Every finding on record at Heritage Park

Based on interview and record review, the facility failed to ensure accurate assessments and communication with the off-site dialysis center for 4 of 7 resident reviewed (Resident 1, Resident 6, Resident 23 and Resident 109).Findings Include:1.Resident 1's record was reviewed on 02/17/2026 at 1:50 PM. Diagnosis included metabolic encephalopathy, end stage renal disease, dependence on renal dialysis, arteriovenous fistula, acquired and kidney transplant failure.A review of Resident 1's physician's orders, dated 2/16/2026 at 3:37 PM, indicated for the dialysis access site, left upper arm fistula, to monitor access site and effected extremity for signs and symptoms of infection, edema, pain, numbness, bleeding and leaks. Ensure the access site was clean, dry and dressing was intact as ordered. Notify MD of unusual findings and document in progress notes.A review of Resident 1's Dialysis Appointment Assessment record indicated not applicable for bruit and thrill on 1/18/2026 and 1/23/2026.Resident 1's progress notes were reviewed. No documentation was located indicating a change to Resident 1's dialysis site to account for the change in assessment.2. Resident 6's record was reviewed on 02/16/2026 at 12:19 PM. Diagnosis included acute kidney failure, chronic kidney disease and dependence on renal dialysis.A review of Resident 6's physician's orders, dated 12/17/2025 at 10:52 PM, indicated, dialysis access site, right Internal Jugular (IJ) dialysis, to monitor the access site and effected extremity for signs and symptoms of infection, edema, pain, numbness, bleeding and leaks. Ensure access site was clean, dry and dressing was intact as ordered. Notify MD of unusual findings and document in progress notes.A review of Resident 6's physician's orders dated 12/16/2025 at 12:12 PM indicated check for Bruit and thrill.A review of Resident 6's Dialysis Appointment Assessment record indicated bruit and thrill were present on 2/11/2026, 2/9/2026, 2/6/2026, 2/5/2026, 2/3/2026 and 1/30/2026.A review of Resident 6's dialysis binder indicated the facility did not complete the pre-dialysis section on the dialysis center communication tool on 2/14/2026, 2/10/2026, 2/3/2026, 2/5/2026, 1/29/2026, 1/20/2026, 1/15/2026 and 1/13/2026.3. Resident 23's record was reviewed on 02/16/2026 at 12:57 PM. Diagnosis included end stage renal disease, dependence on renal dialysis and hydronephrosis with renal and ureteral calculous obstruction.A review of Resident 23's physician's orders dated 02/23/2021 at 04:41 PM indicated dialysis access site right chest to monitor access sites for signs and symptoms of infection, edema, pain, numbness, bleeding and leaks. Ensure access site was clean, dry and dressing was intact as ordered. Notify MD of unusual findings and document in progress notes.A review of Resident 23's Dialysis Appointment Assessment record indicated not applicable for bruit and thrill on 1/31/2026, 1/29/2026, 1/22/2026, 1/10/2026 and 1/8/2026.A review of Resident 23's Dialysis Appointment Assessment record indicated bruit and thrill were present on 2/5/2026, 1/17/2026, 1/6/2026 and 1/3/2026.A review of Resident 23's Dialysis Appointment Assessment record indicated bruit and thrill were absent on 2/14/2026, 2/7/2026, 2/3/2026 and 1/24/2026.Resident 23's progress notes were reviewed. No documentation was located indicating a change to Resident 23's dialysis site to account for the difference in assessments.A review of Resident 23's physician's orders, dated 02/23/2021 at 04:41 PM. indicated dialysis was at 9:40 am., fill out the top portion of the dialysis communication form and send book with the resident. Complete the bottom portion of the dialysis event upon return.A review of Resident 23's dialysis binder indicated the facility did not complete the pre-dialysis section on the dialysis center communication tool on 02/07/2026.4. Resident 109's record was reviewed on 02/16/2026 at 12:57 PM. Diagnosis included end stage renal disease, dependence on renal dialysis and chronic kidney disease stage 5.A review of Resident 109's physician's orders dated 02/11/2025 at 01:57 PM indicated dialysis access site left forearm fistula to monitor access site and effected extremity for signs and symptoms of infection, edema, pain, numbness, bleeding and leaks. Ensure access site was clean, dry and dressing was intact as ordered. Notify MD of unusual findings and document in progress notes.A review of Resident 109's physician's orders, dated 02/17/2025 at 09:45 AM, indicated check for bruit and thrill.A review of Resident 109's Dialysis Appointment Assessment record indicated not applicable for bruit and thrill on 1/23/2026.A review of Resident 109's Dialysis Appointment Assessment record indicated an assessment for bruit and thrill was not completed on 2/16/2026, 2/13/2026 and 2/11/2026.A review of Resident 109's dialysis binder and medical record indicated the facility did not have a dialysis center communication tool sheet for 2/16/2026, 2/13/2026, 2/9/2026, 2/6/2026, 2/2/2026, 1/30/2026, 1/18/2026, 1/19/2026, 1/16/2026, 1/12/2026, 1/9/2026 and 1/7/2026.In an interview, on 2/18/25 at 12:25 PM, the Regional Nurse Consultant (RNC) indicated there would not be bruit or thrill with an Internal Jugular (IJ) port.In an interview, on 2/18/2026 at 1:48 PM, the Administrator indicated the facility did not have any additional communication sheets that were not in the binder.In an interview, on 2/18/2025 at 1:58 PM, the DON indicated the facility completed the communication sheets to see how much fluid was taken off, the resident's weight, if labs were completed or if the resident had any complications. The DON indicated the communication sheets were used to monitor the residents' overall care and wellbeing. The DON indicated bruit and thrill should always be present and if it was not the facility should be contacting the physician or dialysis.In an interview, on 2/19/2026 at 12:04 PM, the Director of Nursing (DON) indicated the dialysis communication tool should be completed and sent to dialysis with every resident. The DON indicated the facility completed a dialysis assessment for every resident, which included their vitals, whether medication was sent with the resident and whether the resident had eaten. The DON indicated the dialysis assessment was not sent with the resident to dialysis. The DON indicated the dialysis center communication tool was what the facility sent with the resident and where the facility would provide the information to dialysis.A current policy, dated 11/2017, provided by the RNC indicated, Ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The nurse in charge at time of transfer will provide resident with all appropriate paperwork as required by the Dialysis Center. The facility will employ a method of communication between the facility and the dialysis center to relay changes in condition and response to treatment. The physician will be notified of any unusual findings and/or change in condition based upon the assessments.

Based on observation and record review, the facility failed to ensure proper labeling was completed for insulin pens related to open dates and expiration dates. For 5 of 5 residents reviewed (Resident 10, Resident 56, Resident 94, Resident 130 and Resident 132) Findings include:During an observation on 2/18/26 at 8:38 AM with Registered Nurse (RN) 2 on the 300-medication cart, inside the following opened medications were observed: Resident 10 had a Lantus insulin Pen with no open or expiration date documented. Resident 56 had a Basaglar insulin pen with no open or expiration date documented. Resident 94 had a Lantus insulin pen with no open or expiration date documented. Resident 132 had a Glargine insulin pen, with no open or expiration date and a Novolog insulin pen with no opened or expiration date documented. 1. Resident 10's record was reviewed on 2/18/26 at 9:00 AM. Diagnosis included,Type 2 diabetes mellitus with diabetic chronic kidney disease.A review of physician orders indicated to give Lantus Solostar Units-100 Insulin (insulin glargine) insulin pen, 100 unit/milliliter, give 15 units subcutaneous once a day 07:00 AM - 11:00 AM.2. Resident 56's record was reviewed on 2/18/26 at 9:10 AM. Diagnosis included Type 2 diabetes mellitus without complications.A review of physician order indicated to give Lantus Solostar U-100 Insulin (insulin glargine) insulin pen, 100 unit/mL, give 15 u subcutaneous twice a day 07:00 AM - 11:00 AM, and 07:00 PM - 10:00 PM. 3. Resident 94's record was reviewed on 2/18/26 at 9:20 AM. Diagnosis included Type 2 diabetes mellitus without complications. A review of physician orders indicated Lantus Solostar U-100 Insulin (insulin glargine) insulin pen 100 unit/mL give 40 units subcutaneous once a day 07:00 AM - 11:00 AM.4. Resident 132's record was reviewed on 2/18/26 at 9:30 AM. Diagnosis included Type 2 diabetes mellitus with diabetic neuropathy, unspecified.A review of physician orders indicated insulin aspart U-100 insulin pen 100 unit/mL give 30 units subcutaneous before meals along with coverage for sliding scale three times a day 08:00 AM, 12:00 PM, 05:00 PM. insulin pen; give 28 units subcutaneous twice a day 08:00 AM, 08:00 PM. In an interview, on 2/18/26 at 8:38 AM, Registered Nurse 2 indicated all insulins should have been labeled with an open date.According to the Cleveland Clinic article, dated 2/12/24, titled Insulin Pens, insulin pens should be stored unopened in a refrigerator until the expiration date printed on the box. Write the date on the insulin pen when it is opened. Most pens are good for 28 days once the pen is opened.A current facility policy, titled Medication storage and expiration policy, dated 11/24, was provided by the Regional Nurse consultant on 2/18/26 at 12:57 PM. The policy indicated. Medications should have an expiration date on the label.Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has shortened expiration date once opened. 3.1-25(j)(m) and (n)

Based on interview and record review, the facility failed to ensure non-pharmalogic interventions were completed for 1 of 1 resident reviewed. (Resident 8)Findings include:Resident 8's record was reviewed on 2/17/26 at 11:01 AM. Diagnosis included chronic pain. A review of physician orders indicated to give hydrocodone-acetaminophen 5-325 milligram (mg) 1 tablet as needed for moderate to severe pain. every 8 Hours as needed. A review of the Medication Administration Record (MAR), dated February 2026 indicated Resident 8 received hydrocodone-acetaminophen for pain on 2/15/26 at 3:20 PM. No non-pharmalogical interventions were documented as attempted. A review of the MAR, dated January 2026 indicated Resident 8 received hydrocodone-acetaminophen for pain on the following dates: On 1/11/26 at 6:33 PM, no non-pharmalogical interventions were documented as attempted. On 1/13/26 at 2:36 PM, and at 9:06 PM, no non-pharmalogical interventions were documented as attempted. On 1/14/26 at 5:17 AM, no non-pharmalogical interventions were documented as attempted. On 1/17/26 at 7:05 AM, and at 2:54 PM, no non-pharmalogical interventions were documented as attempted. On 1/18/26 at 12:53 PM, no non-pharmalogical interventions were documented as attempted. On 1/19/26 at 12:13 PM, no non-pharmalogical interventions were documented as attempted. On 1/20/26 at 7:55 PM, no non-pharmalogical interventions were documented as attempted. On 1/21/26 at 5:23 PM, no non-pharmalogical interventions were documented as attempted. On 1/23/26 at 5:09 PM, no non-pharmalogical interventions were documented as attempted. On 1/24/26 at 10:34 AM, no non-pharmalogical interventions were documented as attempted. On 1/25/26 at 11:29 AM, and 3:05 PM, no non-pharmalogical interventions were documented as attempted. On 1/27/26 4:15 PM, no non-pharmalogical interventions were documented as attempted. On 1/28/26 10:11 AM, no non-pharmalogical interventions were documented as attempted. In an interview, on 02/18/2026 at 12:38 PM, the Director of Nursing (DON) indicated non-pharmalogical interventions should be done prior to administering as needed pain medication. In an interview, on 02/18/2026 at 1:04 PM, the Regional Nurse Consultant indicated they do not have a policy more specific to non-pharmalogical interventions prior to pain medication administration. A current facility policy, titled Pain Management, dated 7/24, was provided by the Regional Nurse Consultant on 12/18/26 at 12:57 AM. The policy indicated. A plan of care will be written with the initiation of pain medication and individualized to the resident, addressing potential side effects, limitations due to pain, behavioral symptoms, and alternative pain relief techniques. 3.1-37(a)

Based on interview and record review the facility failed to ensure updated vaccinations were completed related to the COVID-19 vaccine for 2 of 5 residents reviewed. (Resident 52 and Resident 163)Findings include:1. Resident 52's record was reviewed on 2/16/26 at 1:01 PM. Diagnosis included Parkinson's disease without dyskinesia, without mention of fluctuations.A review of the COVID-19 vaccine consent form, dated 10/28/25, indicated the facility was given verbal consent from the Power of Attorney/Health Care to give the vaccine to Resident 52. The COVID-19 vaccine was not documented as given to the resident. 2. Resident 162's record was reviewed on 2/16/26 at 1:30 PM. Diagnosis included Epilepsy, unspecified, not intractable, without status epilepticus. A review of the COVID-19 vaccine consent form, dated 10/28/25, the facility was given verbal consent from the Power of Attorney/Health Care to give the vaccine to Resident 162. The COVID-19 vaccine was not documented as given to the resident. In an interview, on 2/18/25 at11:05 AM, the Infection Preventionist (IP) indicated the two residents did not get the COVID-19 vaccine. The IP indicated she just started in December, and the position was vacant prior to her starting, she did order the vaccinations but with COVID in the building, the vaccine had not been given at this time. No other paperwork was presented prior to exit.A current facility policy, titled Resident COVID-19 vaccination, dated 12/20, was provided by the Director of Nursing on 2/18/26 at 1:28 PM. The policy indicated. Residents who accept the vaccine will be scheduled in a timely manner.

