 3XXX,d+[DATE](o)

Based on interview and record review, the facility failed to thoroughly investigate allegations of a staff member working while impaired and the potential residents' physical or emotional suffering from the impaired staff member's interactions for 1 of 1 staff member reviewed for allegation of abuse. (CNA 12) Finding includes: A Facility Reported Incident (FRI), dated 5/24/24, indicated Resident B had voiced concerns by social media. The resident indicated a male employee refused drug testing when it was reported he was altered. The staff was terminated due to refusal of the testing and left the building. The facility completed resident interviews, staff interviews, skin assessments, and education as deemed necessary. The clinical record for Resident B was reviewed on 7/10/24 at 12:25 p.m. The diagnoses included, but were not limited to, fusion of the spine in the lumbar region, generalized anxiety disorder, depression, and chronic obstructive pulmonary disease. An undated note from social media was provided by the Administrator on 7/11/24. The note was a copy of the social media post by Resident B. The resident indicated a male staff had touched her in an inappropriate manner and was extremely drunk. The male staff was dismissed from his job. The FRI, dated 5/24/24, did not include the allegation of Resident B being touched in an inappropriate manner. The full investigation of the incident was requested from the Administrator on 7/9/24, and again on 7/11/24 at 1:50 p.m. The resident interviews were provided on 7/11/24 and no staff interviews were included. The staff interviews along with the complete investigation were again requested. On 7/12/24 at 10:34 a.m., the completed investigation of the incident including the staff interviews was again requested. The Administrator indicated the Clinical Support was reviewing the file. The staff interviews were not provided by the facility until 7/12/24 at 11:45 a.m. A staff statement by the Assistant Director of Nursing (ADON), dated 5/13/24, indicated Resident B's husband called her to report the resident had concerns about a male CNA who provided care to her. The resident was in her room and indicated she was okay. The resident was asked about the concerns with the male CNA, and she indicated the CNA was acting weird and she could smell alcohol on his breath. The CNA kept getting close to her and putting his hand near her chest and shoulder area. The resident denied CNA 12 had touched her inappropriately. The investigation documents or statement from the ADON during the interview with Resident B did not include how the resident felt or her emotional status after the interaction with CNA 12. A staff statement by the ADON, dated 5/13/24, indicated CNA 12 was brought by the nurse in [NAME] Hall to the other side of the building since the nurse was questioning if the CNA was impaired. The CNA was already in the [NAME] Hall by the linen closet. The CNA looked confused and then he found a pillowcase and gave it to the resident who requested it. The CNA was asked to go to the ADON office and was not walking in a straight line. CNA 12 sat down and could hardly keep his eyes open and was slurring his words. The Administrator was called and sent a Reasonable Suspicion Checklist for Drug and Alcohol Screening Form. CNA 12 continued with signs of impairment including slurred and rambling speech, typing slowly on his cellular phone, kept closing his eyes, and staring. CNA 12 indicated he would never hurt a resident. CNA 12 admitted to drinking on the job and decided to not get tested . The Administrator had set up an Uber ride to take CNA 12 home. A staff statement by RN 13, dated 5/13/24, indicated CNA 12 was oriented to the evening shift on [NAME] Hall. He only assisted one resident to lay down, weighed another resident, passed one dinner tray, and toileted one resident. CNA 12 was not responding to call lights. RN 13 had to show CNA 12 where the linen closet was located 4 times and where the soiled utility room was 3 times. The CNA took a dirty brief into the clean linen room. Two residents had complained CNA 12 had run over their feet while assisting them to the bathroom. He did not act like he knew what he was doing. CNA 12 had very bloodshot reddened eyes and he was dozing at the nurse's station. RN 13 asked CNA 12 to go to the [NAME] unit to assist. He had to be physically assisted to go to [NAME] Hall. The ADON was informed he appeared to be impaired. The staff statements from the ADON and RN 13 did not indicate the exact amount of residents CNA 12 cared for while on duty and did not clarify how many residents were toileting since RN 13's statement indicated one resident was toileted and 2 residents had their feet ran over while being assisted to the bathroom. A staff statement by the Administrator, dated 5/14/24, indicated Resident B was interviewed about her interaction with CNA 12. Resident B indicated the CNA was acting oddly, was confused, asked the same question multiple times and was offering her assistance out of bed. Resident B was worried the CNA might try to touch her although he did not. The investigation documents or statement from the Administrator during the interview with Resident B did not include how the resident felt or her emotional status after the interaction with CNA 12. A psychiatric Nurse Practitioner note, dated 5/20/24, indicated the resident had increased depression due to the recent passing of her mother. The progress notes and facility investigation did not include the NP being informed of a possible interaction with CNA 12. The progress notes and facility investigation did not include a psychosocial assessment from the Social Services Director. The complete investigation provided by the facility only included three resident skin checks and 4 resident check list questions about abuse. The facility documents or investigation did not include statements from the residents about interactions with CNA 12. The facility documents or investigation did not indicate if these were the residents who complained of having their feet run over by CNA 12. During an interview, on 7/11/24 at 1:50 p.m., the Administrator indicated he was working at the facility on 5/13/24 and he had seen CNA 12 between 3:00 p.m. and 5:00 p.m. and did not notice anything unusual. Later in the day, he received a call from the ADON, and she indicated CNA 12 was not acting right. CNA 12 was staring off into space. He talked to CNA 12 on the telephone, and he refused to let the drug screen be completed. The CNA was assisted out of the facility and to his home. The ADON had talked to Resident B, and she said she was okay, and nothing had occurred. The investigation started the next day. Resident B stated CNA 12 was going to try to touch her although he did not. The resident's husband was upset about the situation, and he said CNA 12 touched the resident. Resident B again stated the staff did not touch her. He did not know if social services had documented any conversations or follow up with Resident B. The incident occurred on 5/13/24 and was not reported until 5/24/24 when Resident B put her concerns on a social media post. The resident's son had called after the social media post and after the resident was discharged to report she had past sexual abuse and would get nervous if she thought it could happen again. A current policy, titled Abuse-Conducting and Investigation, dated as last reviewed on 6/17/24 and received from the Administrator at entrance, indicated .It is the policy of this facility that allegations of abuse .are promptly and thoroughly investigated. The facility will prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress .Resident have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported .The alleged victim will be examined for any signs of injury, including a physical examination or psychosocial assessment, if needed .The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary [if any] for the protection of residents. Depending on the type of allegation received, it is expected that the investigation would include, but is not limited to .Conducting observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents .Conducting interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witnesses, practitioner, interviews with personnel from outside agencies .Conducting record review for pertinent information related to the alleged violation, as appropriate, such as progress notes .The administrator/designee will review the Incident Report for completeness and assure that the physician and resident representatives have been notified of the circumstance .The written summary of the investigation should include, but is not limited to A review of the Incident Report .An interview the person[s] reporting the incident .An interview with the resident, if appropriate .Interviews with staff members on all shifts having contact with the resident at the time of the incident .Interviews with the resident's roommate, family, and/or visitors who may have information about the incident .Interviews other residents who received care of services from the alleged perpetrator .A review of all circumstances surrounding the incident .Emotional support and counseling will be provided to the resident during and after the investigation, as needed This citation relates to Complaint IN00435305. 3.1-28(d)

Based on interview and record review, the facility failed to submit a discharge MDS (Minimum Data Set) assessment upon discharge, making the assessment greater than 120 days since the last submitted assessment for 1 of 2 residents reviewed for resident assessments. (Resident 67) Finding includes: The clinical record for Resident 67 was reviewed on 7/12/24 at 3:10 p.m. The diagnoses included, but were not limited to, hypo-osmolality (nutrient levels in the blood are lower than normal), hyponatremia (low sodium level in the blood), alcohol abuse, pneumonia, cystitis (infection in the bladder), dysphagia (difficulty swallowing), and protein calorie nutrition. An admission MDS assessment, dated 2/9/24, indicated it was submitted 2/9/24 and was approved. A discharge MDS assessment, dated 5/1/24, indicated the assessment was pending and was not submitted. During an interview, on 7/12/24, the MDS Coordinator indicated the discharge assessment should have been completed and submitted. During an interview, on 7/12/24 at 3:28 pm, the Administrator indicated the facility used the RAI manual, there was no facility policy. 3.1-31(b)

