Every finding on record at Hickory Creek at Columbus

Based on observation, record review, and interview, the facility failed to ensure care planned interventions were implemented for 2 of 12 residents reviewed for Care Plans. (Residents 19 and 7)Findings include:1. Resident 19's room was observed on 09/10/2025 at 1:35 P.M. The resident's call light was observed near her bed. The call light was white, and there was no bright colored tape attached to the call light.The resident was observed on 09/11/2025 at 9:07 A.M. The resident was in her room in bed. The resident's call light was within reach. There was no brightly colored tape attached to the call light. The resident's clinical record was reviewed on 09/10/2025 at 2:27 P.M. An Annual Minimum Data Set (MDS) assessment, dated 07/02/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, hypertension, and seizure disorder. The resident used a wheelchair and was dependent on staff for mobility. The resident experienced one fall without injury and one fall with an injury that was not major since the last assessment. The resident's Fall Care Plan, with a start date of 08/04/2023, included the following interventions:- A current intervention, with a start date of 11/04/2024, that indicated the resident was to have brightly colored tape on her call light.During an interview, on 09/11/2025 at 1:53 PM, Certified Nurse Aide (CNA) 3 indicated staff used pocket sheets that reflected the resident's current interventions. CNA 3 reviewed the current pocket sheet, dated 09/11/2025. The pocket sheet indicated there should be brightly colored tape on the resident's call light. The resident's room was observed with CNA 3 on 09/11/2025 at 1:59 P.M. The resident's call light was observed in an open drawer near the bed. There was no brightly colored tape on the call light. 2. Resident 7 was observed on 09/08/2025 at 9:44 A.M. The resident was in her room in a high-backed wheelchair next to her bed. The resident's call light was attached to the wall but was not visible or within reach of the resident. The resident indicated she could not call for assistance because she didn't have a call light within reach.The resident was observed on 09/10/2025 at 9:30 A.M. The resident was in her room in a high-backed wheelchair. The resident's overbed table was in front of her and she was holding a washcloth in each hand. The resident indicated she needed assistance, but she didn't have her call light. A soft touch call light was observed in the top drawer of the resident's nightstand behind the resident's wheelchair. The resident indicated she was capable of using the soft touch call light. CNA 4 entered the resident's room and was asked about the call light. CNA 4 indicated the resident didn't use the call light, but she would go ahead and place the call light in the resident's lap. She then assisted the resident with putting her eyeglasses on, placed and then repositioned the resident's neck pillow, and began looking for the resident's peppermint candies at the resident's request. The resident's record was reviewed on 09/12/2025 at 2:00 P.M. A Quarterly MDS assessment, dated 08/18/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Parkinson's disease, anxiety, and depression. The resident did not have a limited range of motion of her upper or lower extremities. The resident did use a wheelchair and was dependent on staff for most activities of daily living.A Behavior Care Plan, with a start date of 09/11/2023 and a revision date of 08/14/2025, indicated the resident used her call light excessively. The goal was for the resident to use her call light to notify staff that she was requesting help as needed, and included the following intervention:- A current intervention, with a start date of 09/11/2023, to ensure the call light was within the resident's reach when she was in her room.During an interview, on 09/12/2025 at 10:30 A.M., the Director of Nursing indicated the facility did not have a policy for following care plans.During an interview, on 09/12/2025 at 2:01 P.M., the Administrator indicated the facility did not have a policy for call lights related to call light usage. Call lights should be available for residents' use.3.1-35(g)(2)

Based on record review and interview, the facility failed to provide physician prescribed medications in a timely manner for 2 of 6 residents reviewed for medications. (Residents 6 and 29) Findings include:1.The clinical record for Resident 6 was reviewed on 09/11/2025 at 10:24 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 07/16/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease, anxiety, and depression. The Electronic Medication Administration Record (EMAR) indicated the resident was to receive the medication Paxlovid 100/150 milligrams (mg), twice a day, once from 7:00 A.M. to 11:00 A.M., and once from 5:00 P.M. to 10:00 P.M., for a diagnosis of COVID-19, with a start date of 08/31/2025, and a discontinued date of 09/04/2025. The record indicated the medication was not administered due to being unavailable on the following dates and times: -08/31/2025 at 7:00 A.M. to 11:00 A.M., -08/31/2025 at 5:00 P.M. to 10:00 P.M., -09/01/2025 at 7:00 A.M. to 11:00 A.M., -09/01/2025 at 5:00 P.M. to 10:00 P.M., and -09/02/2025 at 7:00 A.M. to 11:00 A.M. The Progress Notes from 08/30/2025 through 09/08/2025, were provided by the Administrator on 09/12/2025 at 10:49 A.M., and included, but were not limited to, the following: -A note, dated 08/30/2025 at 7:18 P.M., indicated the resident was symptomatic, had tested positive for COVID-19, had a deep unproductive cough, and was in droplet isolation. New orders received from Telehealth indicated the resident was to receive Paxlovid 150/100 mg, by mouth, twice a day, for five days. The clinical record lacked documentation the physician or the pharmacy was notified of the medication not being available. 2. The clinical record for Resident 29 was reviewed on 09/11/2025 at 10:12 A.M. A Quarterly MDS assessment, dated 08/06/2025, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, diabetes, and dementia. The EMAR indicated the resident was to receive the medication Paxlovid 150/100 mg, twice a day, once from 7:00 A.M. to 11:00 A.M., and once from 5:00 P.M. to 10:00 P.M., for a diagnosis of COVID-19, with a start date of 08/31/2025, and a discontinued date of 09/04/2025. The record indicated the medication was not administered due to being unavailable on the following dates and times: - 08/31/2025 at 7:00 A.M. to 11:00 A.M.,- 08/31/2025 at 5:00 P.M. to 10:00 P.M.,- 09/01/2025 at 7:00 A.M. to 11:00 A.M.,- 09/01/2025 at 5:00 P.M. to 10:00 P.M., and- 09/02/2025 at 7:00 A.M. to 11:00 A.M. The Progress Notes from 08/30/2025 through 09/08/2025, were provided by the Administrator on 09/12/2025 at 10:49 A.M., and lacked documentation the physician or the pharmacy was notified of the medication not being available. During an interview, on 09/12/2025 at 10:04 A.M., Licensed Practical Nurse 2 indicated the physician's orders for medications were sent to the pharmacy. It usually took less than 24 hours to receive medications. If a nurse needed to administer a medication and it was not available in the facility, they could contact the pharmacy to get the medication STAT ordered. With a STAT order, there was usually a four-hour turn around. They could also get the medication from the local pharmacy, someone from the facility could go pick it up or have the medication delivered. During an interview with the Infection Preventionist (IP) and the Director of Nursing (DON), on 09/12/2025 at 10:12 A.M., the IP indicated it was a long weekend when the medication was ordered. The DON indicated typically, instead of just documenting a medication as unavailable nursing staff should document if they reached out to the pharmacy and notified the physician. If they put a notation in the resident's record, nursing staff would know what was going on. The current Medication Shortages/Unavailable Medications policy, with a revised date of 08/01/2024, was provided by the Administrator on 09/12/2025 at 10:49 A.M. The policy indicated, .If the medication shortage is discovered at the time of medication administration, Facility staff should immediately notify the Pharmacy.If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for a STAT (immediate) delivery.If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. 3.1-25(a)

Based on observation and interview, the facility failed to ensure foods were stored in a sanitary manner related to unlabeled foods for 1 of 3 kitchen observations.Findings include:During the initial tour of the facility kitchen with [NAME] 5 on 09/08/2025 at 7:46 A.M., the following items were observed in the refrigerator:-A tray that contained two cups of ambrosia salad, a small bowl of potato salad, and a ham sandwich in plastic bag. The items nor the tray were labeled with a prepared on or use by date,-A tray that contained four small cups of a fruit crumble dessert, a small cup of cucumber tomato salad, and a small cup of tapioca pudding. The items nor the tray were labeled with a prepared on or use by date, -A large, unlabeled pitcher that was less than half full of an orange drink, and -A large, unlabeled pitcher that was less than half full of a pink drink.During an interview, on 09/08/2025 at 7:48 A.M., [NAME] 5 indicated the items on trays were from the weekend and should have been labeled with prepared on date. The drink pitchers should have been labeled with a prepared on date. All items not labeled were removed and disposed. The current facility policy, titled Food Storage, most recently revised on 05/25, was provided by the Administrator on 09/12/2025 at 10:46 A.M. The policy indicated, .Leftover prepared foods.The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded.3.1-21(i)(2)3.1-21(i)(3)