Based on interview and record review the facility failed to act timely on pharmacy recommendations for 1 of 5 residents reviewed. (Resident 105). Findings include: Resident 105's record review was reviewed on 3/6/25 at 9:16AM. A review of Resident 105's pharmacist consultation reports indicated on 12/12/24 his medication Florastar, a probiotic, was suggested to be discontinued. The physician response was I have re-evaluated the therapy and wish to implement the following changes. Written in the comment section by the medical provider was will do. A review of Resident 105's progress notes indicated he had a regulatory visit with a medical provider on 1/3/25 at 6:39AM. There was no note or orders to indicate the physician had been made aware of the December recommendation to discontinue the Florastor. A review of Resident 105's physician orders indicated the medication Florastar 250mg was discontinued on 2/19/25. In an interview, on 3/6/25 at 2:23PM, the Director of Nursing (DON) confirmed the medication Florastar should have been discontinued on the regulatory visit following the December pharmacy review, but it was not. The regulatory visit occurred on 1/3/25. The medication was not discontinued until 2/19/25. A policy was provided by DON on 3/7/25 at 11:32AM titled, Medication Regimen Review dated 12/1/07 with most recent revision date of 6/1/24. The policy indicated .13. The attending physician/prescriber should address the consultant pharmacist's recommendations no later than their next scheduled visit to the facility to assess the resident per facility policy or applicable state and federal regulations . 3.1-48a(1)

Based on observation, interview and record review the facility failed to ensure medications were secured for 1 of 8 residents reviewed (Resident 120). Findings include: During an observation on 3/5/25 at 9:42 AM, an open bottle of Tums, a tube of biofreeze (topical analgesic), two tubes of barrier creams and a Symbicort (inhaled lung medication) inhaler were observed sitting on top of Resident 120's bed. During an interview, on 3/5/25 at 9:50 AM, Licensed Practical Nurse (LPN) 2 indicated medicines may be kept at bedside if an assessment indicates they demonstrate the ability to self-administer the medication correctly and secure it in a locked box. He indicated the medications observed on Resident 120's bed should not be left out when unattended. He indicated Resident 120 was out of the building at a medical appointment. LPN 2 collected the medications and placed them in a secure box in the room. Resident 120's record was reviewed on 3/7/25 at 9:06 AM. Diagnoses included chronic obstructive pulmonary disease, end stage renal disease, and chronic pain syndrome. A review of Resident 120's current quarterly Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). A review of Resident 120's current care plan titled Resident chooses to self-administer medication- Tums, initiated 10/9/24, indicated the resident had a problem of wishing to self-administer medication with a goal date of 4/2/25. Interventions included completing a medication self-administration evaluation quarterly and keeping medication out of the reach of other residents. A review of Resident 120's current care plan titled .potential for impaired gas exchange .initiated 6/10/24, indicated Resident 120 had a problem of impaired gas exchange due to chronic obstructive pulmonary disease with a goal date of 4/2/25. Interventions included administering medications as ordered. A review of Resident 120's current care plan titled Cognitive Loss/Dementia, initiated 12/30/24 indicated Resident 120 was unable to make daily decisions without cues and supervision, with a goal date of 4/2/25. Interventions included giving feedback when an inappropriate decision was made. A review of physician orders dated 6/7/24 indicated Resident 120 should inhale 2 puffs of budesonide formoterol (Symbicort) twice daily and rinse his mouth after use. The order did not include the medication could be kept at bedside. A review of physician orders, dated 1/6/25, indicated Resident 120 should take a Tums 500 mg tablet three times daily. The order indicated Tums tablets could be kept at Resident 120's bedside. No physician order for the use of biofreeze was available for review. Progress notes, dated February 1 through March 12, 2025, did not include documentation regarding self -administration of medications. A document titled Medication Self Administration Request/Evaluation, dated 10/29/24, indicated Resident 120 was evaluated for his ability to safely administer and store his Tums. No further self-administration evaluations were available for review. In an interview, on 3/6/25 at 2:23 PM, the Director of Nursing indicated residents should be assessed for the ability to self-administer and properly secure medications at bedside. She indicated only medications with specific orders to be kept at bedside should be stored at bedside in a lock box. She indicated medications should not be left out in the room unattended. A current policy, dated 12/1/07, provided by The Director of Nursing on 3/6/25 at 2:38 PM, indicated to ensure safe and appropriate self-administration of medications the facility should educate residents and ensure they could correctly store their medications in a locked compartment. The policy also indicated the facility should list all medications the resident may self-administer. The policy indicated the facility should routinely assess the resident's cognitive, physical, and visual ability to carry out the responsibility of self-administration. Self-administered medications should be kept locked in a storage compartment in the resident's room, so another resident was not able to access the medications. 3.1-25 (m)

Based on observation, interview, and record review the facility failed to provide personal care and hygiene to dependent residents for 4 of 34 residents reviewed. (Resident 122, Resident 27, Resident 72, and Resident 113). Findings include: 1) During an observation and interview, on 2/22/24 at 10:08 A.M., Resident 122 in her room indicated she had a very hard time getting her teeth brushed. She indicated staff were too busy to assist her with brushing her teeth at night and reluctant to do it during the day. Resident 122 was observed dressed in a hospital gown. She indicated if she were able to dress herself there was no way she would be dressed in a hospital gown, but she had no choice and being dressed in the gown was the least of her concerns. Resident 122's record was reviewed on 2/23/23 at 11:16 A.M. Resident 122 diagnoses included history of stroke affecting dominant right side, paralysis of right side of body, respiratory failure, heart disease, muscle weakness, anemia, and unsteadiness in her feet. Resident 122's MDS (Minimum Data Set) comprehensive assessment, dated September 2023 indicated Resident 122 had no cognitive decline at time of assessment, required extensive assistance with personal hygiene such as brushing teeth, but applying make up and washing her face was assessed as supervision. Resident 122's care plan indicated a problem with impaired dental hygiene due to required assistance with activities of daily living related to stroke and right-side paralysis. One of the approaches was to assist Resident 122 with oral care. Resident 122 also had the problem of required assistance with activities of daily living including bed mobility, eating, and toileting. Two of the interventions were to assist with oral care at least two times daily and assist with dressing as needed. 2) During a resident council meeting on 2/23/24 at 1:49 P.M., Resident 27 indicated he was soaked every night. Resident 27 indicated he was informed by a CNA, when he put on his call light to be changed after waking up wet, his peer had fallen, and she would be with him as soon as possible. Resident 27 indicated the CNA did not return. Resident 27's record was reviewed on 2/27/24 at 9:16 A.M. Resident 27's diagnoses included cerebral palsy, diabetes, bipolar disorder, vascular disease, edema, and lack of coordination. Resident 27's MDS comprehensive annual assessment dated [DATE] indicated he had no cognitive decline, and was frequently incontinent of both bowel and bladder. Resident 27's care plan, dated 6/9/21, indicated a problem of urinary incontinencedue to diabetes, diuretics, and antipsychotic medications. Interventions, dated 6/9/21, was to assist with incontinent care as needed, assist with toileting upon rising, before or after meals, at bedtime, and as resident requests. The care plan indicated Resident 27 was at risk for skin breakdown. Interventions dated 6/9/21, was encourage Resident 27 to turn and reposition at least every 2 hours, provide assistance as needed. The care plan, titled ADL (Activities of Daily Living), dated 6/9/21, indicated Resident 27 required assistance with toileting. 3) During a resident council meeting, on 2/23/24 at 1:49 P.M., Resident 72 indicated he was frequently wet often soaking his brief and bed. Resident 72 indicated he was wet about everyother day or more. Resident 72 indicated he complained about being wet, it was a problem everyone knew about, it was ongoing, and frequent. Resident 72 indicated he voiced his feelings of frustration and was unable to come up with a solution himself describing some steps he took such as not drinking after 7 P.M. rather than taking medication. During an observation on 2/27/24 at 4:39 A.M., Resident 72's brief was soaked and was wet through a pad under him. Resident 72's record was reviewed 2/27/24 at 10:18 A.M. Resident 72's diagnoses included a nerve disease (myasthenia gravis), seizures, stroke affecting right dominant side, diabetes, vascular disease, and hypertension. Resident 72's MDS comprehensive annual assessment dated [DATE] indicated no cognitive decline, required substantial/maximal assistance toileting, substantial/maximal assistance dressing, and was frequently incontinent of both bowel and bladder. Resident 72's care plan, dated 5/16/24, indicated a problem of requires assistance and/or monitoring am/pm care, with the goal resident would have ADL needs met. The care plan indicated the residnet required assistance with ADLs dated 6/26/20, interventions were to assist with toileting and/or incontinent care as needed. The care plan indicated Resident 72 was at risk for skin breakdown dated 6/26/20. Interventions included to encourage the resident to turn and reposition at least every 2 hours, provide assistance as needed, and give incontinent care as needed using peri wash and moisture barrier. 4) During an observation, on 2/27/24 at 4:46 A.M., Resident 113 was observed with a bulging brief. Yellow liquid was observed on the blue pad under the resident. Resident 113's record was reviewed 2/27/24 at 11:12 A. M. Resident 113's diagnoses included arthritis, failure to thrive, hypertension, depression, muscle weakness, contracture, chronic pain, and history of fractures. Resident 113's MDS comprehensive assessment dated [DATE] indicated mild cognitive decline, the resident required extensive assistance with toileting, and was frequently incontinent of bowel and bladder. Resident 113's care plan dated 7/12/23, indicated required assistance with toileting due to incontinence. Interventions included: assist with incontinent care as needed, assist with toileting upon rising, before or after meals, at bedtime, and as needed, ensure the resident was toileted overnight. The care plan indicated the resident required assistance with ADLs. Interventions, dated 7/12/23, indicated to assist with bed mobility, and assist with toileting and or incontinent care as needed. Grievances indicated 2 grievances for lack of ADL care. Dated 12/18/23 for delayed call light response time and staff not toileting timely, the resident was left in clothes from the day before. Another grievance dated 9/17/23 indicated a resident was in the same clothes from Friday to Sunday, and was found in soiled underwear. The resident was to be wearing briefs, not underwear. In an interview on 2/27/24 at 4:56 A.M., CNA 3 (Certified Nurse Aid) indicated she was the regular staff who works the 200 hall. She indicated she was aware of staff in the past who would decline to work the hall to the point of clocking out and going home because it was so heavy. She indicated 22 or 23 residents the majority were check and change. She indicated she was usually the only staff (other than the nurse)scheduled on the hall able to complete the required 3 checks per night only by starting at 10pm, the very beginning of her shift. CNA 3 indicated the nurse usually helped with the first and second bed checks depending on how the night went. CNA 3 explained some of the residents were too heavy or required 2 people, so she would have to go to another hall to obtain help. She explained she was unable to go to the closest hall, it was also very heavy with lifting and tasks. CNA 3 indicated she would also be required to help other halls becasue it was just as heavy and there was only 1 CNA scheduled on that hall as well. In an interview, on 2/27/24 at 5:06 A.M., LPN 4 (Licensed Practical Nurse) indicated she had been in the building since 2 P.M. the day before due to call offs. LPN 4 indicated she had not been much help to the CNA on third shift. The CNA task sheets, dated 2/27/24, received from the ADON (Assistant Director of Nursing) indicated the 100-hall had 20 residents with needs for toileting throughout the night, and the 200-hall had 17 residents with needs for toileting throughout the night. Two residents of the 17 were 2 person assists. In an interview on 2/28/24 at 9:18 A.M., the ADON (Assistant Director of Nursing) indicated the staffing for third shift was different. She indicated the 100/ 200 halls were scheduled 1 CNA each. The cottage had (2) CNA's, 300/500 hall shared a CNA, 600/700 Hall shared a CNA, and 800/900 hall shared a CNA for a total of 7 CNAs. The nursing and QMAs were the same, for a total of 11 staff in the building. If more than 7 CNAs showed up to work, they would be down staffed and if less showed up they would pull from the cottageor used the on-call schedule. A policy titled Resident Rights last updated 07/23, provided by the ADON on 2/27/24 at 12:42 P.M., indicated residents have the right to receive the services and/or items included in the plan of care have a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely. 3.1-38(3)