Based on interview and record review, the facility failed to resubmit a PASARR (Preadmission Screening and Record Review) for a resident after a new mental health diagnosis and medication were added for 1 of 3 residents reviewed for PASARR. (Resident 70) Finding includes: The clinical record for Resident 70 was reviewed on 7/10/24 at 9:52 a.m. The diagnoses included, but were not limited to, major depressive disorder, moderate vascular dementia, psychotic disorder with delusions, and sleep disorder. A medical diagnosis list indicated the resident was added a diagnosis of mild major depressive disorder on 2/2/24 A physician's order, with a start date of 2/3/24, indicated the resident was prescribed sertraline (an antidepressant medication) 25 mg (milligram). A PASARR, with a notice date of 4/24/23, indicated Resident 70 was evaluated and had no mental health diagnosis or mental health medications There was no record of another PASARR being completed after the major depressive disorder diagnosis or antidepressant medication were added. During an interview, on 7/12/24 at 10:37 a.m., the Social Services Director (SSD) indicated the resident did not do another PASARR after the added diagnosis and medication. The resident should have had another PASARR completed, and it was just missed. A current policy, titled Pre-admission Screening and Resident Review (PASARR), dated as reviewed on 9/25/23 and received from the Administrator on 7/12/24 at 3:30 p.m., indicated .A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later .Any resident with newly evident or possible serious mental disorder, ID or a related condition must be referred, by the facility to the appropriate state-designated mental health or disability authority for review. Examples of individuals who may not have previously been identified by PASARR to have MD, ID or a related condition include, but is not limited to: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to notify the physician of blood glucose levels out of the physician's parameters and to follow-up on a hospice order for a Broda chair (chair which helps accommodate residents with impaired mobility) for 3 of 3 residents reviewed for quality of care. (Resident L, C and 136) Findings include: 1. During an interview, on 7/10/24 at 10:00 a.m., Resident L indicated he had high blood sugar readings while being at the facility. The clinical record for Resident L was reviewed on 7/10/24 at 3:16 p.m. The diagnoses included, but were not limited to, mild chronic stage 2 kidney disease, hypertensive heart disease with heart failure, and type 2 diabetes with diabetic neuropathy. A current physician's order, with a start date of 7/26/23, indicated to notify the physician for blood sugars greater than 400. A facility vital log indicated Resident L had the following blood sugars: On 3/26/24, his blood sugar was 433. On 3/27/24, his blood sugar was 452. On 3/27/24, his blood sugar was 432. On 3/28/24, his blood sugar was 426. On 4/1/24, his blood sugar was 493. On 4/2/24, his blood sugar was 531. On 4/5/24, his blood sugar was 444. On 4/11/24, his blood sugar was 423. On 4/26/24, his blood sugar was 434. During an interview, on 7/11/24 at 10:53 a.m., the Administrator indicated he did not see any call outs to the physician for the high blood sugars. 36454 2. During an interview, on 7/10/24 at 12:02 p.m., Resident C's family member indicated the resident's blood sugar readings were in the 400 and 500 range and the facility did not try to give her a different insulin. The clinical record for Resident C was reviewed on 7/10/24 at 10:37 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, generalized anxiety disorder, and generalized muscle weakness. A physician's order, dated 3/24/24, indicated to check the fasting blood sugar one time a day. A physician's order, dated 3/24/24, indicated to notify the physician for blood sugars less than 60 or greater than 400. The resident had the following blood sugar readings: a. On 5/22/24 at 6:16 a.m., the blood sugar was 429. b. On 6/4/24 at 6:13 a.m., the blood sugar was 453. c. On 6/7/24 at 6:16 a.m., the blood sugar was 448. d. On 6/9/24 at 6:12 a.m., the blood sugar was 538. e. On 6/12/24 at 6:05 a.m., the blood sugar was 436. c. On 6/13/24 at 5:34 a.m., the blood sugar was 437. A physician's order, dated 6/9/24, indicated to recheck the blood sugar at 7:30 a.m., and notify the physician if the reading was greater than 400. The progress notes showed the physician was only notified on the elevated blood sugar on 6/9/24. 3. During an observation, on 7/10/24 at 11:45 a.m., Resident 136 was lying in bed in her room with her eyes closed. During an observation, on 7/11/24 at 3:37 p.m., the resident was lying in bed in her room and her eyes were closed. During an observation, on 7/12/24 at 1:50 p.m., the resident was lying in bed in her room, her eyes were closed, and the room was darkened. The clinical record for Resident 136 was reviewed on 7/12/24 at 1:56 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis affecting the right dominant side, chronic obstructive pulmonary disease, and pressure ulcers. During an interview, on 7/11/24 at 3:37 p.m., CNA 10 indicated the resident was on hospice, was totally dependent for care, and did not get out of bed on the evening shift. During an interview, on 7/11/24 at 3:47 p.m., LPN 11 indicated the resident was fairly new and was on hospice. The family preferred for the resident not to get out of bed. A physician's order indicated to be admitted to Hospice with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction. A hospice social worker note, dated 7/3/24, indicated the resident's daughter stated the resident was very social prior to her strokes and she still enjoyed having companionship although she was unable to talk as much as she would like to. During an interview, on 7/10/24 at 11:55 a.m., the Activity Director indicated the resident would get up in her Broda (chair for positioning) although she did not know what time of day she got up. The resident did not have a Broda chair in her room. During an interview, on 7/12/24 at 2:19 p.m., the Hospice Registered Nurse (RN) indicated the Broda chair was ordered upon admission to hospice on 7/3/24. The hospice had some changes in leadership, and it was just missed for approval. Since the Broda chair was ordered, it was an expectation the resident would be getting up in the Broda chair. The resident had a decline in condition although was not in the active phase of dying. The facility staff and the hospice staff would determine in collaboration how long the resident would be up daily. The Broda chair would be approved today as soon as the RN got the request to the correct person in hospice. A Hospice Services Agreement, approved on 7/19/21, indicated .Hospice will ensure that all Hospice Services are provided to Hospice Patients in a manner which meets or exceeds professional standards and principles that apply to individuals providing services in Facility. Hospice will provide all reasonable and necessary Hospice Services to Hospice Patients in a timely manner and accordance with each Hospice Patient's Hospice Plan of Care .Hospice Services will include .medical direction and management of the Hospice Patient .medical supplies, durable medical equipment .Coordination of Services .Hospice will participate, upon request, in interdisciplinary and other care planning conferences required to coordinate the Hospice Services, Facility Services, and other services provided to an individual Hospice Patient .Hospice shall retain professional management responsibility for Hospice Services provided in accordance with the Hospice Plan of Care A current policy, titled Changes in Resident's Condition or Status, dated as last reviewed on 8/9/23 and received from the Administrator on 7/12/24 at 10:55 a.m., indicated .This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status . This citation relates to Complaint IN00436564. 3.1-37(a)

Based on observation, interview and record review, the facility failed to turn and reposition a resident every 2 hours as ordered to promote healing and to prevent future pressure injuries for 1 of 4 residents reviewed for pressure ulcers. (Resident 50) Finding includes: During an observation, on 7/8/24 at 1:26 p.m., Resident 50 was sitting up in bed waiting for her lunch tray. She was paralyzed from the waist down with her right arm severely limited in range of motion and function with severe muscle wasting. The clinical record for Resident 50 was reviewed on 7/11/24 at 3:36 p.m. The diagnoses included, but were not limited to, paraplegia, type 2 diabetes mellitus, neuromuscular dysfunction of bladder, abnormal posture, depression, colostomy, indwelling urethral catheter, seizures, stage 3 and 4 pressure ulcers of sacral region, right and left buttock stage 3 pressure ulcers, recurrent moderate major depressive disorder, generalized anxiety disorder, and chronic obstructive pulmonary disease. A physician's order, dated 11/15/22, indicated to turn the resident every two hours for comfort and wound healing. If the resident is asleep, turn her anyway, per resident. A care plan, initiated on 11/30/22, indicated to turn the resident every 2 hours due to limited mobility, pressure ulcer, and to prevent new pressure injuries. It indicated she was dependent for bed mobility. A Skin/Wound note, dated 6/8/24 at 12:28 p.m., indicated the resident was compliant with every 2-hour turning. A care management note from the facility interdisciplinary team, dated 6/20/24 at 11:02 a.m., indicated the resident had a pressure wound to her coccyx which had been there for several years, did not get out of bed except for showers, and she was to be turned and repositioned every 2 hours to promote wound healing. The certified nursing assistant (CNA) task record, dated 6/13/24 through 7/12/24, indicated the resident required extensive assistance of 1 person for bed mobility. It indicated the task of bed mobility did not occur on some night shifts (6/16/24, 6/17/24, 6/20/24). The CNA task record, dated 6/28/24 through 7/11/24, indicated the charting of every 2-hour turns was missing on: 6/28/24 for 10:00 a.m., 12:00 p.m., 4:00 p.m., 6:00 p.m., and 8:00 p.m. 6/30/24 for 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., 6:00 p.m., and 8:00 p.m. 7/1/24 for 5:00 p.m., 7:00 p.m., and 11:00 p.m. 7/2/24 for 2:00 a.m., 4:00 a.m., 6:00 a.m., 4:00 p.m., and 6:00 p.m., 7/3/24 for 4:00 p.m., 6:00 p.m., and 11:00 p.m. 7/4/24 for 12:00 a.m., 2:00 a.m., 10:00 a.