Based on record review and interview, the facility failed to notify the physician of blood glucose levels per the physician's order for 1 of 14 residents reviewed for notification of change. (Resident 8) Findings include: The clinical record for Resident 8 was reviewed on 08/28/24 at 2:25 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/21/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, hypertension, diabetes, anxiety, and depression. A current physician's order, with a start date of 03/20/24, indicated the resident was to be administered insulin lispro per a sliding scale. The physician was to be notified if the resident's blood glucose level was greater than 350. The June, July, and August 2024, EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident's blood glucose levels were greater than 350 on the following dates and times: - On 06/10/24 at 11:00 A.M., the resident's blood glucose level was 368, - On 06/20/24 at 11:00 A.M., the resident's blood glucose level was 355, - On 06/25/24 at 11:00 A.M., the resident's blood glucose level was 367, - On 07/08/24 at 11:00 A.M., the resident's blood glucose level was 399, - On 07/21/24 at 11:00 A.M., the resident's blood glucose level was 389, - On 08/19/24 at 7:00 A.M., the resident's blood glucose level was 358, and - On 08/19/24 at 11:00 A.M., the resident's blood glucose level was 394. The resident's clinical record lacked any documentation the physician was notified of the blood glucose levels. During an interview on 08/29/24 at 2:09 P.M., LPN (Licensed Practical Nurse) 2 indicated the resident's blood glucose levels were documented on the EMAR/ETAR. If the blood glucose was out of the parameter and if the nurse was required to call the physician it would be documented on the EMAR/ETAR and in a progress note. They would document if there were any new orders in a progress note. During an interview on 08/29/24 at 2:55 P.M., the DON (Director of Nursing) indicated the resident did not suffer any ill effects related to the physician not being notified of the blood glucose levels. The current facility policy titled, Blood Glucose Monitoring, with a revision date of 2/2015, was provided by the DON on 08/29/24 at 2:45 P.M. The policy indicated, .The physician will be notified when the resident's blood glucose is outside the physician stated parameters . 3.1-5(a)(2)

Based on record review and interview, the facility failed to monitor a resident's blood pressure as ordered by the physician's for 1 of 14 residents reviewed for quality of care. (Resident 7) Findings include: The clinical record for Resident 7 was reviewed on 08/27/24. A Quarterly MDS (Minimum Data Set) assessment, dated 08/05/24, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, diabetes, depression, and insomnia. A current physician's order, with a start date of 06/13/24, indicated the staff were to obtain the resident's blood pressure daily and to notify the physician's office if the systolic (top number) was less than 100. The blood pressure record was to be taken to the next appointment on 12/13/24. The June, July, and August 2024, EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) lacked any documented blood pressures. The Vitals Report for June, July, and August 2024, lacked documented blood pressures for Resident 7 on the following dates: 06/15/24, 06/16/24, 06/18/24, 06/20/24, 06/21/24, 06/24/24, 06/25/24, 06/29/24, 06/30/24, 07/27/24, 07/28/24, 07/31/24, 08/01/24, 08/02/24, 08/05/24, 08/06/24, 08/10/24, 08/11/24, 08/15/24, 08/16/24, 08/19/24, 08/20/24, and 08/22/24. During an interview on 08/29/24 at 11:05 A.M., LPN (Licensed Practical Nurse) 2 indicated when a resident had an order to monitor their blood pressure it would be documented on the EMAR/ETAR. During an interview on 08/29/24 at 11:08 A.M., the DON (Director of Nursing) indicated the resident's blood pressure should have been monitored daily per the physician's order. The current facility policy titled, Documenting Guidelines for Nursing with a revision date of 7/24, was provided by the DON on 08/29/24 at 2:45 P.M. The policy indicated, .To accurately document in an organized manner all information related to the resident in the medical record . 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's record accurately reflected the administration of a narcotic medication for 1 of 3 residents reviewed for resident records. (Resident B) Findings include: The clinical record for Resident B was reviewed on 01/12/24 at 2:17 p.m. An admission MDS (Minimum Data Set) assessment, dated 12/02/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, prostate cancer and Chronic Obstructive Pulmonary Disease. The November 2023 EMAR (electronic medication administration record) indicated the resident could receive oxycodone/acetaminophen (a narcotic pain medication) 5 mg (milligrams), 325 mg every four hours PRN (as needed) for pain. During an interview on 01/12/23 at 2:13 P.M., Resident B indicated on Sunday 11/26/23 RN 2 asked him after lunch to take his PRN pain medication. He told her he was not having any pain and didn't need the medication. She told him if he didn't take it she would have to throw it away. The Controlled Substance Record indicated the resident received oxycodone/acetaminophen 5 mg, 325 mg on 11/26/23 at 7:15 A.M. and 1:00 P.M. Review of the November 2023 EMAR lacked documentation of the administration of the oxycodone/acetaminophen 5 mg, 325 mg on 11/26/23 at 7:15 A.M. and 1:00 P.M. During an interview on 01/16/24 at 2:01 P.M., RN 3 indicated a PRN medication should not be removed from the medication cart until the resident makes the request for the medication. Blanks in the EMAR indicated the medication was not given. When a controlled substance needed to be destroyed, there should be two nurses, the medication was placed in the drug buster container and both nurses sign the controlled substance record sheet. The current facility pharmacy policy with a revision dated of 01/10/22, was provided by the Director of nursing on 01/16/24 at 3:00 P.M. The policy indicated, .Document the administration of controlled substances in accordance with Applicable Law .Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms .Medication administration will be recorded on the MAR (Medication Administration Record)/EMAR or TAR (Treatment Administration Record) after given . This citation relates to Complaint IN00422886. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to store medications appropriately related to insulin pens for 1 of 2 medication carts reviewed. (Back Hall medication cart) Findings include: On 06/12/23 at 10:55 A.M., the Back Hall medication cart was observed with RN 2, and contained the following: - A Lispro insulin pen for Resident 5, with an open date of 05/14/23. The nurse verified the open date. The pen was 1/4 full. The resident had received the insulin that morning. - A Lispro insulin pen for Resident 7, with an open date of 05/14/23. The nurse verified the open date. The pen was 1/4 full. The resident had received the insulin that morning. During an interview on 5/14/23 at 10:58 A.M., RN 2 indicated the Lispro insulin pens were good for 30 days after the open date. During an interview on 06/12/23 at 2:00 P.M., the Administrator indicated the facility did not have a specific medication storage policy, they followed the pharmacy recommendations. The current facility pharmacy manual, with a revised date of 01/01/22, was provided by the DON on 06/12/23 at 11:45 A.M. The manual indicated, .Insulin Lispro pen once opened is good for 28 days . The pens should have been taken out of use after 06/10/23. 3.1-25(j) 3.1-25(o)