Based on observation, interview, and record review the facility failed to document mental health diagnoses and identify triggers of the resident's behaviors for 3 of 3 residents reviewed for behavioral and emotional health services (Residents 25, 100, 126). Findings include: 1. On 2/17/23 at 9:37 AM Resident 25 was observed to have a flat affect. The resident made brief eye contact then looked away. She did not respond verbally. On 2/17/23 at 11:34 AM a record review indicated Resident 25's diagnoses included Alzheimer's, bipolar disorder, insomnia, restlessness and agitation, anxiety, unspecified psychosis, suicidal ideations, depressive disorder, and conversion disorder with mixed symptom presentation. A quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had no cognitive deficit. The MDS indicated the resident did not display any behaviors. A care plan problem for mood state dated 8/15/22 indicated the resident was at risk for signs and symptoms of depression. The focus indicated the resident had diagnoses of depression and a history of suicidal ideations. The care plan did not include identification of triggers as an intervention. The care plan did not include interventions for suicidal ideations. A care plan problem for mood state dated 8/15/22 indicated the resident was at risk for signs and symptoms of anxiety. Signs and symptoms included worried facial expressions, repetitive movements, sweating, shaking/tremors, irritability, racing thoughts, insomnia, increased worry, poor appetite, and tearfulness. The care plan interventions did not include identification of triggers. A hospital discharge summary dated 8/15/22 indicated the resident voiced suicidal ideations during her hospital stay. A social service assessment dated [DATE] indicated the resident had a history of suicidal ideation. During an interview on 2/22/23 at 11:35 AM, the Social Service Assistant indicated a diagnosis of conversion disorder should be on the care plan. She indicated triggers for behaviors should be attempted to be identified and placed on the care plan. She indicated a history of suicidal ideation should be on the care plan. She indicated racing thoughts, sweating, irritability, insomnia, and tearfulnessshould be on the cae plan. She indicated staff should attempt to determine the resident's triggers of symptoms and/or behaviors. She indicated behaviors were monitored at monthly behavioral reviews. During an interview on 2/23/23 at 9:33 AM, the Social Service Director (SSD) provided a social service assessment. The social service assessment dated [DATE] at 5:19 PM indicated the resident had a history of talking about suicide but had made no comments or attempts in the last 7 months. The assessment did not include conversion disorder as a diagnosis. She provided 3 behavioral health monthly reviews. The first behavioral health monthly review had an observation date of 12/9/22 at 5:16 PM, but the recorded and completed dates were 2/22/23 at 5:17 PM. The second behavioral health monthly review had an observation date of 1/6/23 at 5:14 PM, but the recorded and completed dates were 2/22/23 at 5:15 PM. The third behavioral health monthly review had an observation date of 2/22/23 at 5:18 PM with recorded and completed dates of 2/22/23 at 5:19 PM. The monthly reviews did not include suicidal ideation or conversion disorder as diagnoses. She provided page 6 of the resident's care plan. She reviewed a care plan problem dated 8/15/22. The care plan focus indicated the resident was at risk for signs and symptoms of depression, had diagnoses of depression and a history of suicidal ideation. She indicated there were no care plan interventions for suicidal ideations. She indicated there should have been interventions for suicidal ideation. She provided a psychiatric Nurse Practitioner progress note. She indicated since the NP's primary diagnosis for Resident 25 was Alzheimer's she believed all other mental disorders and behaviors could be covered under dementia on the resident's care plan. 2. A record review on 2/17/23 at 12:04 PM indicated Resident 100 had a diagnosis of adjustment disorder. A quarterly MDS assessment dated [DATE] indicated the resident had mild cognitive deficit. The MDS indicated the resident had a diagnosis of adjustment disorder. The MDS indicated the resident exhibited behaviors of verbal aggression towards others. A care plan problem for psychosocial wellbeing dated 11/17/22 indicated the resident had unsettled relationships with staff related to recent allegations of abuse. The care plan indicated the resident had a diagnosis of adjustment disorder and had explosive outbursts directed at staff. The care plan interventions did not include attempts to identify triggers to the resident's behaviors. During an interview on 2/22/23 at 11:35 AM, the Social Service Assistant indicated triggers for behaviors should be attempted to be identified and placed on the care plan. She indicated all residents are screened upon admission. During an interview on 2/23/23 at 9:55 AM, the SSD presented page 5 of the resident's care plan. She reviewed a problem of psychosocial wellbeing. The problem indicated the resident had unsettled relationships with staff due to allegations of abuse. The resident was followed by psychiatric services, and the resident had a diagnosis of adjustment disorder. She indicated the care plan interventions did not include attempting to identify triggers for the resident's behavior. 3. A record review on 2/17/23 at 1:45 PM indicated Resident 126 had diagnoses of unspecified dementia, anxiety, restlessness and agitation, insomnia, psychotic disturbance, mood disturbance, and adjustment disorder with mixed disturbance of emotions and conduct. A care plan problem dated 7/11/22 titled behavioral symptoms related to anxiety indicated the resident exhibited worried facial expressions, repetitive movements, shortness of breath, nausea, sweating, tremors, irritability, restlessness, and insomnia. Interventions did not include to attempt to identify triggers of the resident's symptoms. The resident's care plan did not address adjustment disorder. A quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive deficit. The MDS indicated the resident did not exhibit any behaviors. The MDS indicated the resident's diagnoses included non-Alzheimer's dementia, anxiety, and adjustment disorder with mixed disturbance of conduct and emotions. During an interview on 2/22/23 at 11:35 AM the Social Service Assistant indicated a diagnosis of adjustment disorder should be on the care plan. She indicated triggers for behaviors should be attempted to be identified and placed on the care plan. She indicated racing thoughts, sweating, irritability, insomnia, nausea, shortness of breath, and tearfulness should be on the care plan. She indicated all residents are screened upon admission. She indicated the assessments could be located under the observation tab and would be titled ASC Social Service Assessment. She indicated staff should attempt to determine the resident's triggers of symptoms and/or behaviors. She indicated behaviors were monitored at monthly behavioral reviews. A review of the resident's record did not indicate a social service assessment had been completed. On 2/23/23 at 9:55 the SSD provided a social service assessment dated [DATE] at 4:17 PM. The assessment indicated the resident had current diagnoses of adjustment disorder, dementia, anxiety, and insomnia. During an interview on 2/23/23 at 11:00 am the SSD provided a psychiatric Nurse Practitioner progress note dated 1/24/23 at 8:39 AM. She indicated since the NP did not list the resident's diagnosis of adjustment disorder, she believed all other mental disorders and behaviors could be covered under dementia on the resident's care plan. A current policy titled Behavioral Health dated 10/22 provided by the Assistant Director of Nursing (ADON) on 2/22/23 at 1:53 PM indicated residents will be referred to behavioral health providers based on person centered assessment for situations such as mental health disorders, psychotropic medication management, behavior intervention development, substance use disorders, trauma assessment/care plan development and/or adjustment or mood issues. A current policy titled Behavior Management dated 7/1/22, revised 8/22 and 10/22 provided by the SSD on 2/23/23 at 9:33 AM indicated care plans should include individualized interventions that are proactive and responsive. The policy indicated residents with known behaviors would have a monthly review to determine if interventions for behaviors are current and effective. 3.1-43(a)(1)

Based on interview and record review the facility failed to ensure timely assessments for weight loss for 1 of 4 residents reviewed. (Resident 118) Findings include: Resident 118's recorded review began on 02/22/23 at 10:12 AM. Diagnosis included dysphagia, dehydration, and anorexia. Resident 118's physician orders included; ice cream at lunch, update weight due to weight loss, daily weight x7 to establish baseline weight, mirtazapine 15mg tablet at bedtime for anorexia, offer bedtime snack, weekly weights x4, and ensure plus. Resident 118's record indicated he was in hospital from 12/5/22 to 12/21/22 and from 1/5/23 to 1/7/23. A review of the Medication Administration Record (MAR) dated February 2023 indicated on night shift there were 2 times the bedtime snack was not documented as offered. There was no documentation of readmit weight or refusal on 12/21/22. There were no weights documented from 11/7/22 to 1/3/23. Weight was documented on 11/7/22 as 221. On 1/3/23 weight was documented as 184. A 37-pound (16%) weight loss in 2 months. Progress noted indicated Resident 118 was seen by a physician on 12/5/23 prior to discharge to the hospital for increased weakness and lab results. No order for routine weights was documented. The Physician saw Resident 118 on 12/22/23 after return from hospitalization on [DATE]. Resident 118's weight was not addressed during the assessment, nor documentated on return to the facility. Resident 118 was seen by the physician on 12/27/22. Resident 118's poor appetite and intake were not mentioned. Resident was seen on 12/29/22 for lab follow up. His weight was not addressed. Resident 118 was seen on 1/2/23 for follow up. During the assessment on 1/2/23 physician addressed the apparent weight loss and requested a weight. Resident 118 had an interdisciplinary team meeting on 1/2/23 regarding an are to his right upper great toe. During this meeting it was documented there were no nutritional concerns. Resident 118 was seen by the physician on 1/3/23 for a follow up visit. The physician documented the facility had obtained an updated weight. He suspected the redident had a large weight loss. The loss was obvious in his face and his abdominal area. A lot of this was likely due to the prolonged hospitalization for oral intake and recent GI surgery. Resident 118 was reviewed by the RD (Registered Dietician) on 1/5/23. It was documented he had intermittent periods of NPO (nothing by mouth) status while hospitalized and meal intakes were decreased. There was no documentation of Resident 118's current weight or a plan to stabilize his weight. Resident 118's chart was reviewed on 1/23/22 by the dietician who documented Resident 118's weight was stable. Resident 118 was reviewed by the interdisciplinary team on 2/8/23 regarding significant weight loss. Resident 118's nutritional assessments were as follows: Dated 10/11/22, Resident 118 was trending weight loss Dated 10/21/22, Resident 118 had no significant weight loss There was no documentation of nutritional assessments available for the months of November or December. Dated 1/3/23, Resident 118 had less than 75% intake on breakfast, lunch, and dinner, Ensure and Remeron were ordered, and weight loss discussed. A Dietician review dated 1/5/23 indicated he refused his readmission weight, his weight loss was attributed to hospitalization and medical issues. The review noted Resident 118 was not having decreased appetite. On 1/13/23, meal intake was above 75%, the resident was still on ensure twice daily, and there was no weight loss. In an interview on 2/22/23 at 11:02AM, the Regional Registered Dietician and the facility RD (Registered Dietician) indicated anytime a resident was in the hospital over 24hrs they were to be weighed weekly x4 weeks on return. The RD indicated there were no weights documented upon Resident 118's return from the hospital on 12/21/22. In an interview 2/22/23 at 12:16PM, the Regional RN (Registered Nurse) indicated there were no weights documented for Resident 118 upon return from the hospital or for the following week. A current policy titled Resident weight monitoring indicated . residents will be weighed no less thean monthly or per physician's orders. and . upon admission, the resident's weight . will be recorded. 3.1-46

Based on interview and record review the facility failed to ensure trauma informed care was implemented for 1 of 3 residents reviewed. (Resident 72). Findings include: Resident 72's recorded review began on 02/22/23 at 09:25 AM. The record indicated diagnosis included bipolar disorder, post-traumatic stress disorder (PTSD), anxiety disorder, and panic disorder. Resident 72 went to [NAME] Center for psychiatric services with phycologist Dr.[NAME], in November of 2022. A facility note indicated the appointment was for pain management. Dr [NAME] was not a pain management doctor. The next appointment at [NAME] Center with same psychologist was in January of 2023. Office visit notes were not available at time of survey. In an interview , on 2/22/23 at 2:16PM, the ADON (Assistant Director of Nursing) indicated Resident 72's notes from the visit in January 2023 were not available due to the need for a medical request to be sent to [NAME] Center to release the records . The necessary paperwork had not been filed. There was no request for information to provide continuity of care for psychological disorders to Resident 72. Resident 72 had the following orders: any/all changes of psych meds must be approved by Dr. [NAME] at [NAME] Center, divalproex delayed release 500mg tabled twice daily for bipolar disorder, bupropion 75mg tablet twice a day for depressive disorder, Celexa 20mg and 40 mg tablets (to give 60mg) daily for depressive episodes, hydroxyzine 50mg twice daily for anxiety disorder, and monitoring for significant side effects of the medications listed. Resident 72's current MDS (Minimal Data Set) assessment indicated the following: Section C BIMS (Brief Interview for Mental Illness) score was 15, signified no cognitive disfunction. Section D Mood indicated he felt down, depressed, or hopeless 7-11 days; and was moving or speaking slowly or fidgeting for 7-11 days; in previous 14 days of assessment. Section E Behavior, indicated no hallucinations, delusions, aggression, threatening, physical symptoms, rejection of care, or wandering in previous 14 days of assessment. Section I Active Diagnosis indicated medical diagnosis, anxiety disorder, depression, bipolar disorder, schizophrenia, and post-traumatic stress disorder. Schizophrenia was not listed in Resident 72's chart under diagnosis, face sheet, CCD (Continuity of Care Document), and physician orders sheet. Schizophrenia was listed in physician provider progress notes. Resident 72's current care plan indicated the following problems with the goal and interventions: Problem: Resident was at risk for potential physical aggression, psychotic features, mood changes. Diagnosis PTSD, Bipolar, Schizoaffective disorder and receives mood stabilizing medications. Goal: would not display changes in mood, psychotic features, physical aggression through next review. Approaches: document behavior, assess any physical cause, provide personal space, provide reassurance/comfort/validate feelings. Problem: Resident preference to keep his room door open, feels claustrophobic when door is shut too long due to diagnosis bipolar, anxiety, PTSD, and schizoaffective disorder. Goal was to Honor resident's preferences to keep door open when using his c pap machine while sleeping over next review. Approach was to honor resident's preferences and keep room door open for resident. Problem: Resident had been determined mentally ill per level 2 assessment. Level 2 diagnosis was bipolar, depressive disorder, and PTSD. Goal was Resident would have mental health needs met through next review. Approach was to provide mental health services, rehab services, socialization, leisure, recreation, and supportive counseling from staff. There were no documented specific problems related to PTSD triggers, symptoms, goal, approaches. In an interview on 02/22/23 at 11:08 AM, SS 2 (Social Services) indicated the level 2, anxiety, physical aggression, and mood changes were care planned. SS2 indicated Resident 72 should have been care planned specifically for PTSD and indicated she would do so. SS2 indicated the care plan was a tool to address needs of the resident and inform staff best way to provide care. SS2 indicated Resident 72 presented with shortness of breath, was easily agitated, had control issues, breathing rate would increase, became easily angered, and panicked when having psych issues. SS2 indicated Resident 72 had confided in her just last week regarding the PTSD cause. She indicated the only symptom Resident 72 was able to link to the PTSD was waking up from a bad night. He did not identify any triggers and expressed a feeling of safety overall. SS2 was able to link Resident 72's dislike of staff touching and need to shower self in front regardless of thoroughness. SS2 indicated Resident 72 no longer saw facility psych provider because he did not trust them to not change his medications. SS2 indicated Dr. [NAME] attempted to put Resident 72 back on Seroquel in November and he has not been able to do so. On 2/22/23 at 1:53 PM, a current policy and procedure titled Trauma Informed Care, revised October 2022, was provided by ADON indicated; Resident who are trauma survivors receive culturally competent trauma-informed care . and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. For the resident to feel safe in their environment and trust caregivers despite past trauma .trauma informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies and procedures and practices to avoid re-traumatization.3 .this plan of care will incorporate individual experiences, customary routines, and cultural preferences of the individual's needs. On 2/22/23 at 1:53 PM, a current policy and procedure titled IDT (inter disciplinary team) Comprehensive Care Plan Policy, revised October 2019, was provided by ADON indicated . The care plan will include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial needs . On 2/22/23 at 1:53 PM, a current policy and procedure titled Behavior Management, revised August 2011, was provided by ADON indicated;7. Direct care staff will be educated as to the interventions for resident reviewed by IDT. No state rule applies.