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. 7/5/24 for 12:00 a.m., 2:00 a.m., 3:00 p.m., 5:00 p.m., 7:00 p.m., and 11:00 p.m. 7/6/24 for 3:00 a.m., 5:00 a.m., 9:00 a.m., 4:00 p.m., 6:00 p.m., and 11:00 p.m. 7/7/24 for 10:00 a.m., 3:00 p.m., and 11:00 p.m. 7/8/24 for 4:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. 7/9/24 for 12:00 a.m., 3:00 a.m., and 5:00 a.m. 7/10/24 for 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 5:00 p.m., 7:00 p.m., 9:00 p.m., and 11:00 p.m. 7/11/24 for 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., and 8:00 a.m. A Skin/Wound note, dated 7/01/24 at 1:33 p.m., indicated the resident continued to have a slow healing sacrococcygeal wound. The resident was to be turned and repositioned every 2 hours and to utilize a wedge cushion for positioning. The physician was updated regarding continued skin issue. During an interview, on 7/8/24 at 1:26 p.m., the resident indicated she was supposed to be turned every 2 hours, but evenings and nights often did not turn her. They waited for her to turn her call light on and ask, despite her telling them she wanted to be woken up every 2 hours during the night. She did not want to have to call and/or wake herself up with an alarm because it was far more disruptive to her sleep and made it more difficult for her. She indicated it was very important to her because she had chronic pressure wounds which she really wanted to heal and because she did not want to get any new wounds. During an interview, on 7/10/24 at 11:14 a.m., the resident indicated, on 7/9/24, she had been turned around 4:00 p.m., and then took a nap. She turned her call light on after she woke up around 8:00 p.m., and believed she was turned about 20 minutes later. She was then not turned again until roughly 1:00 a.m. and 5:00 a.m. She indicated this was a regular occurrence, especially on evening and night shift except for when certain CNAs were on duty. She had complained about this multiple times, and she had personally told CNAs she wanted to be woken up every 2 hours no matter what. It had been an on-going issue, and this was why she even had an order to turn every 2 hours even when she was sleeping. During an interview, on 7/12/24 at 9:59 a.m., the Social Services Director indicated during the resident's care plan meeting, on 6/25/24, there was a nursing concern of evening/night CNAs not always turning every 2 hours. The Director of Nursing (DON) was present at the meeting and was addressing the issue. This was not the first time the resident had brought this issue up. During an interview, on 7/12/24 at 10:23 a.m., the Director of Nursing (DON) indicated every 2-hour checks and turning had been an ongoing concern. She had re-educated the CNAs to turn even when Resident 50 was asleep and to set alarms on their phones to help them remember. The facility had several brand-new CNAs who had just completed their certifications. During an interview, on 7/12/24 at 10:32 a.m., CNA 1 indicated they would try to turn her on even hours because it usually worked out better and to make it easier to remember. The resident had often complained that the night staff only turned her during their last round before the day shift came on. She tried to remind other staff members during their report/hand-off. A current job description, titled Certified Nursing Aide (CNA) Job Description: Primary, dated 11/10/16 and received from the Administrator on 7/11/24 at 1:30 p.m., indicated .The Certified Nursing Aide is responsible for providing routine daily nursing care to assigned patients to assure patient safety and attain or maintain the highest practicable physical .well-being .Must be able to lift, turn, move, position, and transport patients .Must be able to accurately document and chart patient care A policy for preventing pressure ulcers and/or routine turning of residents was requested on 7/12/24. The facility indicated they did not have a policy, and they did not provide one. 3.1-40(a)(2)

Based on interview and record review, the facility failed to follow the physician's orders for indwelling urinary catheters for 2 of 3 residents reviewed for indwelling catheters. (Resident C and H) Findings include: During an interview, on 7/10/24 at 12:02 p.m., Resident C's family member indicated the resident's catheter needed to be changed the day she was being discharged and the staff would not listen. The family decided to take the resident to the emergency room after her discharge from the facility so they could put in a new catheter. The clinical record for Resident C was reviewed on 7/10/24 at 10:37 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, obstructive reflux uropathy (urine backing up in the kidneys), generalized anxiety disorder, and generalized muscle weakness. A care plan, dated 12/2/23 and revised on 6/21/24, indicated the resident had obstructive uropathy and had an indwelling urinary catheter. The interventions included, but were not limited to, catheter care every shift and educating the resident and family on catheter care. A physician's order, dated 6/3/24, indicated an indwelling catheter to straight drainage, size 22 French (Fr indicates diameter of catheter) with 30 cc bulb. Change the indwelling catheter for infection, obstruction, or when the closed system was compromised. A progress note, dated 6/14/24 at 2:11 p.m., indicated Resident C was crying and stated something was wrong with her catheter. The catheter bag was on the floor with the resident sitting on the bed and the catheter tubing was taut and hematuria (blood in the urine) was noted. The nurse offered to deflate the balloon and reposition the Foley catheter. The resident initially refused and then the daughter stated she would take the resident to the emergency room and have a new catheter put in. The resident consented and the catheter balloon was deflated, then the indwelling catheter was advanced, and the balloon was re-inflated. The catheter was draining tea colored urine. The progress note did not include a notification to the physician of the blood in the catheter tubing. A progress note, dated 6/14/24 at 3:55 p.m., indicated the resident was discharged with her daughter and the daughter indicated she was taking the resident to the emergency room . During an interview, on 7/10/24 at 2:50 p.m., RN 9 indicated Resident C did her all her own catheter care. During an interview, on 7/10/24 at 3:31 p.m., the Director of Nursing (DON) indicated it was a nursing measure to deflate a catheter bulb, advance the catheter and to re-inflate the catheter bulb. The resident had a huge risk of infection. The facility did not need to get the deflating of the catheter bulb, advancing the catheter and re-inflation of the bulb cleared by the urologist. The facility would not notify the urologist or physician of the blood in the catheter unless it was a huge amount of blood. Usually, blood in a catheter would resolve on its own in 24 hours. 49891 2. During an observation, on 7/08/24, Resident H was in the hallway in her wheelchair with her foley catheter in a dignity bag. The clinical record for Resident H was reviewed on 7/10/24 at 9:50 a.m. The diagnoses included, but were not limited to, peripheral vascular disease, retention of urine, polyneuropathy, acquired absence of left leg above the knee, restless legs syndrome, cerebral infarction without residual deficits, and obstructive and reflux uropathy. A physician's order, dated 2/2/24, indicated indwelling catheter to straight drainage. Size: 18 Fr Bulb: 30 cc. Change for infection, obstruction, or when the closed system was compromised as needed. A progress note, dated 4/3/24 at 4:47 p.m., indicated the resident complained the Foley catheter was leaking. The nurse deflated the balloon, advanced the catheter and re-inflated the balloon. The electronic medical record did not include a physician's order for the procedure of deflating the balloon, advancing the catheter, and re-inflating the balloon of the catheter. A progress note, dated 4/4/24 at 11:24 a.m., indicated the Foley catheter was lying on the resident's bed with the balloon still inflated. A new 18 Fr 30 cc Foley catheter was placed utilizing aseptic technique. A progress note, dated 4/9/24 at 6:00 p.m., indicated the Foley catheter was found lying in the resident's incontinence brief with the balloon intact. A new 18 Fr 10 cc Foley catheter was placed utilizing aseptic technique. During an interview, on 7/10/24 at 11:35 a.m., the resident indicated her catheter was not secured in any way to her leg to prevent pulling or dislodgement. The electronic medical record did not include documentation of the use of a device to secure the catheter for the resident. A current policy, titled Indwelling Urinary Catheter (Foley) Management, dated as reviewed on 8/24/23 and received from the Administrator on 7/10/24 at 3:10 p.m., indicated .The facility will ensure .Insertion, ongoing care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures .If .leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment .Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter. This citation relates to Complaint IN00436564. 