Based on interview and record review, the facility failed to identify pressure ulcers in a timely manner and document treatment administrations for 1 of 2 residents reviewed for pressure ulcers. (Resident 1) Findings include: During an interview on 06/07/23 at 9:31 A.M., Resident 1 indicated she had pressure wounds on her bottom that had recently healed. The resident's record was reviewed on 06/11/23 at 4:51 P.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/19/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, heart failure, renal disease, and hypertension. The resident required extensive staff assistance with transferring, toileting, and personal hygiene. The resident was at risk for pressure ulcers, and currently had one Unstageable pressure ulcer (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough [moist, non-viable tissue] or eschar [dead tissue]). A Wound Management Detail Report, dated 05/10/23, indicated a pressure ulcer was identified on the resident's left buttock that measured 1.3 cm (centimeters) x (by) 0.6 cm. The wound was unstageable, as it was 100% (percent) covered by slough. A Progress Note, dated 05/10/23 at 3:02 P.M., indicated a new, unstageable pressure ulcer was identified on the resident's left buttock. A new physician's order was obtained for treatment. The treatment was the daily application of Santyl (a medication that removed dead tissue from wounds) and an Optifoam dressing (a waterproof foam dressing with a high fluid-handling capacity). A Wound Management Detail Report, dated 05/26/23, indicated the pressure ulcer on the resident's left buttock measured 1 cm x 1 cm. The wound was still unstageable, as it was 100% covered by slough. A Wound Management Detail Report, dated 05/26/23, indicated a new pressure ulcer was identified on the resident's right buttock that measured 1.6 cm x 2 cm. This wound was unstageable, as it was 100% covered by slough. A Progress Note, dated 05/26/23, indicated a new, unstageable pressure ulcer was identified on the resident's right buttock. New interventions included a new wound treatment order, a low air loss mattress, and new physician's orders for a multivitamin and zinc supplements. The progress note indicated the current treatment order for the right buttock wound was Medihoney (a honey wound gel) and an Optifoam dressing. The May 2023 ETAR (Electronic Treatment Administration Record) was provided by the DON (Director of Nursing) on 06/12/23 at 1:03 P.M. The record indicated the following physician ordered treatments were administered: - The Santyl and Optifoam dressing treatment was administered daily to the left buttock from 05/10/23 until it was discontinued on 05/26.23, and - The Medihoney and Optifoam dressing treatment was administered daily to the left buttock from 05/26/23 until it was discontinued on 05/30/23. - A treatment listed on the May 2023 ETAR indicated nursing staff were to apply Skin Prep (a liquid, film forming dressing) to the dry area on the right buttock every shift from 05/10/23 until the treatment was discontinued on 05/30/23. The record lacked documentation of any other treatment to the wound on the resident's right buttock. Both wounds were documented as resolved on 05/30/23 in the Wound Management Detail Report. During an interview on 06/12/23 at 11:25 A.M., the DON indicated the wounds on the resident's buttocks should have been identified before they were unstageable wounds. The wound on the resident's right buttock was identified one day and gone a few days later. During an interview on 06/12/23 at 2:35 P.M., CNA (Certified Nurse Aide) 3 indicated staff were to look out for skin impairments. They would observe the residents' skin while assisting a resident with toileting, bathing, dressing, and undressing. If they found a wound, they would notify the nurse. They also filled out shower sheets on shower days and would note any skin impairments there. Resident 1 required enough assistance with ADLs (Activities of Daily Living) that her skin would be observed at least daily. The current facility policy, titled Skin Management Program, with a most recent revision date of 05/22, was provided by the DON on 06/12/23 at 1:03 P.M. The policy indicated, .It is the policy .to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable .a resident with pressure ulcers receives necessary care and treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing .Interventions to prevent wounds from developing and/or promote healing will be initiated . 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure residents rights to privacy and confidentiality were not violated, related to an unauthorized video recording for 1 of 3 residents reviewed. (Resident B) Findings include: During a record review on 9/26/22 at 10:25 a.m., the Administrator provided an incident report dated 6/22/22. The report indicated CNA 2 had posted a snap chat of herself in a residents room online and for a brief moment Resident B was observed in the background. The clinical record for Resident B was reviewed on 9/26/22 at 10:35 a.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment, dated 8/15/22, indicated the resident was moderately cognitive impaired. She had minimal difficulty hearing, had clear speech, she was understood, understands others, and had adequate vision with corrective lenses. She required extensive assistance of two staff for mobility; and one staff extensive assistance for transfer and Activities of Daily Living (ADLs). She was always incontinent of bladder and frequently incontinent of bowel. During an interview on 9/27/22 at 1:42 p.m., the Director of Nursing (DON) indicated CNA 2 had taken a snap chat video of herself sitting on a resident's bed, the resident was in the bed, and you could not tell which resident it was. The DON indicated it was Resident B. After being shown the snap chat, she took it to the Administrator. Then they took it to the Senior [NAME] President of Operations. They reviewed the video and decided to treat it as a violation of policy for the use of cell phones. During an interview on 9/27/22 at 2:07 p.m., the Social Services Director indicated she was told that a staff member had laid down in the bed with Resident B, took a picture of herself and the resident,then she had posted it to snap chat. During an interview on 9/27/22 at 2:12 p.m., CNA 3 indicated she saw a video of CNA 2 on snap chat. When she saw it, she notified and showed it to the DON. She was able to identify Resident B from the video. The current facility policy titled Media Relations, and not dated, was provided by the Administrator on 9/27/22 at 1:50 p.m. The policy indicated, .Social Media .Under no circumstance are photos, videos, or any image of a resident or their information to be posted on any social media sites . This Federal tag relates to Complaint IN 618. 3.1-3(o)

Based on observation, interview, and record review, the facility failed to implement appropriate pain management interventions before or during a wound treatment resulting in the resident crying out, gritting her teeth, moaning, and grimacing during the treatment for 1 of 3 residents reviewed for pain management. (Resident 28) Findings include: During an observation on 06/21/22 at 11:07 A.M., RN 3 explained to Resident 28 that she was going to change the wound dressing on the resident's right heel. She washed her hands and donned gloves. RN 3 started to cut the dressing off the resident's foot when the resident started saying it hurts, it hurts. The resident's eyes were closed. She was gritting her teeth, moaning, and grimacing. RN 3 removed the dressing while the resident continued to cry out. The RN was stopped and asked if the resident could have pain medication. The RN indicated when she finished administering the wound treatment, she would see if the QMA (Qualified Medication Aide) could get the resident some pain medication. RN 3 cleansed the wound and removed her gloves. The nurse then donned new gloves, applied the cream to the wound, applied the dressing, and doffed her gloves. The resident continued to say she was in pain multiple times during the treatment. After the treatment was complete, RN 3 asked the QMA to give the resident some pain medication. During an interview on 06/21/22 at 11:26 A.M., Resident 28 indicated her foot hurt every time the dressing was changed. She was never offered any pain medication before the treatment began; they would wait and offer her medication once the treatment was complete. During an interview on 06/21/22 at 11:37 A.M., the DON (Director of Nursing) indicated the resident didn't have a lot of pain from her wound. If she sat up for long periods of time, she would say it would be throbbing and they would give her Tylenol. The resident didn't usually have any complaints during the dressing changes. During an interview on 06/21/22 at 1:34 P.M., LPN (Licensed Practical Nurse) 4 indicated before changing a dressing she would ask the resident if they wanted pain medication or if they were having any pain. She never changed the resident's wound dressing, so she was unsure if the resident had pain in the area. A Wound Management Detail Report, dated 05/12/22, indicated the resident had an unstageable pressure ulcer to the right heel that was present on admission. The wound measured 4.3 cm (centimeters) X (by) 2.9 cm. A Wound Management Detail Report, dated 06/07/22, indicated the resident's wound measured 2 cm X 4 cm. The resident winced when you touched the wound. A Progress Note, dated 06/16/22, indicated the resident's wound dressing was changed. The resident's heel was tender to touch with the dressing change, but the resident denied pain after the dressing was completed. The clinical record for Resident 28 was reviewed on 06/17/22 at 12:04 P.M. An Admission MDS (Minimum Data Set) assessment, dated 05/18/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current facility policy titled, Dressing Change Clean Technique, with a revision date of 06/2021 was provided by the DON on 06/21/22 at 2:46 P.M. The policy indicated, .5. Assess for the presence of pain and pre-medicate if necessary. If pain present, do not proceed with procedure. Note: If resident complains of pain or shows non-verbal signs of pain at any time during the procedure, stop and gently cover wound to protect from contamination. Assess pain and provide intervention . The current facility policy titled, Pain Management, with a revision date of 10/20 was provided by the DON on 06/21/22 at 2:46 P.M. The policy indicated, .to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, including pain management . 3.1-37(a)