Based on interview and record review, the facility failed to ensure non-pharmacological interventions were implemented and pain level was assessed prior to administering pain medication for 1 of 2 residents reviewed. (Resident 57) Resident 57's record was reviewed on 2/21/2023 at 11:26 AM. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries, type 2 diabetes mellitus with hyperglycemia, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, end stage renal disease, gout, unspecified, presence of cardiac and vascular implant and graft, unspecified, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic chronic kidney disease. A Minimum Data Set (MSD) assessment, dated 01/11/2023, indicated Resident 57 had a brief interview for mental status (BIMS) score of 11 (moderate cognitive impairment). A physician's order, dated 9/24/2021, indicated to give Acetaminophen tablet 325 milligrams (mg) (over the counter medication to treat pain or fever), give 650mg oral (by mouth) every 6 hrs. (hours) prn (as needed). Do not exceed 4 grams of Acetaminophen from all other sources. A physician's order, dated 6/23/2022, indicated to give Hydrocodone-Acetaminophen Schedule II tablet 5-325mg (opioid pain medication), give 5-325mg orally 6 hrs. prn. Resident 57's orders did not include an order to implement non-pharmacological interventions prior to administering a pain medication. A current care plan, dated 6/14/2021, indicated Resident 57 was at risk for pain related to: tooth extractions (removals), decreased mobility, CVA (stroke) with right side hemiparesis (weakness on the right side of the body), coronary artery disease (heart disease), diabetes mellitus type II ( an impairment in the way the body regulates and uses sugar), end stage renal disease (kidneys not functioning), anemia (low red blood cell count), dependence on renal dialysis ( a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), depressive episodes, gastro esophageal reflux disease ( heartburn), dry eye syndrome, gout (a form of arthritis, which brings on sudden, severe attacks of pain, swelling, redness, and tenderness in one or more joints, most often the big toe), obstructive uropathy (when urine cannot drain through the urinary tract) with a suprapubic catheter (tube inserted into the bladder through the lower abdomen to drain urine), peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the arms and legs), cardiomyopathy (a disease of the heart muscle which causes the heart to lose its ability to pump blood efficiently), and hyperlipidemia (high concentration of fat in the blood). The goal indicated Resident 57 would be free from adverse effects of pain. The interventions included: administer medication as ordered, assist with positioning to comfort, document effectiveness of prn medications, notify the medical doctor (MD) if pain was unrelieved and/or worsening, observe for adverse effects of pain medication including, but not limited to, over sedation, constipation, skin rash, nausea/vomiting, loss of appetite, change in mental status, stomach upset, document abnormal findings and notify the MD, observe for nonverbal signs of pain: changes in breathing, vocalizations (speaking out loud), mood/behavior changes, eyes change expression, sad/worried face, crying, teeth clenched, changes in posture, and offer non pharmacological interventions such as quiet environment, rest, shower, back rub, repositioning. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated January 2023, indicated Resident 57 received Acetaminophen 650mg on 1/2/23 at 5:40 PM, 1/5/23 at 5:41 PM, 1/7/23 at 3:49 AM, 1/11/23 at 5:10 AM, 1/12/23 at 7:14 PM, 1/16/23 at 5:07 AM, 1/17/23 at 2:49 AM, 1/18/23 at 3:48 AM and 5:47 PM, 1/19/23 at 4:12 AM and 6:09 PM, 1/21/23 at 4:40 AM, 1/22/23 at 4:12 AM, 1/26/23 at 5:04 AM, 1/27/23 at 5:05 AM, 1/30/23 at 7:46 PM, and 1/31/23 at 4:59 AM. The MAR and TAR, dated February 2023, indicated Resident 57 received Acetaminophen 650mg on 2/1/23 at 4:01 AM, 2/6/23 at 4:48 AM, 2/8/23 at 4:33 AM, and 2/9/23 at 6:52 PM. Resident 57's MARs and TARs, dated January 2023 and February 2023, contained no documentation regarding the nonpharmacological interventions attempted prior to administering Acetaminophen to Resident 57. Resident 57's MARs and TARs, dated January 2023 and February 2023, contained no documentation of Resident 57's pain level prior to administering Acetaminophen. The MAR and TAR, dated January 2023, indicated Resident 57 received Hydrocodone-Acetaminophen 5-325mg on 1/8/23 at 2:35 PM, 1/24/23 at 2:38 PM and 8:10 PM, 1/27/23 at 7:29 PM, 1/28/23 at 11:19 AM, 1/29/23 at 8:33 AM and 4:09 PM, 1/30/23 at 3:36 PM, and 1/31/23 at 12:10 PM. The MAR and TAR, dated February 2023, indicated Resident 57 received Hydrocodone-Acetaminophen 5-325mg on 2/1/23 at 5:01 PM, 2/3/23 at 7:29 PM, 2/5/23 at 10:07 AM, and 2/5/23 at 6:38 PM. Resident 57's MARs and TARs, dated January 2023 and February 2023, contained no documentation regarding the nonpharmacological interventions attempted prior to administering Hydrocodone-Acetaminophen to Resident 57. Resident 57's MARs and TARs, dated January 2023 and February 2023, contained no documentation of Resident 57's pain level prior to administering Hydrocodone-Acetaminophen. A review of Resident 57's vital sign documentation, dated January 2023, indicated no documentation of pain level. Resident 57's vital sign documentation, dated February 1- 21, 2023, contained documentation of Resident 57's pain level at 0 of 10 on 2/21/2023 at 8:06 AM. No other documentation of pain level was found in the February 2023 vital sign section of Resident 57's record. A review of Resident 57's progress notes, dated 1/1/23-2/22/23, indicated no documentation of the nonpharmacological interventions attempted prior to administering Acetaminophen. A review of Resident 57's progress notes, dated 1/1/23-2/22/23, indicated no documentation of Resident 57's pain level prior to administering Acetaminophen. A review of Resident 57's progress notes, dated 1/1/23-2/22/23, indicated no documentation of the nonpharmacological interventions attempted prior to administering Hydrocodone-Acetaminophen. A review of Resident 57's progress notes, dated 1/1/23-2/22/23, indicated no documentation of Resident 57's pain level prior to administering Hydrocodone-Acetaminophen. In an interview on 2/22/23 at 10:10 AM, LPN 7 indicated if a resident had several pain medications ordered, she would administer the medication based on the resident's pain level. She would administer the stronger pain medication if the resident had a high pain rating. LPN 7 indicated she would document the resident's pain rating, based on a scale 1-10, location of the pain, and a description of the pain. LPN 7 indicated she would reassess the resident's pain 30-45 minutes after administering the pain medication and would document the effectiveness. LPN 7 indicated that documentation of pain assessment was done on the MAR or in a progress note with each administration of a pain medication. In an interview on 2/22/23 at 3:46 PM, the Regional Nurse indicated documentation of a resident's pain level was not done in the vital sign section of the resident's record. She indicated an agency nurse might have documented Resident 57's pain level in the vital sign area due to documenting a resident's pain level in the vital sign section in other facilities. The Regional Nurse indicated a resident's pain assessment was done on the MAR. In an interview on 2/23/23 at 9:50 AM, the Regional Nurse indicated implementing nonpharmacological interventions before giving pain medication was considered a standard of care. She indicated the nonpharmacological interventions were not documented because nurses do not document interventions that were considered standard of care. The Regional Nurse indicated that nurses did not have the time to document all interventions that are considered standard of care. 3.1-37(a)

Based on interview and record review, the facility failed to ensure Resident Council grievances were resolved in a timely manner for 5 of 7 months reviewed. Finding include: On 1/11/23 at 3:59 P.M., the Resident Council President was interviewed. During the interview, he indicated there had been several grievances brought up by members of the Resident Council during the past several months. The concerns had not been resolved. The grievances included, cold food on room trays, long call light response times, and lack of linens. When questioned, he indicated Resident Council didn't receive written responses to their concerns although they talked about the same issues month after month. Resident Council meeting minutes reviewed indicated the following concerns: -July 2022: 600 hall call light times were long on 3rd shift. -August 2022: Call lights took forever; long wait for care especially on the weekends; and staff were throwing away linens causing a shortage. -September 2022: Continue with long wait times for call lights to be answered; showers not consistently done on weekends; food on room trays were cold due to meals being in the hall carts too long; more towels, washcloths and linens were needed-staff were throwing them away. -October 2022: Continue with long call wait times; agency staff were not good; linens were short at all times even though staff were working on this issue. -November 2022: Long call wait times especially on night shift; not getting showers at times; some meals were hot, others cold; food on room trays served on the 200 hall was not very hot; there was not enough washcloths, especially on the evening shift; and new linens were needed-there was not enough. -December 2022: Food on room trays were cold. -January 2023: Food on room trays were cold; still not enough linens in the morning. On 1/12/23 at 2:04 P.M., the Social Services Director for long term care residents was interviewed. She indicated following Resident Council meetings, she would report concerns but wasn't aware of the process for resolution of the grievances after she notified the Administrator. She indicated the facility had a Resident Council meeting follow up form but wasn't used consistently. She had 1 of these forms completed for a September grievance but had no others for the remaining months reviewed. The Resident Council meeting follow up form, dated 9/7/22, indicated a concern with long call lights at times and need for help in the main dining room. The action taken response was not dated and read that call lights were being answered better and the main dining room had more help when the overhead page was used to tell staff help was needed. A current policy, titled Resident Council was provided by the SSD on 1/12/23 at 2:04 p.m. and stated: The facility will promote and support the residents' right to participate and organize resident council. The council will be used to communicate concerns, give suggestions for future programming and events, and otherwise participate in and guide facility life .Procedure: 6. Concerns or suggestions from the meeting will be addressed by the appropriate department. The Executive Director will review all minutes and concerns to ensure thorough resolution of concerns. The facility responses to concerns/suggestions will be reviewed by the Resident Council President and the resident council on their next meeting This Federal tag relates to Complaint IN00395621. 3.1-3(l)

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for 1 of 2 residents reviewed (Resident F). Findings include: An Indiana report form, submitted by the facility, on 12/30/22 at 1:30 p.m., indicated potential misappropriation of resident property had occurred and the facility was investigating the allegation. On 1/13/23 at 9:45 A.M., Resident F's record was reviewed. The resident had been admitted for short term rehabilitation following hospitalization and had brought her home medications with her when she arrived to the facility. On 1/12/23 at 2:20 P.M., the Interim Director of Nursing Services (DNS) was interviewed. She indicated when Resident F was admitted , she had Percocet (narcotic pain medication) with her in a pale yellow envelope. The envelope holding the narcotics was placed in the locked medication room but were not double locked. The resident discharged on [DATE]. Prior to leaving the facility, staff were unable to locate the Percocet. The facility conducted an investigation which included review of security cameras. The DNS indicated the camera footage showed an agency nurse put the bottle of Percocet into her pocket. The appropriate agencies were notified and the agency nurse would no longer be allowed in the facility. A current facility policy, titled Abuse Prohibition, Reporting, and Investigation, was provided by the Administrator on 1/10/23 at 12:25 p.m. and stated the following: It is the policy of American Senior Communities to provide each resident with an environment that free from abuse, neglect, misappropriation of resident property, and exploitation This Federal tag relates to Complaint IN00398288. 3.1-28(a)

Based on interview and record review, the facility failed to ensure reconciliation and proper storage of a controlled substance for 1 of 1 residents reviewed for pharmacy services (Resident F). Findings include: An Indiana report form, submitted by the facility, on 12/30/22 at 1:30 p.m., indicated potential misappropriation of resident property had occurred and the facility was investigating the allegation. On 1/13/23 at 9:45 A.M., Resident F's record was reviewed. The resident had been admitted for short term rehabilitation following hospitalization and had brought her home medications with her when she arrived to the facility. On 1/12/23 at 2:20 P.M., the Interim Director of Nursing Services (DNS) was interviewed. She indicated when Resident F was admitted , she had Percocet (Schedule II controlled narcotic pain medication) with her in a pale yellow envelope. The envelope holding the narcotics was placed in the locked medication room and staff were instructed to send the medication home as they would not be used while at the facility. The medication was not placed in a 2nd secured container in the medication room and was not reconciled (A system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered and/or, are in the process of disposition to prevent loss or diversion of the controlled medication) nor sent home. The resident discharged on [DATE]. Prior to leaving the facility, staff were unable to locate the Percocet. The facility conducted an investigation which included review of security cameras. The DNS indicated the camera footage showed an agency nurse put the bottle of Percocet into her pocket. She indicated the controlled pain medication had not been reconciled initially nor periodically following placement in the medication room nor had it been placed in a 2nd secured container but should have been. Nursing staff were to reconcile controlled medications at the end of their shift with the oncoming nurse to ensure accurate medication counts and prevent loss or diversion of these medications. On 1/13/23 at 9:17 A.M., the Administrator provided a current copy of the facility's policy, titled Storage and Expiration of Medications, Biologicals, Syringes and Needles which stated the following: General Storage Procedures: Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device This Federal tag relates to Complaint IN00398288. 3.1-25(e)(2) 3.1-25(n)