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure transportation was available for dialysis for 1 of 1 resident reviewed for dialysis. (Resident 18) Finding includes: During an interview, on 7/9/24 at 10:06 a.m., Resident 18 indicated she had to be hospitalized about a month ago when the facility did not have transportation to dialysis on a Saturday. The facility did not tell the resident until the last minute there was no transportation. The clinical record for Resident 18 was reviewed on 7/11/24 at 11:44 a.m. The diagnoses included, but were not limited to, dependence on renal dialysis, type 2 diabetes mellitus, end stage renal disease, congestive heart failure, right lower leg amputation at level between knee and ankle and acquired absence of the left leg below the knee. A care plan, dated as last revised on 4/9/24, indicated the resident had chronic congestive heart failure. The interventions included, but were not limited to, observing and reporting signs of congestive heart failure including shortness of breath on exertion. A care plan, dated as last revised on 5/14/24, indicated the resident received hemodialysis outside of the facility. The interventions included, but were not limited to, dialysis treatments as ordered. A care plan, dated as last revised on 7/2/24, indicated the resident was at risk for fluctuations in weight related to hemodialysis and fluid imbalances. The interventions included, but were not limited to, reporting any shortness of breath, abnormal breath sounds, and to notify the physician of increasing shortness of breath, increased anxiety or inability to lie flat. A physician's order indicated the resident was to receive dialysis on Tuesdays, Thursdays and Saturdays. A progress note, dated 6/1/24 at 9:24 a.m., indicated the transportation to dialysis was canceled and the facility was unable to take the resident to dialysis. A progress note, dated 6/2/24 at 8:07 a.m., indicated the resident had called 911 and told 911 she could not breathe. The resident indicated she had missed dialysis the day before. A hospital note, dated 6/2/24, indicated the diagnoses were fluid overload, pulmonary edema, congestive heart failure, and acute respiratory failure with hypoxia. The resident was not able to go to dialysis on 6/1/24 due to a transportation issue. The resident had felt short of breath the entire night and was not able to breathe normally this morning. Nephrology was consulted for dialysis needs. The resident received hemodialysis on 6/2/24 with significant improvement in shortness of breath. A progress note, dated 6/4/24 at 6:34 p.m., indicated the resident had returned to the facility from the hospital stay. During an interview, on 7/12/24 at 10: 25 a.m., the Activities Director indicated the transport company used on Tuesdays and Thursday for dialysis would not provide transportation on Saturdays. The transport company who usually transported Resident 18 on Saturdays had staff on vacation and were not available for the transport on 6/1/24. There was a miscommunication and the facility only found out on 6/1/24 about 20 minutes prior to the usual pick-up time for dialysis. The facility was going to call a cab for the transport although the dialysis center was not able to assist the resident to get out of a cab and into the facility. The resident had to miss dialysis on 6/1/24 since the facility could not find transportation to dialysis. An Agreement for Dialysis Services with U.S. Renal Care, approved on 7/19/21, indicated, .Provider is in the business of providing dialysis services. Facility is a licensed health care facility in the business of providing skilled nursing services .Provider shall furnish the equipment, supplies, instruments and other items necessary to provide the Services .Transportation of Residents .Facility shall have the responsibility for arranging suitable transportation of the residents to and from Provider, including the selection of the mode of transportation, qualified personnel to accompany the resident and transportation equipment usually associated with this type of transfer .Facility shall .be responsible for all costs of transportation associated with the transfer of resident to and from Provider and Facility. Facility shall be responsible for, and shall provide the necessary personnel for, assisting the resident in entering into and exiting from Provider 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure an order for side rails was obtained and an assessment for side rails was completed prior to the use of side rails for 1 of 3 residents reviewed for accident hazards. (Resident D) Finding includes: During an interview, on 7/9/24 at 9:02 a.m., Resident D indicated she used the side rails for mobility assistance while in bed. During an observation, on 7/9/24 at 10:25 a.m., Resident D was in bed with the side rails in the raised position. During an observation, on 7/11/24 at 9:37 a.m., Resident D was asleep in bed with both side rails in the raised position. The clinical record for Resident D was reviewed on 7/10/24 at 9:22 a.m. The diagnoses included, but were not limited to, generalized muscle weakness, unspecified protein-calorie malnutrition, attention and concentration deficit, and insomnia. The physician's orders did not include an order for the use of the side rails. The electronic health record did not include a side rail assessment. The electronic health record did not include a signed consent for the use of the side rails. The electronic health record did not include appropriate alternatives attempted prior to installation of the side rails. The care plan did not include the use of the side rails. During an interview, on 7/11/24 at 9:46 a.m., the Administrator indicated Resident D was given a new bed and it already had the side rails. He indicated they had missed obtaining an order or an assessment for the use of the side rails. During an interview, on 7/11/24 at 9:29 a.m., the Administrator indicated they obtained blanket consent from everyone in the facility even if they did not need the side rails at the time. A current policy, titled Bed Rails- Safe and Effective Use of Bed Rails, dated as last revised on 12/30/22 and received from the Administrator on 7/11/24 at 10:00 a.m., indicated .To prevent entrapment and other safety hazards associated with bed rail use .The facility must attempt to use appropriate alternative prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements .Assess the resident for risk of entrapment from bed rails prior to installation .Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation .If bed rails are determined to be appropriate for use with a resident, a reassessment of bed rail(s) use will be assessed at a minimum quarterly and potentially with a change of condition utilizing the Evaluation of Use of Bed Rails Form (Quarterly) .If a bed rail will be utilized, the risks and benefits of bed rail(s) usage will be reviewed with the resident and/or resident representative and consent will be obtained prior to installation of the bed rails or as soon a practically possible. The facility should use the Med-Pass Consent for Use of Bed Rails (LCCA-574) .The facility will document alternative to the use of a bed rail(s) and how these alternatives did not meet the resident's assessed needs prior to the utilization of a bed rail(s). 3.1-45(2)

Based on observation, interview, and record review, the facility failed to address an annual gradual dose reduction (GDR) for an anti-depressant and an antipsychotic for 1 of 5 residents reviewed for unnecessary medications. (Resident J) Finding includes: During an observation, on 7/8/24 at 12:30 p.m., Resident J was smiling and engaged in conversation with the surveyor. The resident was sitting up in her wheelchair, waiting for her lunch tray. During an observation, on 7/9/24 at 10:15 a.m., the resident was up in her wheelchair. The resident was smiling and eager to engage in conversation. The resident was very talkative. During all other observations, between 7/10/24 and 7/12/24, Resident J was smiling, talkative, and readily engaged in conversation. The clinical record for Resident J was reviewed on 7/10/24 at 2:29 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, type 2 diabetes mellitus with hyperglycemia and polyneuropathy, schizoaffective disorder bipolar type, affective mood disorder, major depressive disorder, malignant neoplasm of brain, mild cognitive impairment, history of falling, generalized anxiety disorder, and pain. A physician's order, dated 3/26/20, indicated bupropion (an anti-depressant) 150 milligram (mg) tablet, give 1 tablet by mouth one time a day related to major depressive disorder. A physician's order, dated 5/3/23, indicated olanzapine (an antipsychotic) oral tablet 10 mg, give 1 tablet by mouth two times a day related to schizoaffective disorder, bipolar type. The last GDR for bupropion was contraindicated on 3/26/20. A psychosocial note, dated 3/26/2020 at 12:41p.m., indicated resident's bupropion was up for GDR. Resident is doing well and making positive adjustments in light of recent increased precautions associated to COVID-19. GDR will be contra-indicated today due to present circumstances. There was no annual GDR recommendation for bupropion between 6/1/23 and 7/12/24. The last GDR for the olanzapine was accepted on 4/24/23. There was no annual GDR recommendation for olanzapine between 4/24/23 and 7/12/24. No other GDRs for bupropion or olanzapine were recorded in the electronic medical record. All GDRs for Resident J were requested on 7/10/24 at 2:30 p.m. During an interview, on 7/11/24 at 3:45 p.m., the Administrator indicated he had provided all available GDRs. He did not find any GDR requests from pharmacy during the monthly reviews for bupropion. The last GDR for olanzapine was 4/24/23. The Administrator indicated he believed no one had looked at bupropion again since the order said the GDR was contraindicated on 3/26/20. He did not realize it was denied due to the Covid situation at that time. A current policy, titled Unnecessary Medication, dated as last reviewed on 8/09/23 and received from the Administrator on 7/12/24 at 10:15 a.m., indicated .ensure only mediations required to treat the resident's assessed condition are being used, reducing the need for and maximizing the effectiveness of medications .Gradual Dose Reduction (GDR)- This is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued .The facility's medication management process will support and promote .Selection and use of medications in doses and for the duration appropriate to each resident's clinical conditions, age, and underlying causes of symptoms 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to ensure expired food was discarded, the refrigerator did not contain employee lunches and the dishwasher was washing at the recommended temperature. The deficient practice had the potential to affect 67 of 68 residents who received food from the kitchen. Findings include: During an observation, on [DATE] at 11:36 a.m., the walk-in refrigerator had a container of creamed corn and a container of cottage cheese with expiration dates of [DATE]. The 3-door refrigerator had a yellow sack which contained the Dietary Manager's lunch. During an observation, on [DATE] at 11:45 a.m., the Dietary Manager (DM) started the dishwasher. She indicated the wash cycle temperature needed to be at least 160 degrees. The temperature dial on the dishwasher was stationary at 140 degrees during the wash cycle. She was given a thermometer by the [name of company] technician to place into the machine to get a temperature when the machine ran through a cycle. She placed the thermometer in the dishwasher and ran two cycles. She opened the dishwasher and removed the thermometer. The thermometer had a temperature of 123 degrees. The machine was missing two bolts at the bottom left and when the dishwasher was running water was coming out of the holes. During an interview, on [DATE] at 11:36 a.m., the DM indicated the container of creamed corn, and the cottage cheese was expired and should have been discarded. During an interview, on [DATE] at 11:53 a.m., the DM indicated the temperature on the dishwasher should be at least 160 degrees and the temp was 123 degrees when she used the thermometer. They had a technician out twice and who told the facility nothing was wrong. The dishwasher was also missing two bolts on the lower side of the dishwasher and water was coming out of the holes when the dishwasher was in use. During an interview, on [DATE] at 2:03 p.m., the Service Employee with [name of company] indicated the dishwasher was getting up to the recommended temperature when he arrived at the facility. The temperature was 160 degrees, and it was found nothing was wrong. An Installation and Operation Manual from [name of appliance company] indicated the water requirements for the wash temperature was a minimum of 150 degrees Fahrenheit and a recommended wash temperature of 160 degrees Fahrenheit. During an interview, on [DATE] at 2:04 p.m., the Administrator indicated when he checked the temperature with the DM it went up to 150 degrees and did not hold at the recommended temperature. During an interview, on [DATE] at 2:05 p.m., the Maintenance Director indicated he could not understand why the temperature did not stay at the correct temperature. He thought it could be because they were doing laundry at the same time as running the dishwasher. During an interview, on [DATE] at 9:15 a.m., the Administrator indicated the dishwasher had to go through 5 cycles to get the recommended temperature. During an interview, on [DATE] at 9:33 a.m., the DM indicated since the dishwasher did not get up to the recommended temperature this had a potential to have bacteria left on the plates, cups and silverware which could cause the residents to become sick. A current policy, titled Sanitation, received from the Administrator on [DATE] at 9:57 a.m., indicated .Residents in long-term care facilities are especially vulnerable to organisms and all persons associated with the handling of food be trained in this area .Food-borne illnesses can usually be prevented by proper storage, preparation, distribution, handing and serving of food .Any food not in its original container must be labeled with the date and contents and must be securely covered .The dish machine should be clean inside and out .There is no outdated food (over 72 hours old or per manufacturer's guidelines 3XXX,d+[DATE](i)(3)

Based on record review and interview, the facility failed to timely identify a significant weight loss and implement interventions for 1 of 1 resident reviewed for weight loss (Resident D). Resident D had a significant weight loss of 20.4 pounds and 14.6 % weight loss in 13 days. Finding includes: The record for Resident D was reviewed on 2/28/22 at 4:03 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 2/28/22, indicated the resident had a tube feeding and oral diet to meet her nutritional and/or hydration needs to support her overall metabolic demands. She had malabsorption and ulceration of the gastrointestinal tract and was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 2/28/22, indicated the resident had [CONDITION(S)]. The interventions included, but were not limited to, encourage intake of foods rich in iron, observe and report signs and symptoms of [CONDITION(S)], review the diet and make recommendations as required. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had the following weights: a. On 11/12/21, the weight was 132.3 pounds. b. On 11/16/21, the weight was 132.4 pounds c. On 11/23/21, the weight was 133.3 pounds. d. On 11/30/21, the weight was 137.3 pounds. e. On 12/13/21, the weight was 116.9 pounds and the weight was crossed out. This was a significant weight loss of 20.4 pounds and 14.6 % weight loss in 13 days. f. On 12/27/21, the weight was 114 pounds which was an additional weight loss of 2.9 pounds for a total of 23.3 pounds lost in 27 days. g. On 12/28/21, the weight was 114 pounds. A progress note, dated 12/15/21 at 5:28 p.m., indicated a weight warning with the weight of 116.9 pounds. The action was to continue to weigh the resident, continue to encourage meal trays and to continue to offer sherbet for meals and snacks. A nutrition progress note, dated 12/23/21 at 12:05 p.m., indicated the resident had a PEG (a feeding tube which allowed nutrition to go directly to the stomach) for flush only. Her nourishment was by mouth from a regular diet and her oral intakes varied from 25-75%. The resident was able to make her own choices. The plan was to continue the plan of care and honor the resident's preferences. The significant weight loss on 12/13/21 was not included in the nutrition note and no new interventions were recommended. An IDT (interdisciplinary team) progress note, dated 12/28/21 at 11:25 a.m., indicated the resident's weight loss was reviewed. The resident was to be reweighed to confirm the accuracy of the weight. The meal intakes for the last 7 days were less than 25%. The physician was notified of the decreased appetite, blood pressure readings and fatigue. Labs were ordered and the staff would continue to monitor the resident. The ID note was 15 days after the significant weight loss on 12/13/21. A progress note, dated 12/31/21 at 4:17 p.m., indicated the resident had a critical [MEDICATION(S)] level of 1.6. The physician ordered a urinalysis, labs and a referral to the registered dietician. A progress note, dated 1/3/21 at 11:37 a.m., indicated the labs were provided to the registered dietician (RD) for review of the [MEDICATION(S)] level. The physician had ordered the registered dietician referral on 12/31/21 and the labs were provided to the RD 3 days later. A progress note, dated 1/5/22 at 8:26 a.m., and entered as a late entry for 1/4/22, indicated the staff spoke with the resident's husband regarding discharge planning. He told the staff he noticed his wife was losing weight and advised she may need to see the gastro doctor and/or surgeon in Indianapolis related to her tube feedings. Nursing staff was notified. There was no note to indicate the gastro doctor or surgeon had been contacted. During an interview, on 3/2/22 at 1:28 p.m., the registered dietician (RD) indicated she was aware the weight on 12/13/21 was struck out due to not being sure the weight was correct. She was waiting on the reweight. The reweight was not completed for 2 weeks. She indicated she did not work during the holiday. During an interview, on 3/2/22 at 12:34 p.m., the on call physician for the resident indicated the [MEDICATION(S)] of 1.6 was from [CONDITION(S)], not from [CONDITION(S)] although a significant proteinuria (abnormal quantities of protein in the urine). It would lead to a referral to see a nephrologist. The significant weight loss would need to include consideration in errors in weighing, diuresis and the investigation of the weight loss. A current facility policy, titled Resident at Risk, not dated and received from the Executive Director (ED) on 3/2/22 at 11:39 a.m., indicated .Resident at Risk is an interdisciplinary meeting with representatives from nursing, food and nutrition services, and therapy. Other departments may also attend to provide a holistic patient centered approach to care .To address the ongoing clinical needs of our residents, a meeting is held weekly to ensure that residents who have been identified with nutritional and/or hydration problems/concerns or who have an identified risk factor that may lead to nutritional/hydration issues .The list includes residents who will be discussed in the meeting and will be reviewed with Nursing before distribution to team members .The Review List includes but is not limited to .Residents with a significant weight change-5% in 30 days, 7.5% in 90 days and 10% in 180 days .Residents with unplanned gradual weight loss .6% in 180 days .15% in 270 days .20% in 365 days .Resident with declining intake that has declined for 3 consecutive days from usual intake and residents with intake of 25% or less .Residents to be determined at risk for fluid volume deficit-symptoms .Team members may make recommendations to the resident's physician .If the committee identifies lack of progress towards the goal, the team members will schedule a care conference with involved family members, physician and, facility staff to review advanced care planning such as tube feeding, IVs, Hospice Care, Comfort Care, elimination of weight monitoring, etc .Documentation occurs during the meeting .Documentation by designated committee member will be recorded on a progress note in the medical record and will include .Progression/digression of interventions .Changes to interventions .The care plan is updated during the meeting. Interventions should be specific and individualized and dated .The facility should conduct resident at risk on a weekly basis A current facility policy, titled Weights and Heights, revised on 7/17/21 and received from the ED on 3/2/22 at 11:39 a.m., indicated .All residents are weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter or more as determined by the RAR committee and/or physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 3.1-46(a)(1) 3.1-46(a)(2)