Based on interview, record review, and observations, the facility failed to implement interventions following falls for 2 of 4 residents reviewed for accident hazards. (Residents 15 and 19) Findings include: 1. During an interview on 06/20/22 at 3:13 P.M., LPN (Licensed Practical Nurse) 4 indicated Resident 15 had fallen several times recently. A recent fall had resulted in a fracture to her pelvis bone. She had poor safety awareness and still thought she could get up and ambulate on her own. She was very unsteady. The clinical record was reviewed on 06/21/22 at 11:12 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/05/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, fracture of her pubis, dementia, and diabetes. The resident required extensive assistance of two staff members for bed mobility, transfers, and toilet use. The progress notes were provided by the DON (Director of Nursing) on 06/21/22 at 11:05 A.M. A note, dated 04/20/22 at 1:26 P.M., indicated a CNA (Certified Nurse Aide) had found the resident sitting on the floor in the dining room. The resident indicated she was trying to pick a piece of paper up off of the floor and lost her balance. The NP (Nurse Practitioner) had been notified of the resident's blood pressure being 70/40. The NP gave a new order to obtain orthostatic blood pressures lying, sitting, and standing, every shift for three days and to document the blood pressure values. No orthostatic blood pressures were documented in the progress notes. The EMAR/ETAR (Electronic Medication Administration Record/Treatment Administration Record) for April 2022 was provided by the DON on 06/20/22 at 2:00 P.M. The record indicated the resident had an order, with a start date of 04/20/22 and an end date of 04/22/22, to obtain orthostatic blood pressure lying, sitting, and standing daily for three days. The record lacked documentation that the blood pressures had been obtained and no values were documented. The Vitals Report was provided by the DON on 06/20/22 at 2:00 P.M. The report indicated one set of orthostatic blood pressures had been obtained on 04/20/22 at 5:08 P.M. No other orthostatic blood pressure values were documented in the record. A care plan indicating the resident was at risk for falls was provided by the DON on 06/20/22 at 1:05 P.M. An intervention, with a start date of 04/21/22, indicated to obtain orthostatic blood pressures (lying, sitting, and standing) every shift for three days. The current IDT (Interdisciplinary Team) Comprehensive Care Plan Policy, with a revised date of 10/2019, was provided by the DON on 06/21/22 at 2:51 P.M. The policy indicated, .The care plan will include measurable goals and resident specific interventions based on resident needs .to promote the resident's highest level of functioning . 2. Resident 19 was observed in her room in bed on 06/17/22 at 9:45 A.M. The resident's bed was in a low position, and a low air loss mattress was in place. The resident was laying on her right side leaning towards the wall. The resident was yelling out and indicated she would like some help to sit up. Staff were alerted and repositioned the resident in bed. The resident's clinical record was reviewed on 06/17/22 at 11:44 A.M. A Quarterly MDS assessment, dated 05/05/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, senile degeneration of the brain, hypertension, [CONDITION(S)], malnutrition, and dysphagia. The resident received hospice services. The resident required extensive assistance from two staff members for bed mobility. The resident experienced one fall with a minor injury since the last assessment. A progress note, dated 05/01/22 at 08:57 P.M., indicated the resident was yelling help me help me get me off the floor. Staff entered the room, and the resident was sitting on her buttocks on the floor with her back resting on the frame of her bed. The resident was assessed, and her vital signs were normal. There was no apparent injury, but the resident's entire back was reddened. The resident was incontinent of stool at time of fall. The bed was in a high position, and the bed linens were scattered on the floor adjacent to the bed. The resident was assisted back into bed and pillows were placed on the side of the bed not resting against the wall to define bed parameters. The DON, Nurse Practitioner, Hospice Services, and the resident's family were notified of the fall. An IDT fall review note, dated 05/02/22 at 10:03 A.M., indicated the resident experienced a fall on 05/01/22 at 9:00 P.M. The resident rolled out of bed, was assessed by the nurse, and assisted back to bed with proper positioning. There were no injuries, and the resident was not in pain. The determined root cause of the fall was that positioning was difficult due to the resident leaning. The intervention put into place was to address the root cause of the fall. The facility was to ask the hospice nurse for a scoop mattress to help with positioning. During an interview on 06/21/22 at 1:20 P.M., the Hospice RN indicated facility nursing staff could contact hospice anytime. They could call the office or speak to the hospice nurse directly. A scoop mattress was something hospice could provide the resident. The facility never talked to hospice about a scoop mattress for the resident. The resident's fall risk care plan, with a start date of 10/31/20, was reviewed. The interventions included, but were not limited to, an intervention with a start date of 05/02/22 to have hospice assess the resident for a bolster mattress (a mattress with soft foam bolsters in place to define the edges of the bed and prevent falling). During an interview on 06/21/22 at 2:05 P.M., the DON indicated the resident did not currently have a scoop mattress. The current facility policy, titled Fall Management Program, dated 04/22/21, was provided by the DON on 06/21/22 at 2:50 P.M. The policy indicated, .ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .all falls will be discussed .to determine root cause and other possible interventions to prevent future falls .the care plan will be reviewed and updated, as necessary . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to prevent an unstageable (full thickness tissue loss) pressure ulcer for 1 of 2 residents reviewed for pressure ulcers. (Resident 13) Findings include: During an observation on 06/21/22 at 10:02 A.M., Resident 13 was assisted back to his room from the hallway. RN 3 explained to the resident she was going to change the dressing to his buttocks. She washed her hands and donned gloves. She removed the old dressing that had a small amount of blood on the dressing. The wound was approximately the size of a nickel with a red/pink wound bed. The skin surrounding the wound was pink and healing. There was no odor. RN 3 cleansed the wound, doffed her gloves, washed her hands, and donned new gloves. She retrieved a tube of ointment from a plastic bag using both gloved hands. She removed the cap, applied a small amount directly to the wound bed, and spread the ointment with her left gloved finger. She covered the wound with a foam dressing. The clinical record for Resident 13 was reviewed on 06/17/22 at 9:42 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/03/22, indicated the resident was moderately cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two or more staff members with personal hygiene and total staff assistance with bathing. The resident had an unhealed unstageable pressure ulcer. The March and April 2022 Progress Notes were provided by the Corporate Clinical Nurse on 06/20/22 at 2:47 P.M. The Progress Notes included the following: - 03/12/22 at 12:29 A.M., the resident had redness to the coccyx and needed assistance with all care, - 04/06/22 at 5:48 P.M., the resident required assistance of one to two staff with ADL's (Activities of Daily Living). The [CONDITION(S)] continued on the bilateral buttocks, - 04/20/22 at 12:57 P.M., the resident reported pain with sitting on bottom. A treatment was being completed by the nurse. There was redness noted and no open areas. The April 2022 Shower Day Skin Audit records were provided by the Corporate Clinical Nurse on 06/20/22 at 3:09 P.M. The shower audits indicated the following: - 04/06/22, the resident had no new areas, continued with redness to the coccyx/sacrum and hips/buttocks, and ointment was initiated, - 04/20/22, the resident had redness to the coccyx/sacrum and hips/buttocks, there was unusual redness to the resident's body. - 04/25/22, the resident had no new areas, continued with redness to the coccyx/sacrum. The form indicated the areas were old areas. A Progress Note, dated 04/25/22 at 11:52 A.M., indicated a wound was found on the upper left buttock that measured 3 cm (centimeters) X (by) 3 cm. The wound was reported to the Nurse Practitioner and a new order was