Based on interview and record review, the facility failed to assess for a urinary tract infection (UTI) in a resident with an indwelling catheter and history of UTI's for 1 of 3 residents reviewed (Resident D). Findings include: On 1/11/23 at 12:35 P.M., Resident D's record was reviewed. Diagnoses included diabetes, dementia, urinary retention with an indwelling foley catheter, and urinary tract infection. He was hospitalized in July and September of 2022 for sepsis due to urinary tract infections. A care plan, dated 2/17/22 and revised 7/7/22, indicated Resident D had an indwelling catheter due to obstructive uropathy and was at risk for infections. Interventions included: avoid obstructions in the drainage, change catheter per physician order, encourage fluids, monitor urinary output and report signs of urinary tract infection (UTI) such as fever, new-onset low blood pressure, change in mental function, purulent discharge from catheter, or pain and swelling. Progress notes indicated the following: -7/22/22 at 1:37 p.m., the Nurse Practitioner (NP) indicated Resident D was seen urgently for increased lethargy, altered mentation, and tachycardia (fast heart rate). The resident's family member had noticed some changes in his mentation the day before. The resident appeared septic due to a UTI as a urine dip was positive for signs of infection and his urine was very cloudy in his foley catheter tubing. He was transferred to the hospital for treatment. -7/27/22 at 5:09 p.m., the resident returned to the facility from his hospital stay. He remained on antibiotic therapy for his UTI. -7/28/22 at 12:47 p.m., the NP visited the resident following re-admission to the facility. While hospitalized , Resident D had been diagnosed with sepsis, UTI, high blood sodium, acute kidney injury and toxic metabolic encephalopathy (brain dysfunction). He was treated for urinary obstruction and catheter not draining. He was given antibiotics, IV fluids, and his kidney function was closely monitored. He improved and returned to the facility. He was to follow up with urology and have his foley catheter changed each month. -8/15/22 at 1:24 p.m., the NP visited for follow up to his hospitalization in July. Since returning from the hospital, his kidney function had improved and his blood work had returned to normal. -8/18/22 at unknown time, a Urology NP note indicated the resident had been seen following recent hospitalization for UTI and sepsis in July. His catheter was observed draining clear yellow urine. The plan included to continue with foley catheter, to be changed monthly and as needed; irrigate foley daily with 60-120 milliliters of sterile water; if signs of UTI-facility was to change the foley catheter and obtain a urine culture; and stay well hydrated. -9/20/22 at 3:17 p.m., the physician indicated Resident D had been seen for a routine visit. He'd had a recent hospitalization for obstructive uropathy and UTI. No changes were made to his care plan. -9/23/22 at 7:10 p.m., the resident's blood sugar was checked before supper and was elevated. The NP was notified and new order given for fast acting insulin, 15 units to be given immediately and recheck the blood sugar in 1 hour. The blood sugar was rechecked and remained elevated and another 15 units of insulin was given. -9/24/22 at 7:30 a.m., the resident had been up in his wheelchair for breakfast and had eaten 75% of his meal and drank 360 milliliters of fluid. His blood sugar was checked and was elevated. He was given 15 units of insulin. When asked if the resident felt ok, he had responded yea. At 12:20 p.m., the resident was still seated in his wheelchair in his room and appeared pale in color, was diaphoretic (sweating heavily) but cool to touch and was lethargic. His blood sugar was checked and remained elevated. The resident's family member came into visit, indicated something wasn't right with the resident and he needed sent to the hospital immediately. The family member was concerned about his recent elevations in blood sugar, his catheter and concern for UTI's. The resident had little urinary output in the morning-approximately 30 milliliters. The NP was notified and orders given to be sent to the hospital. An NP progress note with a late entry made on 9/30/22 at 3:33 p.m., indicated the NP had received a phone call on the evening of 9/23/22 about the resident's elevated blood sugar. He was given 15 units of rapid acting insulin. Another phone call was received on the morning of 9/24/22. The nurse indicated the resident's family member was concerned that the resident wasn't acting like himself, had decreased urine output, cloudy urine, diaphoresis, and abnormal mentation. An order was given to send the resident to the hospital for treatment. Hospital records indicated Resident D was brought to the ER due to lethargy and inability to feed himself. His foley had pus coming out of it and his urinary output was decreased. He was admitted to the hospital for sepsis due to UTI and kidney infection, acute kidney failure, and urinary retention. Resident progress notes hadn't indicated the resident had been assessed for a UTI when his blood sugars became elevated on 9/23/22. A TAR (Treatment Administration Record) for September 2022, indicated by nurse initials the resident's catheter had been irrigated on that day. There was no urinary assessment completed when the resident had only 30 ml of urine in his catheter bag and no description documented of the urine which had been observed with pus while at the ER. On 1/13/22 at 11:14 A.M., Nurse 2 was interviewed. She indicated nurses were responsible for completing catheter care every shift and for assessing residents for indicators of urinary tract infections. Nurses were responsible for documenting the urinary output from a foley catheter although CNA's (Certified Nurse Assistants) were allowed to empty the catheter bags. On 1/13/22 at 11:45 A.M., the Interim Director of Nursing Services was interviewed. She indicated the facility had no specific policy for UTI assessments or catheter care. A copy of the facility nursing policy for irrigation of an indwelling urinary catheter was provided. The policy indicated after the nurse completed irrigation of a catheter, the procedure was to be documented in addition to pertinent information. This Federal tag relates to Complaint IN00396006. 3.1-41(a)(2)

Based on observation and interview, the facility failed to ensure PPE was utilized, and hand hygiene was completed for 5 of 5 residents reviewed. ( Resident 138, Resident 247, Resident 249, Resident 136 and Resident 49) Findings include: On 3/29/22 The following observations were made on the yellow zone rooms. All rooms were in Transmission based precautions (TBP): 11:51 AM, observation on 900 hall, LPN 12 exited unknown resident room with a blue gown on. LPN 12 walked down the middle of the hall, doffed the blue Personal Protective Equipment (PPE) gown in middle of hallway, rolled it up and threw it away in a trash can inside room [ROOM NUMBER]. room [ROOM NUMBER] was occupied by Resident 138 who was in transmission based precautions. 11:52 AM, observation of a random visitor wearing black scrubs walking down the hallway with a yellow PPE gown, disposable gloves, and a backpack and enter room [ROOM NUMBER]. room [ROOM NUMBER] was occupied Resident 249 who was in transmission based precautions. 11:59 AM, observation of LPN 12 donned a blue gown, entered a room [ROOM NUMBER] with a medication cup, alcohol swabs, glucometer machine and an insulin pen. Resident 49 resided in room [ROOM NUMBER] and was in transmission based precautions. At 12:02 PM, LPN 12 came out of the room, walked down the middle of hallway, doffed the blue gown, rolled it up and threw it away in Resident 138's trash can. 12:07 PM, observation of LPN 12 donned a blue PPE gown, with medication and cup entering room [ROOM NUMBER]. Resident 136 resided in room [ROOM NUMBER] and was on transmission based precautions. During this observation, the same random visitor wearing black scrubs walked through the hallway with the same yellow PPE gown and disposable gloves on. 12:10 PM, observation of LPN 12 exited the room with the blue PPE gown on, walked down the in the middle of the hallway doffed the PPE gown, rolled it up and throw it away in Resident 138's trash can. 12:14 PM, observation of LPN 12 exited Resident 247's room, walked down the middle of the hallway doffed the PPE gown, rolled it up and threw it away in Resident 138's trash can. Resident 247 was residing in room [ROOM NUMBER]. Resident 247 was in transmission based precautions. During the same observation, same random visitor wearing black scrubs came back down the hallway still with the same yellow PPE gown and disposable gloves on, and entered Resident 136's room. 12:17 PM, observation of same random visitor wearing black scrubs, exited Resident 136's room, wearing the same yellow PPE gown, walked through the facility hallways, and was observed exiting the facility. 12:25 PM, observation of 2 random visitors wearing yellow PPE gowns walking through the facility 900 hallway. 3:01 PM, observation of LPN 13 entered Resident 49's room without donning a PPE gown. 3:02 PM, observation of LPN 13 was observed re-entering Resident 49's room, exited room, went across the hallway to Resident 247's room to answer the call light, but did not don PPE gown. LPN 13 came out of room down to the dresser where PPE was located, obtained a box of gloves, then re-entered Resident 247's room but did not don a PPE gown. 3:05 PM, observation of another staff member donning a yellow PPE gown and waiting outside Resident 247's door to enter the room with LPN 13. LPN 13 was in room without a PPE gown. Other staff members are observed to be donning PPE gown before entering rooms. 3:23 PM, observation of LPN 13, at medication cart, re-adjusted face mask, did not use ABHS afterwards. Then LPN 13 dispensed medication from a packet into his bare hands and placed it into a medication cup. He then was observed to be entering Resident 49's room without donning PPE gown. 3:31 PM, observation of LPN 13, obtained a lancet form the medication cart and twisted it open with bare hands, and then pulled out a strip to use for the glucometer with his bare hands. LPN 13 did not use ABHS before or after. 3/30/22 at 9:25 AM, observation of random visitor walking through main door from front desk wearing yellow PPE gown, walking through the hallways at 10:00 AM, the random visitor with the same PPE gown on walked through the hallway, and left the facility. On 3/29/22 at 9:46 AM, in an interview, the Infection Preventionist (IP), indicated staff were to wear full PPE when providing care, so when they entered a room, they would don the PPE, and before leaving the room they would doff the gown, gloves, but keep the mask and face shield on, then use hand hygiene. Staff have been informed they should gown up anytime they go in a room because they never know what could happen. When visiting someone in the yellow zone, visitors were given a gown to put on at the front desk, they put it on at the front desk, since they don't know how to properly don PPE, they put it on at the front. They are to take off the gown before they leave them room. The 800 and 900 halls were considered yellow zone. On 3/29/22 at 10:19 AM, in an interview, the IP (Infection Preventionist), indicated the facility did not have facility polices regarding the PPE and just use the skills competency forms. On 3/29/22 at 12:26 PM, in an interview, Licensed Practical Nurse 12 (LPN), indicated when entering a yellow zone room, they were to put on a gown, gloves, N-95, hand gel when going in and out, then when exiting the room, they are to remove gown, gloves. On 3/29/22 at 3:37 PM, in an interview, LPN 13, indicated when entering a room staff would don PPE and when exiting staff should doff the gown before going into the hall. A policy was provided by Medical Records, on 4/5/22 at 11:25 AM titled Standard and Transmission-Based Precautions (Isolation) Policy. The policy indicated to implement appropriate transmission-based precautions to prevent the transmission of infection A facility skill competency, Personal Protective Equipment (PPE) donning and doffing, dated 10/2021, was provided by the IP on 3/30/22 at 10:19 AM. The form indicated .Procedure steps .Gown. 1. Perform hand hygiene. 2. Let the clean gown unfold without touching any surface. 3. Slide your hand and arms through the sleeves. Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. 4. Fasten in back of neck and waist, or tie all of the ties on the gown depending on type .Remove PPE at doorway prior to leaving resident room and perform hand hygiene. Dispose of gloves and gown prior to exiting resident room 3.1-18 (b)(1)