Based on interview and record review, the facility failed to provide non-pressure wound treatments per physician orders [REDACTED]. The facility failed to administer prescribed medications and document why the medications were not given as ordered (Residents B, K and F), and failed to assess and follow physician's orders [REDACTED]. Findings include: 1. The record for Resident J was reviewed on 11/8/18 at 12:50 p.m. [DIAGNOSES REDACTED]. During an interview, on 11/8/18 at 3:04 p.m., the Director of Nursing (DON) indicated the resident saw the wound clinic for treatment of [REDACTED]. A review of the (MONTH) (YEAR) Treatment Administration Record (TAR), indicated physician orders, dated 07/11/18 and 08/04/18, for wounds on the buttocks area and bilateral lower legs. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The (MONTH) (YEAR) TAR indicated the order for the buttocks had changed on 08/04/18 and indicated to cleanse the buttocks with soap and water, apply silver alginate, apply dressing and change every day on the second shift. The TAR did not reflect on the 07/11/18 order the order had been discontinued and a new order for wound care was added. The (MONTH) (YEAR) TAR indicated the 07/11/18 order for both wounds was not performed 3 times. The new order for the buttocks, dated 08/04/18, had only been performed 1 time and the resident refused 1 time. The bilateral lower extremity order had not been performed at all. A review of the Wound Assessment/Care records, dated 09/04/18, from the wound clinic indicated the resident had 5 wounds, incontinence associated [MEDICAL CONDITION] (inflammation or erosion of the skin due to moisture contact) of the left and right buttocks, and venous stasis (insufficient blood flow) ulcers of the left posterior lower leg, the right posterior lower leg and the right dorsal (on the top) foot. The wound on the left buttocks measured 17 cm (centimeters) in length by 9 cm in width and was 0.2 cm in depth. The wound bed was blanchable (turns white when compressed), red, fragile and painful, had 50% of granulated tissue (new tissue that appears with wound healing) and 50% of slough (dead tissue that appears stringy and separates from the wound bed) with serosanguineous (yellow fluid with small amounts of blood) drainage. The wound on the right buttocks measured 18 cm in length by 7 cm in width and was 0.2 cm in depth. The wound bed was red, painful, had 50% of granulated tissue and 50% of slough with serosanguineous drainage. The wounds on the legs were not measured but had large amounts of serosanguineous purulent drainage (drainage that is typically oozing yellow fluid with small amounts of blood) with 100% of granulated tissue. The (MONTH) (YEAR) TAR for Resident J could not be located. A Progress Note, dated 09/11/18 at 1:35 p.m., indicated the Resident refused wound care appointment today, as the wrong stretcher was brought and he becomes very uncomfortable when he uses the other stretcher. Wound care on buttocks done the AM. Wounds are stable. Had slight amount of blood draining from wound A Progress Note, dated 09/18/18 at 1:05 p.m., indicated a late entry for 9/17/18 and .bed bath provided treatments rendered per order this shift to bilateral buttocks and PRN (as needed) to BLE (bilateral lower extremities). (B)loody drainage observed to bilateral buttocks excoriations surrounding open areas to buttocks BLE exhibits bloody drainage small blood filled raised area noted to LLE (left lower extremity) resident states acute discomfort during treatment A Progress Note, dated 09/18/18 at 1: 14 p.m., indicated Resident resting well in bed at this time tx (treatment) rendered to Bilateral buttocks resident tolerated well. Scheduled wound clinic apt (appointment) today refused upon (name of transportation company) arrival for pick up with regular size transport cart. resident observed size and refused transfer stating too small and will be uncomfortable. writer spoke with ( name of transportation company) representative in regards to cart size and bariatric cart availability. writer informed of resident having refused 'all available carts sent for transport by this company (name of company). wound clinic notified of appointment cancellation confirmed next week Tuesday appointment only opening available resident aware (name of transport company) ambulance inquired and states bariatric cart is available follow up appointment for wound clinic tues (Tuesday) 9/25/18 transport scheduled at this time with (name of transport company) resident aware. There were no additional Progress Notes from 09/11/18 through 09/18/18. A Progress Note from the wound clinic, dated 09/25/18, indicated the nurse had contacted the long term care facility and .left a message for the DON to contact myself in regards to patient appearance coming to wound center today. Care inadequately provided upon intake found patient not to have dressing changes to buttocks performed for multiple days, and his leg wounds have not been addressed since last Tuesday. Patient found to have multiple area of dry dirty crusted with old product that wound areas not cleaned. Sheets were soiled were urine and stool .DON .unaware of patient condition and will follow-up with staff in regards to patient care situation and council staff for proper care of patient wounds A review of the History of Present Illness from the ER visit, dated 09/25/18, indicated .patient was at the wound care center today, was sent over for management of infected LE (lower extremity) wounds . and was hospitalized for [REDACTED]. A review of a summary from the hospital indicated wound debridement (dead tissue removed from the wound) of a stage 3 pressure ulcer of contiguous region involving the back and left buttock and a debridement of a decubitus ulcer of the right buttock. The wound on the left buttocks measured 15.5 cm in length by 6.3 cm in width and was 0.3 cm in depth. The wound bed was non-blanchable, red, excoriated and painful, had 50% of granulated tissue and 50% of slough with serosanguineous drainage. The wound on the right buttocks measured 17 cm in length by 9.5 cm in width and was 0.2 cm in depth. The wound bed was red, excoriated, non-blanchable and painful. The debridement notes indicated .Wounds much worse .Pt (patient) reports no dressings at all on buttocks over weekend .Dressings on legs gives appearance of rotting off : During an interview on, 11/08/18 at 3:04 p.m., the Director of Nursing (DON) indicated she and LPN 2 were wound care certified and the two worked together to assess wounds in the facility. She also indicated the nurses working the hall were responsible for the dressing changes. During an interview, on 11/08/18 at 3:53 p.m., the DON indicated on 09/25/18 she had received a phone call from the wound clinic and was informed the resident was going to the emergency room (ER) for assessment and treatment of [REDACTED]. A current facility policy, titled Assessment of Wounds (Treatment Record), revised 02/25/15, received from the Regional Vice President on 11/08/18 at 6:05 p.m., indicated .1. It is the responsibility of a licensed nurse to complete the wound assessment and to document the findings on the Treatment Record-Wound Assessment. 2. Assessment and documentation are completed upon admission, re-admission, weekly, and PRN (as needed) .6. The patient's wound is measured using a clean, disposable measuring guide and cotton tip applicator (as indicated) .14. The treatment record is filed in the medical record after completion. 15. Document your findings. Include a description of the wound, including its physical characteristics, in the medical record to avoid miscommunication or misinterpretation A current facility policy, titled Evaluations, Screenings, and Assessments, revised 11/17, received from the Regional Vice President on 11/08/18 at 6:05 p.m., indicated .At the time of admission, each patient is evaluated for special needs related to skin care. Additionally, all patients receive a weekly skin integrity check performed by licensed personnel .Weekly, wound assessments are performed and recorded .Appropriate disciplines are notified if the patient either has skin breakdown or is at risk for the development of skin breakdown. The Nursing department coordinates the response to patient needs (in the area of skin integrity) by the following means. 1. With implementing appropriate preventive measures when the patient has been identified as being at risk. 2. When medically directed, refer to a restorative and therapeutic program for patients. 3. And with medically directed treatment for [REDACTED]. 2a. The record for Resident B was reviewed on 11/05/2018 at 5:47 a.m. [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. a day, 2 adult gummy multivitamin plus minerals once a day, 650 mg of [MEDICATION NAME] four times a day, 600 mg [MEDICATION NAME] (used to treat chronic pain) once a day (started 09/28/18), 100 mg [MEDICATION NAME] once a day at bed time (started 09/13/18 and discontinued 09/15/18), [MEDICATION NAME] 300 mg twice a day (started on 09/15/18 and discontinued on 09/23/2018), [MEDICATION NAME] 400 mg three times a day (started on 09/23/18 and discontinued on 09/28/18) and 1000 units of Vitamin D3 once a day. A review of the (MONTH) (YEAR) TAR indicated the following: a. Two missed doses of [MEDICATION NAME], 09/13 and 09/27. b. Three missed doses of [MEDICATION NAME], 09/13. 09/15 and 09/27. c. Eighteen missed doses of [MEDICATION NAME], 09/13-15, 09/16. 09/19, 09/24-29. d. Eleven missed doses of [MEDICATION NAME], 09/20-30. e. Twenty-one missed doses of potassium chloride. f. Six missed doses of spironolacton. g. Ten missed doses of the multi-vitamin. h. One missed dose of 100 mg of [MEDICATION NAME]. i. Two missed doses of 300 mg of [MEDICATION NAME]. j. Two missed doses of 400 mg of [MEDICATION NAME]. k. Eight missed doses of [MEDICATION NAME]. l. Five out of 10 missed doses of Vitamin D3. There was no indication on the Medication Administration Records as to why the resident did not receive these medications. A review of the Progress Notes for (MONTH) (YEAR) did not indicate why Resident B did not receive those medications. A review of the Census Activity for Resident B did not indicate the resident was out of the facility. During an interview, on 11/07/18 at 3:55 p.m., the DON indicated it was her expectation medications were administered as ordered or documented as to why they were not given. 2b. The record for Resident K was reviewed on 11/08/18 at 10:43 a.m. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A review of the Diabetic Administration Record for August, (MONTH) and November, indicated: a. Four missed doses of sliding scale insulin [MEDICATION NAME] on 8/15, 8/22-23, 8/25, 8/31, as well as, three missed doses of 50 units of insulin [MEDICATION NAME] on 8/15, 8/21 and 8/26. b. Seven missed doses of insulin detemir on 8/15, 8/22-23 and 8/25. c. One missed dose of dulaglutide in 8/28. d. Nine missed doses of sliding scale insulin [MEDICATION NAME] on 09/16, 09/18-19, 09/21 and 09/26, as well as, eight missed does of 50 units of insulin [MEDICATION NAME] on 09/2-4, 09/11, 09/16, 09/19 and 09/21. e. Twelve missed doses of insulin detemir on 09/3, 09/06-09/07, 09/10, 09/14, 09/17, 09/19, 09/21, 09/24 and 09/26. There was no indication on the Medication Administration Records as to why the resident did not receive these medications. A review of the Progress Notes for (MONTH) and (MONTH) (YEAR) did not indicate why the medications were not administered. A care plan, dated 06/26/17, indicated the resident was at risk for complications related to [MEDICAL CONDITION] and [DIAGNOSES REDACTED] related to a [DIAGNOSES REDACTED]. Approaches included, but were not limited to, administer insulin as ordered and perform blood glucose monitoring as ordered. During an interview, on 11/08/18 at 1:29 p.m., the DON indicated it was his expectation that orders were followed and if he was out of the facility, it should be indicated on the MAR. 2c. The record for Resident F was reviewed on 11/05/18 at 8:55 a.m. [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED]. There was no documentation as why the resident did not receive the medication. A review of the MAR for August, indicated the resident did not receive his scheduled [MEDICATION NAME] (a medication used to treat anxiety and muscle spasms) 2 mg, scheduled for three times a day, on the 27th at 11:00 a.m. and 4:00 p.m. and on the 28th at 7:00 a.m. Documentation on 08/27/18 at 4:00 p.m., indicated the medication was not available and would be held until it arrived. A review of the MAR for August, indicated the resident did not receive his scheduled [MEDICATION NAME] (a muscle relaxant) 25 mg, scheduled for four times a day, on the 7th at 9:00 a.m., the 26th at 9:00 p.m. and the 27th at 1:00 p.m. There was no documentation as why the resident did not receive the medication. A review of the MAR for September, indicated the resident did not receive his [MEDICATION NAME] mg at bedtime on the 4th, 5th, 10th, 12th, 13th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 25th, 26th, 27th, 28th, 29th and the 30th. On the 8th and the 23rd, it was documented it was pulled from the EDK (Emergency Drug Kit) There was no documentation as why the resident did not receive the medication on the other days listed above. A review of the MAR for September, indicated the resident did not receive his scheduled [MEDICATION NAME] 2 mg, scheduled for three times a day, on the 22th at 7:00 a.m. and 11:00 a.m., the 26th at 7:00 a.m. and 11:00 a.m. and on the 28th at 11:00 a.m. There was no documentation as why the resident did not receive the medication. A review of the MAR for September, indicated the resident did not receive his scheduled [MEDICATION NAME] 25 mg, scheduled for four times a day, on the 2nd at 12:00 a.m., on the 5th at 6:00 p.m., on the 12th at 12:00 p.m., on the 17th at 12:00 p.m. and 12:00 a.m., on the 23rd at 12:00 a.m., on the 25th at 6:00 p.m. and the 29th at 12:00 p.m. There was no documentation as why the resident did not receive the medication. A review of the MAR for (MONTH) indicated the resident did not receive his scheduled [MEDICATION NAME] (a pain medication) ER (extended release) 20 mg, scheduled for twice a day, on the 25th, 26th, 27th, 28th and the 29th. There was no documentation as why the resident did not receive the medication. A review of the MAR for October, indicated the resident did not receive his [MEDICATION NAME] mg at bedtime on the 2nd, 3rd and the 4th. There was no documentation as why the resident did not receive the medication on the other days listed above. A review of the MAR for October, indicated the resident did not receive his scheduled [MEDICATION NAME] 25 mg, scheduled for four times a day, on the 3rd at 6:00 a.m. There was no documentation as why the resident did not receive the medication. During an interview, on 11/08/18 at 10:54 a.m., the Director of Nursing (DON) indicated the MAR indicated [REDACTED]. During an interview, on 11/08/18 at 2:58 p.m., the DON indicated Resident F's [MEDICATION NAME] was available for a while, she did not know why it was unavailable. He was out [MEDICATION NAME] some time also. She indicated [MEDICATION NAME] available in the EDK and could have been pulled for administration. She indicated she did not have an answer to why his [MEDICATION NAME] was not administered. A current facility policy titled, Medication Shortages/Unavailable Medications, dated on revised on 01/01/13, received from the Regional Director of Clinical Services, on 11/08/18 at 12:30 p.m., indicated .Upon discovery that facility has an inadequate supply of medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .If a medication storage is discovered during normal pharmacy hours .If next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery .If a medication shortage is discovered after normal pharmacy hours .If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: Emergency deliver; or use of an emergency (back-up) third party pharmacy A current facility policy titled, General Dose Preparation and Medication Administration, dated as revised on 01/01/13, received from the Regional Director of Clinical Services, on 11/08/18 at 12:30 p.m., indicated, .After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Document necessary medication administration/treatment information (e.g., when medication are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms 3. During an interview, on 11/07/18 at 8:59 a.m., Resident D's mother indicated her daughter had an implanted port which had not been flushed since admission and it was supposed to be flushed monthly. The record for Resident D was reviewed on 11/07/18 at 10:58 a.m. [DIAGNOSES REDACTED]. An admission Initial Data Collection Tool, dated 05/23/18, did not indicate the resident had an implanted port on the skin condition assessment. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A review of the Medication Administration Record's (MAR's) indicated the following: a. The month of May, there was no mention of a port. b. The month of June, indicated to flush the port every four weeks per facility protocol as a standing order for 12 months. It did not indicated the port was flushed. c. The month of July, there was no mention of a port. d. The month of September, indicated to flush the port with 10 cc of normal saline and flush the port with (500 units) 5 ml of [MEDICATION NAME] 100 units/ml every 4 weeks. It did not indicated the port was flushed. e. The month of October, indicated to flush the port with 10 cc of normal saline and flush the port with (500 units) 5 ml of [MEDICATION NAME] 100 units/ml every 4 weeks. It did not indicated the port was flushed and indicated an appointment was made with the general surgeon. A MAR for the month of (MONTH) was not located in the resident's medical record. During an interview, on 11/07/18 at 11:14 a.m., the DON indicated she could not find anything in (MONTH) or July's MAR indicated [REDACTED] During an interview, on 11/07/18 at 11:21 a.m., the Medical Records nurse indicated she had been in the medical record position for 2 days and she could not locate her (MONTH) MAR. During an interview, on 11/07/18 at 1:50 p.m., the Health Facility Administrator indicated she could not find anything in the progress notes or on admission assessment which discussed the resident's port on admission or where it had been monitored or assessed. A current facility policy, titled Nursing Documentation, revised 03/07, received from the Regional Vice President on 11/08/18 at 6:04 p.m., indicated .Policy .The following outlines basic nursing documentation .Charting every shift on a resident with skilled classification is generally the expectation, particularly when changes occur. Charting is to be completed every shift on all residents with the skilled classification for the first 72 hours This Federal tag relates to Complaints IN 157, IN 701, IN 892 and IN 556. 3.1-37(a) 3.1-37(b)

Based on interview and record review, the facility failed to provide medications to a resident who was suffering from a migraine as prescribed by the physician resulting in harm when the resident was hospitalized with the migraine for 1 of 2 residents reviewed for medication errors (Resident B). The facility failed to ensure medications were administrated as ordered by the physician for 1 of 2 residents for medication errors (Resident F). Finding includes: 1. During an interview on 11/08/18 at 10:22 a.m., Resident B indicated he was sent to the emergency room because he was having a migraine headache for 2 days and the facility did not have his migraine medication. The record for Resident B was reviewed on 11/05/2018 at 5:47 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A progress note, dated 10/10/18 at 1:28 p.m., indicated the resident had been in bed complaining of pain related to a migraine headache and [MEDICATION NAME] was not available. There was no documentation the physician was notified the medication was not available on 10/10/18. There was no documentation in the resident's record which indicated why he was sent to the hospital on [DATE], there was no assessment documented prior to sending the resident to the hospital, the was no documentation they physician was notified of the resident's condition and there was no documentation the family was notified of the transfer to the hospital. A review of the (MONTH) Medication Administration Record [REDACTED]. The hospital Admission Note, dated 10/11/18, indicated the resident presented in the emergency room for a headache and shortness of breath, (h)e had 10/10 headache which decreased to 3-4/10 after taking [MEDICATION NAME] ([MEDICATION NAME]) in ED (Emergency Department). A care plan to address the resident's migraine headaches was not located. A review of the pharmacy delivery receipt with the Director of Nursing (DON), on 11/07/18 at 3:55 p.m., indicated [MEDICATION NAME] was not delivered by the pharmacy. The DON indicated that medication was not available in the facility's emergency drug kit. 2. The