obtained to clean the wound with normal saline, cover with a thin layer of Santyl (an ointment that removes dead tissue) and cover with gauze dressing, daily. A Wound Management Detail Report, dated 05/01/22, indicated the resident had an unstageable-slough (yellow/white material in the wound bed), and/or eschar (dry black tissue) to the left buttocks that measured 3 cm X 3 cm. The wound had necrotic (dead) tissue and was 15% covered in eschar. A Wound Management Detail Report, dated 05/31/22, indicated the resident had an unstageable- slough and/or eschar to the left buttocks that measured 2.8 cm X 1.2 cm. The wound had a light amount of serosanguineous (pale red to pink, thin and watery) exudate with 85% of the wound covered in eschar. The resident was started on an antibiotic that day to aide in wound healing. A Wound Management Detail Report, dated 06/14/22, indicated the resident had a Stage 2 (loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) to the left buttocks that measured 2.4 cm X 0.2 cm. The wound had a light amount of serous (clear, amber, thin, and watery) exudate. The Complete Care Plan was provided by the Corporate Clinical Nurse on 06/20/22 at 2:47 P.M. The Care Plan included the following: A Care Plan, with a start date of 02/23/22, indicated the resident was at risk for skin breakdown due to incontinence and impaired mobility. The resident removed the pressure reducing cushion from the chair. The interventions included to assist the resident with peri- care; keep clean and dry, encourage resident to turn and reposition at least every two hours; provide assistance as needed, house barrier cream at bedside; use as needed, incontinence care as needed using peri wash and moisture barrier, pressure reducing/redistribution mattress on the bed and pressure reducing cushion in the wheelchair. During an interview on 06/20/22 at 1:13 P.M., QMA (Qualified Medication Aide 2) indicated the resident would let staff know when he needed something. The resident had a urinary catheter and needed frequent help and queuing. The resident was incontinent of his bowels. The resident had a sore on his bottom, so the staff had to make sure the dressing was intact, and the resident would get cleaned up in the bathroom. The resident showers were completed twice a week. The staff would observe his skin and alert the nurse of any changes. During an interview on 06/20/22 at 2:14 P.M., LPN (Licensed Practical Nurse) 4 indicated when a resident had a new wound the wound would be assessed, the MD, DON (Director of Nursing), and family would be notified. Treatments would be started if ordered and a wound skin assessment event would be completed on the computer. During an interview on 06/20/22 at 2:07 P.M., the DON indicated the resident had been sitting in a chair in the dining room when his shirt had rolled up and it was noted the resident had a wound on his upper buttocks. The first time it was observed the wound already had necrotic tissue covering it. The nursing staff should monitor the resident's skin when taking them to the bathroom and when assisting them with changing their clothes. The resident would refuse showers at times. Any new redness or wounds should be communicated to the charger nurse and an assessment event completed on the computer. She would follow-up on any new wounds. If a resident had redness to the bottom that was blanchable the staff would apply cream. If a resident was started on a cream as a pressure prevention it would be documented in the progress notes. The current undated facility policy titled, Wound Care Prevention and Intervention was provided by the Corporate Clinical Nurse on 06/21/22 at 2:07 P.M. The policy indicated, The foundation of pressure injury management is prevention. The purpose of the recognition and assessment phases for residents who have not developed a pressure injury is to provide the framework for implementation of a prevention strategy that reduces the risk of pressure injury occurrence . The current facility policy titled, Dressing Change Clean Technique, dated 01/2010 was provided by the DON on 06/21/22 at 2:46 P.M. The policy indicated, .If using an ointment, or gel you may use a cotton-tip applicator or clean gloved finger. (If using clean gloved finger, remove gloves after application, perform hand hygiene, and put on new gloves prior to application of secondary dressing) . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to apply treatments to a resident's wound (Resident 12) for 1 of 15 residents reviewed for quality of care. Findings include: During an interview on 06/20/22 at 2:17 P.M., Resident 12 indicated he had open heart surgery well over a year ago. There had been problems with the wound healing in the past that required the use of a wound vac. The resident lifted his shirt, and his chest was observed. An approximately 12 cm (centimeter) long pink scar was observed in the center of the resident's chest. The resident's chest sloped inward on both sides along the length of the incision site. The resident indicated the surgical wound had been healed for quite some time, but the treatment that was in place a few months ago was to apply a cream to the area twice a day. Nursing staff didn't always apply the cream when it was supposed to be done. The resident's clinical record was reviewed on 06/21/22 at 2:14 P.M. A Significant Change MDS assessment, dated 01/13/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 01/18/22 at 7:49 P.M., indicated the Nurse Practitioner was in to see the resident. A new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Resident Council Minutes for the February 25, 2022 meeting were reviewed on 06/20/22 at 1:18 P.M. In the New Business section of the minutes, Resident 12 indicated the treatment to his chest was not getting done. The resident's January, February, and March 2022 TARs (Treatment Administration Record) indicated the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR lacked documentation the cream was applied at any time during the month of February. A progress note, dated 03/30/22 at 5:44 P.M., indicated a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/21/22 at 2:05 P.M., the Director of Nursing indicated the facility did not have a policy related to following MD orders. It was just standard nursing practice to follow MD orders. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide fingernail care for 1 of 15 residents reviewed for Activities of Daily Living. (Resident 13) Findings include: During an observation and interview on 06/15/22 at 10:51 A.M., Resident 13 had long fingernails on both hands. He indicated his fingernails were long and he wished someone would cut them for him. During an observation and interview on 06/16/22 at 2:18 P.M., the resident was sitting in the hallway on the couch. The resident indicated his fingernails had not been trimmed. The fingernails on the residents left hand were long with some dark debris built up underneath a few of the nails. During an observation on 06/17/22 at 12:43 P.M., the resident was sitting in the dining room, eating lunch. The resident's fingernails were long with a dark buildup of debris underneath several of the nails. During an observation on 06/20/22 at 10:56 A.M., the resident was sitting in the dining room. The resident's fingernails were long and jagged with dark debris underneath several of the nails. The clinical record for Resident 13 was reviewed on 06/17/22 at 9:42 A.M. A Significant Change MDS (Minimum Data Set) assessment, dated 05/03/22, indicated the resident was moderately cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of two or more staff members with personal hygiene and total staff assistance with bathing. During an interview on 06/20/22 at 1:20 P.M., QMA (Qualified Medication Aide) 2 indicated resident showers were to be completed twice a week. During the shower she would check, cut, and clean the residents' fingernails. The Complete Care Plan was provided by the Corporate Clinical Nurse on 06/20/22 at 2:47 P.M. A Care Plan, with a start date of 05/19/22, indicated the resident required assistance and/or monitoring with AM/PM (morning and evening) care. The June 2022 Shower Day Skin Audit record was provided by the Corporate Clinical Nurse on 06/20/22 at 3:09 P.M. The record indicated the resident had received showers on the following dates: - 06/01/22, - 06/13/22, - 06/16/22, and - 06/19/22. During an interview on 06/21/22 at 2:43 P.M., the DON (Director of Nursing) indicated the facility did not have a policy related to ADL (Activities of Daily Living) care related to fingernails. The resident's fingernails should have been cleaned and trimmed on shower days and as needed. If the resident was a diabetic the nurse would trim the nails on shower days and as needed. 3.1-38(a)(2)(A)