Based on observations, interviews, and record review, the facility failed to ensure an assistive device was utilized as ordered by the physician for 1 of 1 resident reviewed. (Resident 97) Findings include: A record review for Resident 97 began on 3/31/2022 at 10:06 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 97's current, annual MDS (Minimum Data Set) Assessment, dated 2/16/22, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 10, which indicated moderate cognitive impairment. The MDS indicated the resident required extensive assistance of one person for dressing and personal hygiene. A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 97's current care plan, provided by the MDS coordinator on 4/4/22 at 10:17 AM, indicated the resident required a palm protector to the left hand for contracture prevention. An evaluation note, by the assistant MDS coordinator, dated 2/16/22, indicated the resident continued on the splinting program for the prevention of further left hand contracture. The resident was able to tolerate wearing the palm protector, and denied pain. Skin care was provided before every shift with no signs or symptoms of skin breakdown. Review of documents titled, Approaches on Profile, referred to as Certified Nursing Assistant (C.N.A.) resident care sheets or POC (plan of care), dated 3/29/22, 3/30/22, 4/1/22, 4/4/22, and 4/5/22 provided by the Director of Nursing (DON) and the Medical Records Coordinator, indicated Resident 97's tasks included the resident would tolerate wearing the left palm protector at all times for contracture prevention, and to remove each shift for skin care. Resident 97's Treatment Administration History (TAH), for March and April 2022, provided by the Medical Record Coordinator, on 4/4/22 at 10:53 AM, showed documentation the resident wore the left palm protector at all times with skin check every shift, except for 4/4/22 and 4/5/22, 6:00 AM to 2:00 PM shift. A comment, by LPN 8, dated 4/4/22 at 7:23 AM, indicated the palm protector was placed in the resident's left palm and the resident removed it. A comment, by LPN 8, dated 4/5/22 at 6:55 AM, indicated the resident refused to put on the palm protector because it hurt too much. No other documentation of the resident removing or refusing the palm protector was noted during March and April. A record review on 4/5/22 at 9:40 AM indicated that there was no care plan in place regarding Resident 97 refusing to keep left palm protector in place. On 3/30/22 at 2:28 PM, Resident 97 was observed lying in bed, unable to move his left arm, left hand was contracted (fingers and thumb bent toward the palm of the hand). No palm protector was in the resident's left hand. Resident 97 indicated staff occasionally applied the palm protector, but not daily. No palm protector was visible in Resident 97's room. On 3/31/22 at 11:46 AM, Resident 97 was observed, seated in a Broda chair (supportive wheelchair), in the dining room. Resident 97 did not have a palm protector in his left hand. No palm protector was noted in the area of resident. On 4/1/22 at 11:25 AM, Resident 97 was observed, lying in bed, call button in his right hand. There was no palm protector in his left hand. No palm protector was visible in Resident 97's room. On 4/1/22 at 1:04 PM, Resident 97 was observed, lying in bed with no palm protector in his left hand. There was no palm protector visible in resident 97's room. On 4/4/22 at 9:19 AM, Resident 97 was observed lying in bed with no palm protector in his left hand. There was no palm protector visible in Resident 97's room. During an interview and observation on 4/4/22 at 9:28 AM, QMA 2, indicated she looked at the C.N.A. paper to find out the care each resident required. QMA 2 looked at her C.N.A. paper and provided it for the surveyor to review. The C.N.A. paper indicated Resident 97 should have had a left palm protector in place at all times. QMA 2 and surveyor went to Resident 97's room. Resident 97 did not have left palm protector in place. QMA 2 could not locate a palm protector in Resident 97's room. QMA 2 indicated the palm protector was sent to the laundry sometimes and it took a day to get it back. QMA 2 could not verify the palm protector was sent to the laundry. On 4/5/22 at 9:04 AM, Resident 97 was observed lying in bed with no palm protector in his left hand. Resident 97 indicated staff put the palm protector in his left hand a couple days ago, but staff did not apply the palm protector very often and he did not remove it. During an interview and observation, on 4/5/22 at 9:08 AM, PCA 9 indicated she received report from the nurse and used the paper plan of care (POC), document titled Approaches on Profile, for reference. PCA 9 provided her copy of the POC for surveyor to review. The POC indicated that Resident 97 would tolerate wearing the left palm protector at all times for contracture prevention, removed each shift for skin care. QMA 9 indicated that she would review the POC sheet and would apply a resident's palm protector when she completed the resident's morning care. QMA 9 indicated that she had not completed all residents' morning care. QMA 9 indicated staff had applied Resident 97's left palm protector but the resident removed it after a few minutes. In an interview conducted on 4/1/22 at 8:00 AM, QMA 14 indicated she looked at the E MAR (electronic medication administration record) to find out what her resident's needs were, medications and treatments to be done. QMA 14 indicated she documented the tasks on the E MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 4/1/22 at 11:57 AM, QMA 7 indicated Resident 97 had a brace applied by therapy for 3-4 hours each day. QMA 7 indicated she was not aware Resident 97 had any other devices (left palm protector). During an interview on 4/5/22 at 10:42 AM, the Physical Therapy Manager indicated nursing is responsible for application of palm protectors on residents through the Restorative Nursing Program. A current policy, titled Restorative Nursing Program, dated 3/2010, was provided by the DON on 4/5/22 at 9:45 AM. The policy indicated . the purpose of the Restorative Nursing Program included to meet or maintain a resident's functional goals after skilled therapy was no longer needed, maintain a resident's optimal level of function within the given environment. The process indicated that the program was coordinated, supervised and carried out by the nursing staff, preferably the MDS coordinator or MDS assistant. The policy indicated that the program could be initiated based on routine assessment of the resident, after cessation of skilled therapy, when the interdisciplinary team determined there was a potential for decline in resident function. Program documentation was to include a resident centered care plan developed by the nurse, programs and care plans evaluated by nursing with any needed changes made at least quarterly, documentation by the C.N.A. in the Point of Care or on a monthly flowsheet, resident goals and appropriateness of the program evaluated by nursing periodically, the resident and/or representative were included in the development of the restorative care plan and informed of the risks and benefits of the program. The Restorative Nursing Program included, but not limited to, splint or brace assistance 3.1-42(a)(2)

Based on observation, record review and interview the facility failed to implement fall prevention interventions of 1 of 24 residents reivewed. (Resident 27) Findings include: Resident 27's recored review began on 3/30/22 at 9:30 AM. The review indicated diagnoses included, but were not limited to, [CONDITION(S)], high blood pressure, and history of falls. Resident 27's BIMS (Brief Interview of Mental Status) score was 5 on an MDS dated [DATE]. An observation, on 3/29/22 from 10:04 AM to 12:42 PM, indicated Resident 27 had two black and purple eyes with a cut on forehead. Resident 27 walked from the dayroom to her room and back three times without assistance of staff or any assistive devices. Staff asked her where she was going when she left dayroom but did not monitor or encourage her to use her walker while she was in the hall or her room. An observation, on 3/30/22 at 11:44 AM, indicated Resident 27 had on black rimmed glasses and was walking in the hallway without any assistance or direct monitoring. Resident 27 stopped and asked staff for direction. No staff encouraged the resident to use her walker. An observation, on 04/01/22 10:08 AM, indicated Resident 27 was laying in a chair sideways with [NAME] legs over one arm. Resident 27 was wearing black rimmed glasses. The resident was easily awakened for a snack at 10:17 AM. Resident 27 ate the snack then laid back into chair again. No ambulation occurred during the observation from 10:08 AM to 12:56 PM. There was no walker near the chair. A review of events indicated Resident 27 had multiple falls. The most recent fall was on 3/28/22. The fall resulted in a bloody nose, cuts to the front and back of her head, and both eyes were black and blue. The root cause of this fall was documented by IDT (inter disciplinary team), on 3/28/22 at 7:30 AM, as lack of safety awareness due to dementia. The progress note indicated proper footwear was an intervention as well as having the NP (nurse practitioner) evaluate the resident. A fall risk assessment completed on 3/22/22 indicated a score of 20, putting Resident 27 at a High Fall Risk. The most recent care plan supplied by the MDS coordinator, on 3/31/22 at 5:04 PM, indicated a problem of falls. The goal was: the resident's fall risk factors would be reduced for significant fall related injury. The target date was set as 5/17/22. The interventions were: NP (Nirse Practitioner) eval dated 3/28/22, Winged mattress on the beed 3/3/22, grab bars on the bed 11/11/21, high low bed against wall 11/11/21, NP review 11/9/21, NP eval 10/11/21, encourage to use front wheeled walker 9/20/21, and nonskid footwear 9/16/21. The comprehensive assessment titled MDS dated [DATE] section G of this assessment which pertained to functional status indicated Resident 27 did not use any mobility devices. The same comprehensive assessment performed 9/22/21. Section G indicated Resident used a walker. The physical therapy discharge summary, dated 9/27/22 indicated Resident 27 was to use a front wheeled walker. The goal was met of Resident 27 walking with front wheeled walker on even ground for 300 ft. It further indicated she walked 200ft without device yet developed some slight loss of balance. In an interview on 4/1/22 at 10:38 AM, the Unit Manager indicated when Resident 27 first came to unit they were to encourage use of walker. Unit manager indicated Resident 27 did not use walker on unit during time of survey. The Unit Manager shared Resident 27 physical therapy discharge indicating resident can walk without assistive devices; per Unit Manager. This discharge was on 9/27/21 and it was when Resident 27 stopped being encouraged to use walker. The indication for Resident 27 to use walker was still an intervention on care plan related to the problem of falls and an active order from provider. The MAR/TAR indicated Resident 27 was being encouraged to use walker as indicated by nursing signatures. An interview with Therapy manager on 4/5/22 at 10:08 AM indicated residents discharge summaries are discussed with the MDS coordinator to be care planned for residents to ensure the interventions were used. 3.1-45 (a)

Based on observation, interview, and record review the facility failed to ensure Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 191 and Resident 18) Findings include: 1. A review of Resident 191's records began on 3/31/2022 at 2:42 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 191's MDS (Minimum Data Set) Admission Assessment was in process and Resident 191's BIMS (Brief Interview for Mental Status) was not yet completed. The facility did not include Resident 191 on the list of interviewable residents. A review of Resident 191's current physician orders, dated March 2022, indicated the following: An order dated 3/23/2022 without an end date, the Resident was to be NPO. An order dated 3/28/2022 without an end date, for a continuous enteral feeding of [MEDICATION(S)] (a nutrition supplement for tube feeding) 1.2 (a calorie measurement/ml, a liquid measurement) to be infused at 60 cc (ml) per hour every shift, 10:00 p.m. to 6:00 a.m., 6:00 a.m. to 2:00 p.m., and 2:00 p.m. to 10:00 p.m. An order dated 3-28-2022 with out an end date, for enteral feeding, to flush tube with 150 ml of H2O (water) every 6 hours every shift. A review of Resident 191's MAR (Medication Administration Record) for the Enteral Administration dated March 2022 indicated the following: The nurses initialed the administration of the continuous enteral feedings of [MEDICATION(S)] 1.2 to indicate it had been infused on the following dates and times: On 3/28/2022 from 10:00 p.m. to 6:00 a.m.; On 3/29/2022 from 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.; On 3-30-2022 from 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.; On 3/31/2022 form 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m. The Enteral Administration Record was lacking a recorded amount of intake of [MEDICATION(S)] 1.2. The nursing staff initialed the administration of 150 ml of water through the G-tube on the following dates and times: On 3/28/2022 at 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.; On 3/29/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.; On 3-30-2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.; and on 3/31/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m. The Enteral Administration Record was lacking a recorded amount of intake of water. A review A review of Resident 191's MAR (Medication Administration Record) for the Enteral Administration April 2022 indicated the following: The nursing staff initialed the administration of the continuous enteral feedings of [MEDICATION(S)] 1.2 to indicated it had been infused on the following dates and times: On 4/1/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m. On 4/2/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m On 4/3/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m., and on 4/4/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m. The order was discontinued on 4/4/2022. The Enteral Administration Record was lacking a recorded amount of intake of [MEDICATION(S)]. The nursing staff initialed the enteral flushing with 150 ml of water every 6 hours every shift, as follows: On 4/1/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m. On 4/2/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m On 4/3/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m., and 10:00 p.m. to 6:00 a.m., and on 4/4/2022 at 6:00 a.m. to 2:00 p.m., 2:00 p.m., to 10:00 p.m. The order was discontinued on 4/4/2022. The Enteral Administration Record was lacking a recorded amount of water intake. Review of Resident 191's Care Plan indicated the resident was at risk for fluid imbalance due to weakness and impaired mobility. The goal for the resident was to be free from signs and symptoms of fluid volume deficit. An approach listed was to Record Intake. An observation of Resident 191 on 3/29/2022 at 12:13 p.m., found the resident sitting up in a chair near the foot of the bed. The tube feed pole was observed positioned behind the resident. The tube feed was infusing through a pump, running at 60 ml/hr, then switched to Flush 150 ml every 6 hours. Resident 191 indicated they were doing good and offered no complaints. An interview with Resident 191 on 3/31/2022 at 11:49 a.m. indicated they were doing good. Observed the tube feed of [MEDICATION(S)] was full and measured greater than 1500 ml in the bottle. The flush bag of water measured 900 ml on the bag. Resident 191 said the nurse had just hung a new bottle. The [MEDICATION(S)] bottle was labeled 3/31/2022 at 11:40 a.m. with a nurses initials. Observed the tube feed pump running at 60 ml/hour and flush 150 ml every 6 hours. The infused amounts on the pump read, 2260 ml feed and 900 ml flush. An interview on 3/31/2022 at 11:50 a.m. with RN 3 indicated they had just hung a new bottle of [MEDICATION(S)] with new tubing. The RN indicated the tube feed was unhooked during speech therapy and the tube feeding was restarted after speech therapy was finished. An observation on 3/31/2022 at 3:37 p.m., of Resident 191's tube feeding. The resident was seated in a chair near the head of the bed and the tube feed pole with pump was position on the left side just in front of them. The pump was hanging crooked on the pole.The pump screen was black and the pump was not running or alarming. Resident 191 indicated the pump had been off for awhile. The [MEDICATION(S)] bottle was hanging on the pole with greater than 1500 ml in the bottle. The flush bag of water measured 900 ml on the bag. There was no difference in the amounts in the [MEDICATION(S)] container or the water flush bag between 11:49 a.m. and 3:37 p.m. An interview with QMA 4 on 3/31/2022 at 3:40 p.m., indicated they worked evening shift and was currently passing medications to residents. QMA 4 indicated they had provided care and medications for Resident 191. QMA 4 indicated Resident 191 received medication through their G-tube. The QMA indicated they were able to administer the medication through the G-Tube but if had any problems with it, they would report to the nurse. QMA 4 indicated they had not yet seen Resident 191 yet this shift. In an observation with QMA 4 of the tube feed pump, the QMA indicated the pump was not working. QMA 4 also indicated the nurse had told them it was not working at shift change and they were working on getting another pump. QMA 4 indicated they would check with the Unit Manager. An observation on 3/31/2022 at 3:45 p.m., QMA 4 reported to Unit Manager 5 about Resident 191's tube feed pump was not working. Observed Unit Manager 5 go to the ADNS (Assistant Director of Nursing Services) and reported the malfunction pump for Resident 191. In an interview and observation on 3/31/2022 at 3:49 p.m., the ADNS indicated Reisdnet 191's pump was off and she had just learned the pump was not working. The ADNS indicated Unit Manager 5 would bring another pump. The ADNS removed the pump from the pole and was able to get the screen to come on. The tube feed pump read 60 ml feeding and 150 ml every 6 hours for flush. The total amount infused read 2420 ml for feed and 900 ml for flush. The ADNS agreed the amount of [MEDICATION(S)] was greater than 1500 ml remaining in the bottle. The ADNS indicated they were not certain where the amount of feed and flush were documented and would find out. The ADNS agreed the pump's infused amount had not been cleared off of the pump. Unit Manager 5 entered the room with a different tube feed pump and indicated the tube feed rate of infusion was 60 ml/ hour and the the flush rate was 150 ml every 6 hour. The ADNS set the rate of infusion for the tube feed and the flush, and observed the tube feed pump was functioning. Unit Manager 5 indicated the tube feed intake was not documented on the MAR (Medication Administration Record) but did not indicate where the enteral intakes were documented. An interview on 3/31/2022 with the ADNS indicated they do not document the volume of tube feed received. They indicated the flow rate is calculated by the Registered Dietitian. The ADNS also indicated when the flow rate stops, the pump alarms, so the nurse would know when the set rate was being infused. The ADNS also indicated the amount of the tube feed administered would be the rate times the number hours infused. It should be documented in the progress notes when something was abnormal or malfunctioned and the physician should be notified when the tube feed amount was not given. 2. A review of Resident 18's record review began on 4/1/22 at 3:55 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 18's Quarterly MDS assessment, dated 1/3/2022, indicated the resident was rarely understood when cognition was assessed. The assessment also indicated Resident 18 received nutrition through a feeding tube. A review of Resident 18's current physician orders, dated March 2022, indicated the following: An order with a Start Date of 11/2/2020 without an end date, the Resident was to be NPO. An order with a Start Date of 3/22/2022 without an end date, for the enteral feeding of [MEDICATION(S)] 1.5 at 100 ml/hour on a cyclic schedule from 8:00 a.m. to 8:00 p.m. An order with a Start Date of 12/8/2021 without an end date, for enteral feeding flush the tube with 30 ml of water every hour 2 times a day, from 8:00 a.m. to 2:00 p.m., and 2:00 p.m. to 8:00 p.m. A review of the MAR Enteral Administration History for March 2022 indicated the following: The nursing staff initialed the administration for cyclic day time feeding of [MEDICATION(S)] 1.5 at 100 ml/hour starting at 8:00 a.m. and off at 8:00 p.m. twice a day.The documentation began on 3/22/2022 and was entered daily through 3/31/2022. The amount of tube feed was not recorded. The nursing staff initialed the administration for the flushing the tube with 30 ml's of water every hour twice a day from 8:00 a.m. to 2:00 p.m. and 2:00 p.m. to 8:00 p.m., 2 shifts every day from 3/1/2022 to 3/31/2022. The amount of water infused through G-tube was not recorded. A review of Resident 18's Care Plan started on 11/02/2020 indicated Resident 18 was at risk for fluid imbalance due to being NPO with tube feedings and flushes. The goal was to be free for signs and symptoms of fluid volume deficit. Approaches for Resident 18 was to Record Intake, Tube feeding and flushes per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an observationon 4/1/2022 at 12:45 p.m., Resident 18 was up in recliner chair. The tube feed was infusing via pump at 100 ml per hour, and the flush was set to infuse 30 ml every 1 hour, The infused amounts were 442 ml for feed and 120 ml for the flush amounts. The hanging bottle of [MEDICATION(S)] was labeled and dated 4/1/2022 at 8:00 a.m., and the level on the bottle measured 1350 ml remained in the bottle. An interview on 4/4/2022 at 11:10 a.m. with the ASC (American Senior Community) Regional Registered Dietitian, indicated the facility did not have a full time Registered Dietitian (RD) but ASC's other facilities were sending their RD to complete assessments 2 times a week, on Tuesdays and Thursdays. She indicated ASC did not have a policy to record enteral intakes. She indicated the documentation on the Enteral Feeding Administration by initialing the infusion rate for the number of hours indicated the feeding was infused per order. The Regional RD indicated the tube feed pump should alarm when the tube feeding was not infusing. The Regional RD indicated they need to have an order to hold tube feeds during therapy and indicated when the pump was off for an undetermined amount of time, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional RD indicated nursing does the initial Care Plans for the tube feed and the RD individualized the Care Plan once the resident was assessed. She indicated the RD completed the initial nutrition assessment for the Admission MDS (Minimal Data Set) Assessment, and indicated Resident 191's first working day of the MDS assessment would be completed. She further indicated the Care Plan to record intake would be for nursing to complete. A review of the current facility policy provided by medical records on 3/31/2022, titled, Enteral Therapy had a Revision Date of 1/2016, indicated .It if the policy of this facility that the licensed nurse, in cooperation with other healthcare team members, must carefully monitor the resident's response to the enteral feedings and feeding techniques to ensure the attainment of therapeutic goals A licensed nurse will take, note and implement physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 3.1-44(a)(2)