record for Resident F was reviewed on 11/05/18 at 8:55 a.m. [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED]. There was no documentation as why the resident did not receive the medication. A review of the MAR for August, indicated the resident did not receive his scheduled [MEDICATION NAME] (a medication used to treat anxiety and muscle spasms) 2 mg, scheduled for three times a day, on the 27th at 11:00 a.m. and 4:00 p.m. and on the 28th at 7:00 a.m. Documentation on 08/27/18 at 4:00 p.m., indicated the medication was not available and would be held until it arrived. A review of the MAR for August, indicated the resident did not receive his scheduled [MEDICATION NAME] (a muscle relaxant) 25 mg, scheduled for four times a day, on the 7th at 9:00 a.m., the 26th at 9:00 p.m. and the 27th at 1:00 p.m. There was no documentation as why the resident did not receive the medication. A review of the MAR for September, indicated the resident did not receive his [MEDICATION NAME] mg at bedtime on the 4th, 5th, 10th, 12th, 13th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 25th, 26th, 27th, 28th, 29th and the 30th. On the 8th and the 23rd, it was documented it was pulled from the EDK (Emergency Drug Kit) There was no documentation as why the resident did not receive the medication on the other days listed above. A review of the MAR for September, indicated the resident did not receive his scheduled [MEDICATION NAME] 2 mg, scheduled for three times a day, on the 22th at 7:00 a.m. and 11:00 a.m., the 26th at 7:00 a.m. and 11:00 a.m. and on the 28th at 11:00 a.m. There was no documentation as why the resident did not receive the medication. A review of the MAR for September, indicated the resident did not receive his scheduled [MEDICATION NAME] 25 mg, scheduled for four times a day, on the 2nd at 12:00 a.m., on the 5th at 6:00 p.m., on the 12th at 12:00 p.m., on the 17th at 12:00 p.m. and 12:00 a.m., on the 23rd at 12:00 a.m., on the 25th at 6:00 p.m. and the 29th at 12:00 p.m. There was no documentation as why the resident did not receive the medication. A review of the MAR for (MONTH) indicated the resident did not receive his scheduled [MEDICATION NAME] (a pain medication) ER (extended release) 20 mg, scheduled for twice a day, on the 25th, 26th, 27th, 28th and the 29th. There was no documentation as why the resident did not receive the medication. A review of the MAR for October, indicated the resident did not receive his [MEDICATION NAME] mg at bedtime on the 2nd, 3rd and the 4th. There was no documentation as why the resident did not receive the medication on the other days listed above. A review of the MAR for October, indicated the resident did not receive his scheduled [MEDICATION NAME] 25 mg, scheduled for four times a day, on the 3rd at 6:00 a.m. There was no documentation as why the resident did not receive the medication. During an interview, on 11/08/18 at 10:54 a.m., the Director of Nursing (DON) indicated the MAR indicated [REDACTED]. During an interview, on 11/08/18 at 2:58 p.m., the DON indicated Resident F's [MEDICATION NAME] was available for a while, she did not know why it was unavailable. He was out [MEDICATION NAME] some time also. She indicated [MEDICATION NAME] available in the EDK and could have been pulled for administration. She indicated she did not have an answer to why his [MEDICATION NAME] was not administered. A current facility policy, titled Medication Shortages/Unavailable Medications, revised 01/01/13, received on 11/08/18 at 6:04 p.m. by the Regional Vice President, indicated .1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled deliver. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery; or, 3.2.2 Use of an emergency (back-up) third party pharmacy. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. 8. When a missed dose is unavoidable, facility nurse should document the missed dose and the explanation for such missed dose on the MAR indicated [REDACTED]. Such document should include the following information: 8.1 A description of the circumstances of the medication shortage; 8.2 A description of pharmacy's response upon notification; and 8.3 Action(s) taken. This Federal tag relates to Complaints IN 157, IN 701 and IN 556. 3.1-48(c)(2)

Based on record review and interview, the facility failed to provide the necessary assessment and intervention for for 1 of 1 residents reviewed for right arm pain. Resident B had a injury of unknown origin to her right arm and was not assessed for pain or pain interventions implemented during the day as the resident yelled out in pain through the day. Findings include: During record review on 3/2/2017 at 10:30 a.m., Resident B [DIAGNOSES REDACTED]. A nursing note on 2/19/2017 at 8:00 a.m. indicated resident had complained of right shoulder and arm pain and it would not move, a strong radial pulse was assessed and no bruising was noted. Resident B indicated she had heard it brake. Vital signs were stable and a Physicians order for an X-ray was obtained. A review of Resident B Medication Administration Record [REDACTED] A review of Resident B Medication Administration Record [REDACTED]. A score of 0 was indicated. (On a scale of 0 to 10 , meaning 10 very high pain level and 0 meaning no pain). During an interview on 3/3/2017 at 2:25 p.m., with CNA# 10, she indicated she was in the dining room at 7:20 a.m., and resident B was set up for for breakfast , resident B did not eat breakfast and complained about her right arm hurting, yelling her arm was broken. Resident B indicated she heard it pop and she could not move it . Resident was assessed by nursing staff. She indicated resident B normally yelled throughout the day but not about her arm being broken. During an interview on 3/3/2017 at 2:20 p.m., with CNA# 14, she indicated she assisted resident B to the dining room for lunch and resident B was complaining about her right arm hurting. She indicated resident B kept saying her arm was broken and resident B said it again later in the day. She indicated she notified nursing staff and the resident was assessed. A witness statement dated 2/19/2017 at 11:00 p.m., QMA #17 indicated it was passed on to her in report Resident B was yelling out saying her arm as broke. During an interview on 3/2/2017 at 12:20 p.m., with the Regional Director of Clinical Services, she indicated RN# 15 did not assess resident B throughout her shift for pain and pain management for an injury of unknown origin. She indicated RN #15 did not call the Physician when the resident was still expressing she was having pain. During an interview on 3/2/2017 at 1:20 p.m., with the Director of Nursing, she indicated RN# 15 did not assess resident B throughout her shift for pain and pain management for an injury of unknown origin. RN# 15 should have assessed resident B throughout the day since she was continuing to complain of pain and notify Physician of resident condition. This Federal tag relates to Complaints IN 947 and IN 309 3.1-37(a)

Based on record review and interview, the facility failed to ensure the safety of a resident while being transferred using a mechanical lift for 1 of 3 residents reviewed for accidents. Resident B sustained a fracture to her right arm during the hoyer transfer and the CNA completing the transfer knew of the injury and did not report it. Findings include: During record review on 3/2/2017 at 10:30 a.m., Resident B [DIAGNOSES REDACTED]. A nursing note on 2/19/2017 at 8:00 a.m., indicated resident had complained of right shoulder and arm pain and it would not move, a strong radial pulse was assessed and no bruising was noted. Resident B indicated she had heard it brake. Vital signs were stable and a Physicians order for an X-ray was obtained. An incident report dated 2/19/2017 at 10:15 p.m., indicated resident B was transferred utilizing a mechanical lift by CNA # 13 between 6:00 a.m., and 6:30 a.m., on 2/19/2017, During the transfer, Resident B had an injury to her right arm. The mechanical lift was utilized by one staff member, CNA # 13. A witness interview form dated 2/20/2017 at 2:00 p.m., indicated CNA#13 was transferring resident B on 2/19/2017 at 6:00 a.m.- 6: 30 a.m. and an injury occurred to resident B right arm. She indicated she did not notify her supervisor. CNA #13 was suspended at this time. A witness interview form dated 2/20/2017 at 8:15 a.m., indicated RN#15 was told by resident B she had increase pain and she indicated she broke her arm. RN# 15 indicated she contacted MD for order for X-ray and order was received. RN # 15 did not investigate injury of unknown origin and left after her shift on 2/19/2017. RN #15 was suspended at this time. A witness interview form dated 2/21/2017, indicated the DON received a phone call on 2/19/2017 at 10:15 p.m., from the facility which indicated resident B's X-ray impression showed a fracture, and the day shift nurse had not reported a change in condition/ incident when they suspected an injury during the day. Resident B's care plans indicated, Resident B had a care plan for risk for fall related injury dated 12/24/2013 with revision on 6/28/2015. A two person assist and transfers with Hoyer (mechanical) lift was indicated. During an interview on 3/2/2017 at 12:20 p.m., with the Regional Director of Clinical Services, she indicated CNA# 13 did not utilize the mechanical lift properly resulting in an injury to Resident B. Mechanical lifts were to be performed with a 2 persons. During an interview on 3/3/2017 at 11:08 a.m., with CNA #10, she indicated Resident B was a mechanical lift for all transfers and 2 people were to operate the mechanical lift. She indicated for resident safety the mechanical lift must have 2 staff for operation. During an interview on 3/3/2017 at 11:11 a.m., with CNA #7, she indicated Resident B was a mechanical lift for all transfers and 2 people were to operate the mechanical lift. She indicated for resident safety the mechanical lift must have 2 staff for operation. During an interview on 3/3/2017 at 12:55 p.m., with CNA #14, she indicated for resident safety the mechanical lift must have 2 staff for operation. The current facility policy, Mechanical Lift Use, not dated, received from the Executive Director on 3/3/2017 at 4:15 p.m., indicated .3. Two (2) persons are required to perform this procedure This Federal tag relates to Complaints IN 947 and IN 309 3.1-45(a)(2)