Based on record review and interview, the facility failed to implement pharmacy recommendations in a timely manner for 4 of 5 residents reviewed for unnecessary medications. (Residents 6, 18, 2, and 13) Findings include: 1. The clinical record for Resident 6 was reviewed on 06/17/22 at 1:20 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 03/24/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, stroke, diabetes, and [CONDITION(S)]. The resident's current physician's orders included an open ended order, with a start date of 07/29/21, indicated the resident was prescribed to have [MEDICATION(S)] (a medication to treat high cholesterol and triglyceride levels), 80 mg (milligrams) at bedtime for [CONDITION(S)]. A Pharmacy Consultation report, issued on 04/15/22, indicated the resident received [MEDICATION(S)] and had not had a blood test for a fasting lipid panel documented in the medical record in the previous 12 months. The recommendation was to monitor a fasting lipid panel and LFTs (Liver Function Tests) on the next convenient lab day and every 12 months thereafter. During an interview on 06/21/22 at 3:37 P.M., the DON (Director of Nursing) indicated the pharmacy recommendation had not been addressed and the recommended blood tests had not been obtained. 2. The clinical record for Resident 18 was reviewed on 06/20/22 at 2:52 P.M. A Quarterly MDS assessment, dated 05/05/22, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, stroke, [CONDITION(S)], [CONDITION(S)], hypertension, [CONDITION(S)], anxiety, and depression. A Pharmacy Consultation report, dated 01/12/22, indicated the resident received [MEDICATION(S)] 40 mg daily and had not had a blood test for a fasting lipid panel documented in the medical record in the previous 12 months. The recommendation was to monitor a fasting lipid panel and LFTs on the next convenient lab day and every 12 months thereafter. The Physician's Order record for January 2022, was provided by the DON on 06/21/22 at 3:36 P.M. The record lacked documentation that the blood tests had been ordered. The DON indicated the labs had not been ordered. 3. The clinical record for Resident 2 was reviewed on 06/16/22 at 2:26 P.M. A Quarterly MDS assessment, dated 05/26/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, stroke, cancer, [CONDITION(S)], hypertension, diabetes, anxiety, and depression. A Pharmacy Consultation report, issued on 05/18/22 indicated the resident received [MEDICATION(S)] and had not had a blood test for a fasting lipid panel documented in the medical record in the previous 12 months. The recommendation was to monitor a fasting lipid panel and LFTs on the next convenient lab day and every 12 months thereafter. The clinical record lacked documentation to indicated the MD had been notified of the pharmacy recommendation. 4. The clinical record for Resident 13 was reviewed on 06/17/22 at 9:42 A.M. A Significant Change MDS assessment, dated 05/03/22, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, diabetes, [CONDITION(S)], heart failure, hypertension, depression, [CONDITION(S)] disorder, and [CONDITION(S)]. A Pharmacy Consultation report, issued on 04/15/22 indicated the resident received [MEDICATION(S)] and had not had a blood test for a fasting lipid panel documented in the medical record in the previous 12 months. The recommendation was to monitor a fasting lipid panel and LFTs on the next convenient lab day and every 12 months thereafter. The clinical record lacked documentation to indicated the MD had been notified of the pharmacy recommendation. During an interview on 06/21/22 at 2:25 P.M., the DON indicated the labs were not completed and the resident's pharmacy recommendations should have been sent to the MD and addressed. The current facility policy titled, Medication Regimen Review, with a revision date of 03/03/20, was provided by the DON on 06/21/22 at 3:13 P.M. The policy indicated, .Facility should independently review each resident's medication regimen directly from the resident's medical chart and with Interdisplinary Care Team members, resident or Responsible Party, as needed .The pharmacist will address copies of resident's MRR's [Medication Regimen Review] to the Director of Nursing and/or physician and to the Medical Director. Facility staff should ensure the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRR's. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected . 3.1-48(a)(3)

Based on interview and record review, the facility failed to follow the facility-wide assessment based on the residents needs and the required resources to provide the care and services needed. This had the potential to affect 33 of 33 residents residing in the facility. Findings include: During an interview on 6/9/22 at 9:55 p.m., LPN (Licensed Practical Nurse) 2 indicated there were only two staff on duty, that shift, in the building. One LPN and a one CNA (certified nurse aide). During an interview on 6/9/22 at 9:59 p.m., CNA 3 indicated she was on the front porch, on a break, came back in and rounded the corner to the right, toward the hallway to the nurses station. When she did she saw Resident C with his arms around the LPN, who was in the floor. CNA 3 went behind him and grabbed his arms, so the LPN could get up. He kicked the CNA in the head, so she turned to secure his foot. When she turned around he stabbed her in the thumb with an ink pen. He had tried to stab the LPN with the pen, but it was upside down and was just clicking. Both staff on duty indicated another resident (Resident E) had called 911. A Progress Note, dated 6/9/22 at 7:34 p.m., indicated the DON (Director of Nursing) was called due to the resident's behaviors. The NP (Nurse Practitioner) was called and an order was received to give the resident [MEDICATION(S)] (hormone that plays a role in sleep) at bed time. A Progress Note, dated 6/9/22 at 10:02 p.m. and recorded as a Late Entry on 6/10/22 at 12:28 a.m., indicated the DON pulled into the facility parking lot and was on the phone with the resident's family member. The resident was being transported to the hospital for evaluation. The Clinical Record for Resident C was reviewed on 6/10/22 at 10:41 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Demographics and Facility Plan, was provided by the Administrator on 6/10/22 at 10:28 a.m. The Assessment Date Completed was 1/31/2022 and the QAPI (Quality Assurance and Performance Improvement) Assessment Date reviewed, was 2/7/22. The Facility Assessment Approval Sheet 2022 indicated each Department Leader had reviewed, accepted, and certified the facility assessment was accurate, represented the facility population and resources needed to provide the necessary person centered care and services the residents required on 2/22/22. The data at the time of the assessment indicated there were nine administrative staff. Direct Care Staff included, three RNs, three LPNs, three QMAs (Qualified Medication Assistant), 13 CNAs, one culinary aide, three cooks, two housekeeping staff, two laundry staff, and one activity staff. The Assessment indicated there were residents in the building that required the following: use of mechanical lifts and those were available, there were residents with urinary catheters, pressure ulcers, infusion therapy, respiratory/oxygen treatments, tube feedings, residents that smoked (including E Cigarettes), residents with diabetes, and bariatric residents. The resident Special Conditions were as followed: 1 resident with Hospice Care (3%), 19 residents (58%) incontinent of bowel and bladder, 1 resident (3%) with intellectual developmental disabilities, 7 residents (21%) with mental health disorders, 23 residents (70%) with dementia diagnosis, 7 residents (21%) with behavioral healthcare needs, and 1 resident (3%) under age 55. The Staffing Pattern Review indicated the following staff per shift: first shift had five LPNs, second shift had four LPNs, and the night shift had three LPNs. There were no Non-Licensed Nursing Staff. During an interview on 6/10/22 at 10:38 a.m., the Administrator indicated she did not do the Facility Assessment. She did not know how the DON was determining staffing or why there were only two staff in the building on 6/9/22 at the time of the occurrence. During an interview and record review on 6/10/22 at 12:06 p.m., the DON indicated she had refigured the Resident Demographics based on the current population of residents. She indicated the following: 1. three residents that required two person assistance, 2. only 60% of the residents had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staffing was based on a PPD (Patients Per Day) occupancy and the acuity of residents. She indicated the following: 1. First shift (6:00 a.m. to 2:00 p.m.) only needed one nurse, one QMA, and three CNAs. 2. Second shift (2:00 p.m. to 10:00 p.m.) needed one nurse for the full shift, one QMA for half the shift, and three CNAs. 3. Third Shift (10:00 p.m. to 6:00 a.m.) needed one nurse and two CNAs. The current facility policy, titled Facility Assessment Policy, with a most recent revision date of 1/2022, was provided by the Administrator on 6/10/22 at 10:28 a.m. The policy indicated, .The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for the residents competently during both day-to-day operations and emergencies .Purpose: .intent .to evaluate the resident population and identify the resources needed to provide the necessary person-centered care and services the resident requires .Procedure: .8. The Staffing Pattern Review section will be completed to ensure that the facility has adequate number of competent staff to meet the needs of the resident .