Based on observation, interview and record review, the facility failed to ensure the medication orders contained the proper route of administration for 2 of 2 residents reviewed. (Resident 191 and Resident 18) Findings include: 1. A review of Resident 191's records began on 3/31/2022 at 2:42 p.m. Diagnoses included but were not limited to, dysphagia (difficulty swallowing), sequelae cerebral infarction (a stroke with residual effects, a gastrostomy (a surgical opening into the stomach from the abdomen used for nutrition and medication), hypertensive [CONDITION(S)] with heart failure, diabetes mellitus, major depressive disorder, and [CONDITION(S)]. Resident 191's MDS (Minimum Data Set) Admission Assessment in in process and Resident 191's BIMS (Brief Interview for Mental Status) was not yet completed. The facility did not include Resident 191 on the list of interviewable residents. A review of Resident 191's current physician orders, dated March 2022, indicated the following: An order dated 3/23/2022 without an end date, the Resident was to be NPO (nothing by mouth). An order dated 3/28/2022 without an end date for [MEDICATION(S)] (a medication for high blood pressure and heart failure) 3.125 mg (milligram, a medication dose measurement) tablet was to be administered by mouth twice a day. An order dated 3/29/2022 without an end date for losartan (a medication for high blood pressure) 100 mg tablet was to be administered by mouth once every day. An order dated 3/29/2022 without an end date for [MEDICATION(S)] powder (a [MEDICATION(S)]) 17 grams (a medication dose measurement) was to be administered by mouth once every day. An order, dated 3/28/2022 without an end date for [MEDICATION(S)], (an antiacid) 500 mg chewable tablet. 1000 mg, (2 tablets) was to be administered by mouth every 4 hours PRN (as needed). An order dated 3/28/2022 without an end dated for [MEDICATION(S)] (for nausea and vomiting) 8 mg tablet was to be administered by mouth every 6 hours as needed for nausea and vomiting. An order dated 3/28/2022 without an end date for [MEDICATION(S)] (an antidepressant) 50 mg tablet was to be administered by mouth as needed for [CONDITION(S)]. A review of Resident 191's MAR (Medication Administration Record) dated March 2022 and April 2022 indicated the following: The nursing staff initialed the MAR indicating the [MEDICATION(S)] 3.125 mg tablet was administered by mouth 2 times a day on 3/31/2022, 4/1/2022, 4/2/2022, 4/3/2022. The [MEDICATION(S)] oral route was discontinued on 4/4/2022. The nursing staff initialed the MAR indicating the losartan 100 mg tablet was administered by mouth daily beginning on 3/31/2022, 4/1/2022, 4/2/2022 and 4/3/2022. The losartan oral route was discontinued on 4/4/2022. The nursing staff initialed the MAR indicated the [MEDICATION(S)] powder 17 grams was administered once a day by mouth on 3/31/2022, 4/1/2022, 4/2/2022, and 4/3/2022. The [MEDICATION(S)] powder oral route was discontinued on 4/4/2022. The MAR indicated the PRN (as needed) medications, [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] were not administered in March, nor in April 2022. The oral route of these PRN medications were discontinued on 4/4/2022. 2. A review of Resident 18's record review began on 4/1/22 at 3:55 p.m. Diagnoses included but were not limited to, dysphagia, moderate protein-calorie malnutrition, gastro-[CONDITION(S)] reflux disease, and [CONDITION(S)]. Review of Resident 18's Quarterly MDS assessment, dated 1/3/2022, indicated the resident was rarely understood when cognition was assessed. The assessment also indicated Resident 18 received nutrition through a feeding tube. A review of Resident 18's current physician orders, dated March 2022, indicated the following: An order with a Start Date of 11/2/2020 without an end date, the Resident was to be NPO ( nothing by mouth). An order with a Start Date of 1/21/2022 without an end date, for [MEDICATION(S)] (for [CONDITION(S)]) 100 mg tablet, was to be administered 300 mg (3 tablets) by mouth every 12 hours. An order with a Start Date of 2/17/2022 without an end date, for [MEDICATION(S)] (anticonvulsant) 50 mg tablet, give 100 mg (2 tablets), to be administrated by mouth at bedtime every night. Review of Resident 18's MAR dated March 2022 indicated the following: The nursing staff initialed the MAR indicating the [MEDICATION(S)] 100 mg tablet was administered by mouth every 12 hours everyday from 3/1/2022 to 3/31/2022. The nursing staff initialed the MAR indicating [MEDICATION(S)] 50 mg, 2 tablets were administered by mouth at bedtime every night from 3/1/2022 to 3/31/2022. An interview with the DON (Director of Nursing) on 4/4/2022 at 9:29 a.m., indicated the Pharmacist reviewed the medication orders and regime prior to filling the medications to be administered. She indicated Resident 191's medications were reviewed by the Pharmacist. An interview with RN 3 on 4/5/2022 at 10:20 a.m., indicated they had provided care for Resident 191. RN 3 indicated Resident 191 was NPO and did not get anything by mouth. RN 3 indicated Resident 191's medications were administrated through the G-tube (gastrostomy tube). An interview with QMA 2 on 4/5/2022 at 10:30 a.m., indicated they had provided care for Resident 18, The QMA indicated Resident 18 had a G-tube and was NPO and medications were given through the G-tube. QMA 4 indicated Resident 18 did not receive any medications orally. A review of the current facility policy, provided by the MDS Coordinator on 4/5/2022 at 10:48 a.m. The policy was titled, Medication Regimen Reviews and Pharmacy Recommendations, with a revision date, 10/2018 and indicated, .It is the policy of ASC (American Senior Community) that the facility maintains the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimized adverse consequences related to mediccation therapy to the extent possible by providing over sight by a licenced Pharmacist, Attending Physician, Medical Director, and Director of Nursing Upon admission to ASC the Consultant Pharmacist will complete an Admission Drug Regimen Review within 72 hours A review of the current facility policy, provided by Medical Records on 4/5/2022 at 11:12 a.m. The policy was titled, 6.0 General Dose Preparation and Medication Administration, with a Revision Date of 1/1/13 and indicated, .This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operation Manual when administrating medications .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident . 3.1-25(i)

Based on interview, and record review the facility failed to prevent, and identify wounds prior to the stage being unidentifiable, and failed to ensure worsening of wounds were monitored, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in [CONDITION(S)], and hospitalization for Resident B. The immediate jeopardy began on February 10, 2021 when the facility failed to prevent and identify wounds prior to stage being unidentifiable and failed to monitor worsening of wounds with update or treatment in wound regimen. The Regional Director of Clinical Services, Senior Director of Clinical Services, Regional Vice President of Operations, and Director of Nursing Services were notified of the immediate jeopardy at 2:15 p.m., on [DATE]. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings include: A review of Resident B's clinical record on [DATE] at 12:48 p.m., indicated the resident had a BIMS (Brief Interview of Mental Status) score of 5, meaning severe cognitive impairment. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Assessment, dated [DATE], indicated Resident B was being readmitted to the facility, from a hospital stay, that began on [DATE]. The Skin Assessment indicated the resident had no alterations on his skin, and skin was warm, dry, and normal in color. A Care Plan, dated [DATE], indicated Resident B was at risk for pressure areas related to decreased mobility, due to the following: diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included: a pressure reducing mattress, encourage to turn, and reposition, float heels while in bed, pressure relieving cushion to chair, and house barrier cream for each incontinent episode. The Care Plan was not revised at readmission on [DATE]. A Braden Scale for Predicting Pressure Sore Risk, dated [DATE], indicated a score of 14 points, meaning the resident was at moderate risk for skin breakdown. A review of the CNA (Certified Nurse Aide) Shower Report Sheets indicated the resident had no skin issues from [DATE] to [DATE]. A Shower Report Sheet, dated [DATE], indicated the following areas were open as marked on the body diagram: right and left heels, side/top of left foot, side/top of right foot, right medial shin, the back of the left shin, and the coccyx. 1. A Pressure Wound Skin Evaluation Report, dated [DATE], indicated the coccyx wound was unstageable, and measured 6.3 cm (centimeters) in length, 2.3 cm in width, and unable to determine depth and tunneling (channels extending into and through the subcutaneous tissue and/or muscle). The skin tissue was 50% necrotic (black, brown, or tan tissue that adheres to the wound bed), and 50% slough (yellow, or white tissue that adheres to the wound bed), no drainage, and no odor was present. The treatment in place was Santyl (collagenase topical ointment used to heal wounds) and a dry dressing. On [DATE], the coccyx wound measured 6 cm in length, 4.7 cm in width, and 3.5 cm in depth, tissue type was 40% slough. The treatment in place was Santyl on the outer edge of the wound, and lightly pack the wound with Dakins (a solution of stabilizing ingredients used in wounds to prevent infection), gauze, and a dry dressing. On [DATE], the coccyx wound measured 6.5 cm in length, 6.5 cm in width, 2.5 cm in depth, with 4.3 cm tunneling. the treatment in place continued to be the Santyl, Dakin's solution packing with a dry dressing. The treatment remained the same. . On [DATE], the wound measured 6 cm in length, 8 cm in width, 2.7 cm in depth, 4.5 cm tunneling, and 1 cm undermining (erosion under the wound edges). The treatment remained the same. On [DATE], the wound measured 9.4 cm in length, 9.5 cm in width, 3 cm in depth, 4.5 cm tunneling, and 1 cm undermining. The treatment remained the same. 2. A Pressure Wound Skin Evaluation Report, dated [DATE], indicated the right heel wound was staged as a DTPI (Deep Tissue Pressure Injury). The wound measured 4 cm in length, 3.7 cm in width, depth was UTD (Unable To Determine), no tunneling, tissue type was 100% necrotic, no drainage, and no odor. The treatment in place was [MEDICATION(S)] (an antiseptic) and a dry dressing. On [DATE], the wound measured 3.5 cm in length, and 4.5 cm in width. Treatment remained the same. On [DATE], the wound measured 3.5 cm in length, and 4 cm in width. Treatment remained the same. On [DATE], the wound measured 2.1 cm in length, and 3.5 cm in width. Treatment remained the same. On [DATE], the wound measured 2.1 cm in length, and 3.5 cm in width. Treatment remained the same. 3. A Pressure Wound Skin Evaluation Report, dated [DATE], indicated the right medial calf wound was staged as unstageable. The wound measured 5 cm in length, 1.5 cm in width, UTD depth, no tunneling, tissue type was 100% necrotic, no drainage, and no odor. The treatment in place was Santyl and a dry dressing. On [DATE], the wound measured 5 cm in length, and 2 cm in width. The treatment in place was changed to [MEDICATION(S)], and a dry dressing. On [DATE], the wound measured 5 cm in length, and 2 cm in width. The treatment remained the same. On [DATE], the wound measured 5 cm in length, and 1.5 cm in width. The treatment remained the same. On [DATE], the wound measured 4.3 cm in length, and 1.8 cm in width. The tissue type was 100% necrotic. The treatment remained the same. 4. A Pressure Wound Skin Evaluation Report, dated [DATE], indicated the right medial malleolous (bony bump on the inner side of the ankle) was staged as a DTPI. The wound measured 1.3 cm in length, 2 cm in width, UTD depth, no tunneling, and tissue type was 100% necrotic. The treatment in place was [MEDICATION(S)], and a dry dressing. On [DATE], the wound measured 1 cm in length, and 2 cm in width. The treatment remained the same. On [DATE], the wound measured 1 cm in length, and 2 cm in width. The treatment remained the same. On [DATE], the wound measured 0.5 cm in length, and 1.5 cm in width. The treatment remained the same. On [DATE], the wound measured 0.4 cm in length, and 1.5 cm in width. The treatment remained the same. 5. A Pressure Wound Skin Evaluation Report, dated [DATE], indicated the right lateral malleolous was staged as unstageable. The wound measured 3.6 cm in length, 5.5 cm in width, UTD depth, no tunneling, tissue type was 100% necrotic, no drainage, and no odor. The treatment in place was [MEDICATION(S)], and a dry dressing. On [DATE], the wound measured 2.5 cm in length, and 5 cm in width. The treatment remained the same. On [DATE], the wound measured 2.1 cm in length, and 5 cm in width. The treatment remained the same. On [DATE], the wound measured 4 cm in length, and 3 cm in width. The treatment in place was changed to Silver Alginate with a dressing. On [DATE], the wound measured 3.5 cm in length, and 4.7 cm in width. The treatment was undefined. 6. A Pressure Wound Skin Evaluation Report, dated [DATE], indicated the right foot - dorsal side of 1st metatarsal ( right bunion) was staged as a DTPI. The wound measured 1.5 cm in length, 1.5 cm in width, depth was UTD, and tissue type was 100% necrotic. The treatment in place was [MEDICATION(S)] and a dry dressing. On [DATE], the wound measured 1.2 cm in length, and 1.2 cm in width. The treatment remained the same. On [DATE], the wound measured 1 cm in length, and 1.2 cm in width. The treatment remained the same. On [DATE], the wound measured 0.5 cm in length, and 1 cm in width .The treatment remained the same. On [DATE], the wound measured 0.5 cm in length, and 1 cm in width .The treatment remained the same. 7. A Pressure Wound Skin Evaluation Report, dated [DATE], indicated the right lateral buttock was staged as unstageable. The wound measured 3 cm in length, 3.5 cm in width, UTD depth, UTD tunneling, tissue type was 100% necrotic/eschar, and no odor. The treatment in place was skin prep (a liquid film forming barrier), and a dry dressing. On [DATE], the wound was healed by the Wound Nurse Practitioner. 8. A Pressure Wound Skin Evaluation Report, dated [DATE], indicated there was a new area to the left buttock. The area was a stage 2. The wound measured 1.5 cm in length, 2.5 cm in width, and 0.1 cm in depth. The treatment in place was Silver Alginate and a dry dressing. On [DATE], the wound measured 2 cm in length, and 2 cm in width, and 0.1 cm in depth. The treatment remained the same. On [DATE], the wound measured 1.4 cm in length, and 1.4 cm in width. The treatment remained the same. On [DATE], the wound measured 1.4 cm in length, and 1.4 cm in width. The treatment remained the same. 9. A Pressure Wound Skin Evaluation Report, dated [DATE], indicated there was a new area to the right medial knee. The area was unstageable on identification. The wound measured 1.8 cm in length, 1.1 cm in width, and depth was UTD. The treatment in place was [MEDICATION(S)]. On [DATE], the wound measured 1.7 in length, and 1.1 in width. The treatment remained the same. 10. A Wound Skin Evaluation Report, dated [DATE], indicated there was a new area to the right side skin fold. The area was identified as MASD (Moisture Associated Skin Damage). There was no drainage or odor. There were no detailed documentation of length, width, depth, tunneling, and color. There was no treatment documented. On [DATE], the area was healed. 11. A Wound Skin Evaluation Report, dated [DATE], indicated there was a new area to the right shoulder. The area was identified as an open lesion. The lesion measured 3.2 cm in length, 4 cm in width, color was pink, there was moderate amount of serous drainage, and no odor. The treatment in place was Calcium Alginate (absorption dressing) and a dry dressing. On [DATE], the lesion measured 2.3 cm in length, and 1 cm in width. The treatment remained the same. There was no detailed documentation regarding depth, tunneling, color, drainage, and odor. There was no documentation to indicate the areas on Left heel, right shin, left calf, and left foot the CNA indicated were open on the shower sheet had been addressed by the facility. A Care Plan was implemented on the initial admission [DATE] for risk for pressure areas, it included the following interventions: - encourage the resident to float heels when in bed. - pressure reducing cushion in wheelchair. - encourage the resident to turn and reposition at least every 2 hours, provide assistance as needed. - house barrier cream at the bedside, use as needed. - incontinent care as needed - pressure reducing mattress on bed. A Care Plan was implemented on [DATE] for impaired skin integrity, it included the following interventions: - assess for pain, and treat as ordered. Notify MD (Medical Doctor) of unrelieved or worsened pain. - assess wounds weekly documenting measurements, and description. - encourage the resident to eat at least 75% of meals. - encourage the resident to float heels when in bed. - encourage the resident to wear heel protectors when in bed. - incontinent care as needed. - labs as ordered. - notify the MD of worsening or no change in the wound or for signs of infection. - observe for signs of infection. - pressure reducing cushion in chair. - Registered Dietician to assess routinely. - supplements as ordered. - treatment as ordered. - turn and reposition the resident every 2 hours. - wound healing vitamins as ordered. On [DATE] the following interventions were added: - encourage the resident to get up in the wheelchair for meals. - Envella specialty mattress. - pillow between knees A Care Plan was implemented on [DATE] for infection to the coccyx wound, it included the following interventions: - assess and document skin condition weekly. - document abnormal findings and notify the MD. - observe for signs of infections. - treatment as ordered. A Care Plan was implemented on [DATE] for a bed mobility program to promote wound healing and prevention of skin breakdown, it included the following interventions: - Restorative FIT program every shift, bed mobility turn and/or reposition every 2 hours and as needed. A Care Plan was implemented on [DATE] for MASD on right side skin fold, interventions were as follows: - administer meds as ordered. - assess and document skin condition weekly and as needed. - document abnormal findings and notify MD\. - keep area clean and dry - notify MD of worsening or unrelieved symptoms - observe for signs of infection. - remind and encourage resident not to scratch area. A Progress Note, dated [DATE], by the Wound NP (Nurse Practitioner) documented the wound areas were unavoidable related to disease progression, condition decline, and COVID 19. The NP ordered a CBC (Complete Blood Count) with differential, cultures and an x-ray of the coccyx, and an RD (Registered Dietician) consult. A Progress Note, dated [DATE], by the RD (Registered Dietician) indicated a recent weight loss, they added strawberry Glucerna shakes 3 times daily. The resident had low [MEDICATION(S)] and prealbumin levels. A Hospital - ER (emergency room ) Transfer Form, dated [DATE] at 2:20 p.m., indicated Resident B was transferred to a local hospital for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the ER record, dated [DATE], indicated the resident had a sacral (Coccyx) wound measuring 9 cm in length, 9 cm in width, the wound was packed and had an odor. The surrounding skin was in good condition. The resident had an altered mental status, he was confused, and hallucinating. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's appearance was underweight, and appeared chronically ill. The labs included: hemoglobin 8.1, platelets 469, creatinine 1.77, increased from 1.4, potassium 5.9. The resident was started on Broad spectrum antibiotic, and was found to have a UTI (Urinary Tract Infection). The Foley catheter was changed, and had been changed at the nursing facility on [DATE]. The resident was to be admitted for acute renal (kidney) failure, [CONDITION(S)] related to either the UTI or the wound, an unspecified organism and renal failure, but no septic shock. admitted with [CONDITION(S)], and possible complicated UTI versus sacral wound. A review of the Wound Care Consultation Report, dated [DATE], indicated the resident had following wounds, and measurements on admission to the hospital: - Sacral (Coccyx) pressure injury, Stage 4, measured 10 cm in length, 10 cm in width, and 4 cm in depth. - Right heel pressure injury, unstageable, 4 cm in length, and 3.5 cm in width. - Right medial ankle, unstageable, 1.5 cm in length, and 2.5 cm in width. - Right lateral ankle, unstageable, 4 cm in length, and 3.3 cm in width. - Right lateral foot, unstageable, 2.5 cm in length, and 2.5 cm in width. - Right posterior medial leg (calf), unstageable, 4.6 cm in length, and 2 cm in width. - Right lateral hip, unstageable, 2.5 cm in length, and 1 cm in width, not identified in the facility. - Left ankle, DTPI, 1 cm in length, and 0.7 cm in width, identified on [DATE] in the facility, but not assessed, treated or monitored. During an interview on [DATE] at 11:15 a.m., Nurse 1 indicated the CNAs follow the resident profile, care plans, and turn clocks to care for the residents who had wounds. During an interview on [DATE] at 11:22 a.m., Nurse 1 indicated Resident B's wounds had made her very sad, and heart broken. She indicated he did not have the wounds upon his readmission on [DATE]. She indicated he had been positive for COVID 19, and things went downhill. He wasn't eating or talking to staff like he normally did. The facility began having conversations regarding Hospice services. She further indicated the facility rented a specialty bed for him. She indicated the coccyx wound just would not heal. She indicated the Wound NP was following him, and had tried everything, including [MEDICATION(S)], and eventually was sent out to the hospital due to [CONDITION(S)]. During an interview on [DATE] at 12:49 p.m., the complainant had indicated the facility notified them that the resident had sores, but was not informed of how bad they were, until the hospital notified them. The resident died on [DATE]. A current facility policy, Skin Management Program, dated ,d+[DATE], and provided by the DNS (Director of Nursing Services) on [DATE] at 3:15 p.m., indicated the following: .a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing . and .monitored and evaluated the impact of the interventions; and revised approaches as appropriate . An educational form, CNA/Nurse Wound Education, undated, provided by the DNS on [DATE] at 3:15 p.m., indicated the following: .the nurse must add additional preventative measures to reduce the risk of further injury. The physician and family are to be notified immediately and orders received for treatment. The nurse is to open a skin event and complete appropriate documentation . and .when doing a skin treatment on a resident, the nurse must document the characteristics of the wound (color, drainage, stage, no s/s of infection, etc) . and .any wounds that appear to be worsening require physician and family notification immediately. Assessment of wound must be documented in the medical record . and .residents refusing a full head to toe assessment require the notification of the DNS and Wound Nurse immediately. The refusal must be documented in the chart as well as family notification . The immediate jeopardy that began on February 10, 2021, was removed on [DATE] when the facility re-educated staff on identifying wounds, nurse notification, staging and documentation of the characteristics of the wounds, ensuring clear communication with family, and began monitoring by observation of residents with high skin risk, but the noncompliance remains at the lower scope and severity level of no actual harm with potential for more than minimal harm, that is not immediate jeopardy, because the facility has not completed a consistent pattern of monitoring. This Federal tag relates to complaint IN 499. 3.,d+[DATE]