Based on observation, interview, and record review, the facility failed to ensure adequate staffing, which contributed to the lack of resident care and services needed for behavior management for 1 of 3 residents reviewed for behaviors. (Resident C) Findings include: During an observation on 6/9/22 at 9:54 p.m., the facility Exit Door was propped open. Police were in the facility due to an altercation between a male resident and a female staff member. During an interview on 6/9/22 at 9:55 p.m., LPN (Licensed Practical Nurse) 2 indicated the male had attacked her while she was trying to administer a medication. There were only two staff on duty in the building, one LPN and a one CNA (Certified Nurse Aide). During an interview on 6/9/22 at 9:59 p.m., CNA 3 indicated she was on the front porch, on a break, came back in and rounded the corner to the right. She went toward the hallway to the nurses station. She saw Resident C with his arms around the LPN, who was on the floor. She went behind him and grabbed his arms, so the LPN could get up. He kicked the CNA in the head, so she turned to grab his foot. The Clinical Record for Resident C was reviewed on 6/10/22 at 10:41 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 6/8/22, was in progress and not complete. The MDS assessment indicated Resident C was severely cognitively impaired, had difficulty hearing, had clear speech, was usually understood, usually understands others, and had impaired vision with corrective lenses. The Behavior Assessment indicated he had rejected care 4 to 6 days during the assessment period. A Progress Note, dated 6/9/22 at 7:34 p.m., indicated the resident was exit seeking most of the shift. He tried to remove the box off of the fire alarm and would not do what the nurse asked of him. The resident began to pace the halls from door to door. He would not go to his room. The DON (Director of Nursing) was called due to the resident's behaviors. The NP (Nurse Practitioner) was called and an order was received to give the resident [MEDICATION(S)] (hormone that plays a role in sleep) at bed time. A Progress Note, dated 06/09/2022 at 9:30 p.m., indicated the resident was sitting in the hall, the nurse went to give him his new medication, [MEDICATION(S)] 5 mg (hormone that plays a role in sleep). The resident raised his arms up at the nurse, all items flew out of the hand of nurse, the resident stood up, took his fist and doubled it up, and hit the nurse in the face, lower chin area. The resident grabbed the nurse, threw her to the floor, pushing her head into the rug, hit the nurse in back of the head twice, and tried to stab the nurse. Another resident saw it all and called 911. The CNA came up the hall from her break, saw the nurse on the floor, then assisted the nurse to get up. The CNA had an altercation with the resident in the process. The police and EMS arrived. The resident was transported to the hospital. A Progress Note, dated 6/9/22 at 10:02 p.m. and recorded as a Late Entry on 6/10/22 at 12:28 a.m., indicated the DON pulled into the facility parking lot and was on the phone with the resident's family member. The resident was being transported to the hospital for evaluation. A Care Plan, dated 06/03/2022, indicated the resident was at risk for elopement per the Elopement Risk Assessment. The resident had memory problems, impaired cognition and was able to ambulate. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had episodes of exit-seeking. During a record review on 6/10/22 at 10:28 a.m., the Administrator provided the Resident Demographics and Facility Plan. The Assessment Date completed was 1/31/2022, the QAPI (Quality Assurance and Performance Improvement) Assessment Date reviewed was 2/7/22, and all Department Directors approved the plan on 2/22/22. The data at the time of the assessment indicated there were nine administrative staff. Direct Care Staff included, three RNs, three LPNs, three QMAs (Qualified Medication Assistant), 13 CNAs, one culinary aide, three cooks, two housekeeping staff, two laundry staff, and one activity staff. The Plan indicated Special Conditions were: 1 resident with Hospice Care (3%), 19 residents (58%) incontinent of bowel and bladder, 1 resident (3%) with intellectual developmental disabilities, 7 residents (21%) with mental health disorders, 23 residents (70%) with dementia diagnosis, 7 residents (21%) with behavioral healthcare needs, and 1 resident (3%) under age 55. The Plan Staffing Pattern Review indicated the following: first shift had 5 LPNs, second shift had 4 LPNs, and the night shift had 3 LPNs. There were no Non-Licensed Nursing Staff. During an interview on 6/10/22 at 10:38 a.m., the Administrator indicated she did not know why there was only 2 staff in the building on 6/9/22 at the time of occurrence. During an interview and record review on 6/10/22 at 12:06 p.m., the DON indicated she had refigured the Resident Demographics based on the current population of residents. Staffing was based on a PPD (Patients Per Day). Staffing was based on occupancy and the acuity of residents. She indicated there were the following population: 3 residents that required two person assistance and only 60% of the residents had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At 12:08 p.m., she indicated the following plan: 1. First shift (6:00 a.m. to 2:00 p.m.) needed 1 nurse, 1 QMA, and 3 CNAs. 2. Second shift (2:00 p.m. to 10:00 p.m.) needed 1 nurse for the full shift, 1 QMA for half the shift, and 3 CNAs. 3. Third Shift (10:00 p.m. to 6:00 a.m.) needed 1 nurse and 2 CNAs. The current facility policy, titled Behavior Management Policy, with a most recent revision date of 5/2019, was provided by the DON on 6/9/22 at 11:2 p.m. The policy indicated, .to provide behavior interventions for residents with problematic or distressing behaviors .that is directed toward preventing, relieving, and/or accommodating a resident's distressed behavior .

Based on interview and record review, the facility failed to provide adequate monitoring, assessment, and follow up care to a resident when management was notified by a Qualified Medication Aide there was a potential medication error. The nurse on duty failed to report to the oncoming shift of a significant change of a resident related to blood sugar monitoring. Resulting in the resident being found unresponsive the next morning with a blood sugar of 19. (Resident D) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began, on [DATE] at 10:03 p.m., when a moderately cognitive resident had a blood sugar check and a high blood sugar of 495 (normal blood sugar range was from 80 to 130 mg/dl). A QMA (Qualified Medication Aide) notified the Director of Nursing that an agency nurse had given 60 units of [MEDICATION(S)] to a resident who did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was found unresponsive the next morning, 911 was called, emergency medical technicians arrived to find Resident D had a blood sugar of 19 mg/dl (Milligrams per deciliter). Resident D coded and was resuscitated in the emergency room . The resident was admitted to ICU (intensive care unit) where she died on [DATE]. The Health Facility Administrator and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 4:32 p.m. Findings include: A record review for Resident D, on [DATE] at 11:22 a.m., indicated the resident was moderately cognitively impaired, had moderate difficulty hearing, and was sent out to the hospital on [DATE] due to being unresponsive. A review of Resident D's medication list did not have any orders for blood sugar checks and the resident was not prescribed any diabetic medications. The record indicated Resident D resided in Room A and had a roommate, Resident C, who had been on 60 units of [MEDICATION(S)] in the A.M. and 50 units of [MEDICATION(S)] in the P.M. and had moved from Room A to Room B on [DATE]. An Admission MDS (Minimum Data Set) assessment, dated [DATE], indicated Resident D's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MAR (Medication Administration Record) for Resident C, was provided by RN 9 on [DATE] at 10:17 a.m. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The number was lined through and Room B was noted as the room number. There were no initials, date, or time of the lined through correction. A progress note, dated [DATE] at 10:03 p.m., indicated an Administration error. LPN 2 (Licensed Practical Nurse) took the residents blood sugar, and the blood sugar was 495. She called the NP (Nurse Practitioner) and received orders for stat (immediate) labs and to recheck the blood sugar level after one hour. After one hour the resident's blood sugar level was 415. A progress note, dated [DATE] at 10:34 a.m., indicated LPN 3 was alerted by the CNAs (Certified Nursing Aide) that her assistance was needed in a resident's room. Upon entering the room, Resident D was found unresponsive to verbal and stimulation touch. The resident's vital signs were assessed and staff were unable to get a blood pressure on the resident. Oxygen Saturation was 90% on a Nasal Cannula at five liters of oxygen. Lungs sounds were diminished on both sides. [CONDITION(S)] was present in all four extremities. Excessive salvia and bubbles were noted in resident's mouth. Heart Rate was 41 beats per minute, and 911 was called. The LPN stayed with the resident until EMTs (Emergency Medical Technicians) arrived and the resident was transported to hospital by ambulance. An ER report was provided by the hospital Medical Records Department on [DATE] at 4:30 p.m. The report indicated Resident D presented to the ED with a complaint of severe [CONDITION(S)] (low blood sugar). When EMS (Emergency Medical Service) arrived at the facility Resident D's blood glucose was 19. EMS indicated she was given [MEDICATION(S)] in route to the ED. Upon arrival to the ED her blood sugar was 36. The report indicated Resident D had to be intubated, coded, and CPR (cardiopulmonary resuscitation) was started. Once ROSC (Return of Spontaneous Circulation) was achieved the resident was admitted to the ICU. Resident D expired on [DATE]. During an interview on [DATE] at 10:35 a.m., the Administrator indicated the facility had to use a lot of agency staff. Resident D was sent out to the hospital due to being found unresponsive. CNA 7 was in and out of the room all night and talked to the resident through the night. No one saw LPN 2 give the resident the [MEDICATION(S)], but the QMAs said the agency nurse told them, she gave 60 units of [MEDICATION(S)] to Resident D. During an interview on [DATE] at 1:30 p.m., QMA 3 indicated on the day of the medication error, she had worked as a CNA, when an agency nurse came to her and QMA 6 and asked if it was normal for Resident D to have blood sugars in the 500s. The nurse was told Resident D was not even supposed to have her blood sugars checked, the prior nurse LPN 4 was called, because QMAs don't do the blood sugars, and she was asked if Resident D was a blood sugar check or received diabetic medication. LPN 4 said, no she does not do any of that. We had the nurse walk us down to the room, to verify the resident, and while on the way the nurse said, well, she will be ok, I gave her 60 units of [MEDICATION(S)]. During an interview on [DATE] at 1:55 p.m., the DON (Director of Nursing) indicated Resident D did not have orders for blood sugars or insulin as her diabetes was diet controlled. The DON indicated she did not have a roommate at the current time. During an interview on [DATE] at 10:30 a.m., the Clinical Support Nurse and the Administrator indicated there were no medications pulled from the EDK (Emergency Drug Kit) on [DATE]. It was in her report that NP 5 did receive a call that Resident D had a high blood sugar and gave an order to monitor and draw labs. The report indicated NP 5 may have given an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C had been in Room A but moved on [DATE] to Room B. Resident C would have had an A.M. dose of 60 units and a P.M. dose of 50 units of [MEDICATION(S)]. During an interview on [DATE] at 11:41 a.m., NP 5 indicated LPN 2 contacted her on [DATE] and indicated she had taken a blood sugar on a resident that was not a known diabetic, and that the resident's blood sugar was over 400. The NP indicated she would have given an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The insulin would have been Novolog or [MEDICATION(S)], which ever one they would have had in the EDK. Six units would have been the amount ordered for a blood sugar over 400 for a patient that was not a known diabetic. She would have gone off call at 10:00 p.m., so does not know anything else concerning the resident. During an interview on [DATE] at 2:14 p.m. LPN 4 indicated she received report on the morning of [DATE] and was in the middle of her medication pass when the CNAs told her Resident D was unresponsive. When she went into the resident's room, Resident D was foaming at the mouth. She was unable to get vitals on her and her blood sugar level was 23. 911 was called and EMS was in the room for at least 20 minutes, there were several of them (maybe five). The evening before ([DATE]), QMA 3 had called to inquire if Resident D was a blood sugar check. The resident did not require her blood sugars to be checked, she never had her blood sugar checked, and she never got insulin. If a resident's blood sugar level was outside the physician's perimeter, then staff would call the NP/MD. Personally, I think she had the people confused, because Resident C was on the opposite end of the hall and she does get 60 units of [MEDICATION(S)]. During the report that morning she had not been told about any [MEDICATION(S)] issues or significant change, she was only told about the NP order to monitor blood sugars. During an interview on [DATE] at 2:20 p.m., QMA 3 indicated she and QMA 6 had worked as the CNAs on the evening of [DATE]. LPN 4 was her nurse and worked 6:00 a.m. to 6:00 p.m. An Agency nurse replaced her at 6:00 p.m. LPN 4 was gone by 6:30 p.m., so LPN 2 would have been doing medication pass around 7:00 to 7:30 p.m., probably closer to 7:00 p.m. We were in the back hall (QMA 3 and 6), the nurse walked up and ask if it was normal for Resident D to have blood sugars in the 500s. We told her she was not a sugar check that we knew. When we walked the nurse to the room, she verified Resident D's name and said well, she will be ok, I gave her 60 units of [MEDICATION(S)]. The DON was notified of a potential medication error. QMA 3 and QMA 6 were off at 10:00 p.m., so they gave report to CNA 7 for the third shift. We told her to keep an eye on the resident [ Resident D]. During an interview on [DATE] at 3:34 p.m., LPN 2 indicated she was an Agency Nurse and on [DATE] it was her first shift in the building. When she came in, she was given report and no other training. She indicated she had written that Resident D was a blood sugar check on her report sheet and would have done that because she was told that. She notified the NP she had taken a blood sugar on a wrong resident and received orders to draw labs. The DON was notified. It took almost an hour to get the labs drawn, the resident was pretty swollen. There was only one more blood sugar taken, and it should be documented. She was not given access to the EDK or access to the computer to chart. She had to call the DON to be able to chart. The MARs were on paper, and it was very confusing. She could not remember if any of the room numbers were lined out on the MAR, the documents were a mess and very confusing. When she entered into each room, she looked at the name and the room number. There were no pictures of the residents on the MAR. She did give lots of insulin that night and does not recall who she gave insulin to, but she did not give insulin to the resident. (Resident D) During an interview on [DATE] at 3:39 p.m., CNA 7 indicated during report the QMAs had indicated she needed to keep an eye on Resident D. She had gone into her room a couple of times, and she was irritable but that was fairly routine for her. When CNA 7 went into the room for the last time between 3:30 and 4:00, Resident D seemed her normal self. During an interview on [DATE] at 12:02 p.m., QMA 6 indicated on [DATE], she and another QMA were working the floor as CNAs. After supper LPN 2 ask us, if Resident D's blood sugars ran in the high 400s. We called the prior shift nurse and she indicated Resident D was not a blood sugar check. LPN 2 said, well, she would be ok, as she gave the resident 60 units of [MEDICATION(S)]. We both walked with her to Room A and ask if that was the person, she gave insulin to, and she said yes. That resident was Resident D. During an interview on [DATE] at 12:15 p.m., the DON indicated the only indication she had of a possible medication error, came from the QMAs, but the nurse denied giving Resident D any insulin. She assessed Resident D when she came in to pick up the blood sample at 10:10 p.m., from LPN 2, to deliver to the hospital; the resident was fine and talking with her. The DON told the nurse to monitor her through the night. The DON did not know when the room numbers on the MARs were crossed out and changed, as she was off work. She did not recall the room numbers being marked out and changed when she had worked the floor, because she knows her residents. It did not occur to her that the agency nurses would not know the residents; and she did not think about putting pictures of the residents in the MAR until after this incident. She had not returned to the facility on [DATE] to check on the resident. After leaving the hospital when she dropped off the blood work she went home. She was not sure of the training that agency staff received other than the required dementia, abuse, etc. During an interview on [DATE] at 12:28 p.m., the Administrator indicated agency staff had a tour of the building and the nurses would tell them where things were, there was no other training for agency staff. That would now be part of the facilities plan of corrections. During an interview on [DATE] at 1:15 p.m., The Nurse Consultant indicated the DON called her that Saturday morning and told her the aids told LPN 4 that the LPN 2 had given Resident D insulin. She was instructed to contact LPN 2. Later that night, the DON indicated the nurse said she did not give any insulin to Resident D. They do not know if the nurse gave the [MEDICATION(S)], because she said she did not give the insulin, in her professional opinion the resident mostly likely did get some insulin. The DON would be responsible for making sure that all documents were corrected, if a resident moved rooms. During a return phone call, from a call placed on [DATE], the emergency room physician indicated in his professional opinion insulin ([MEDICATION(S)]) would have been the cause of a resident's blood sugar dropping from 495 to 19 mg/dl in a 12 to 14 hour period. An infection would cause the blood sugar to go up. It was his understanding the resident was given insulin the night before. A policy, titled Medications - General Policies dated ,d+[DATE] and revised ,d+[DATE], indicated .Administration of Medications .Read the label with the eMAR, second, when pulling up the medication, and third, when preparing to administer the medication to the resident. If there is need for further clarification, check with the physician before giving the medication to the resident .Photographs of residents shall be taken within 24 to 48 hours after admission, retaken periodically as residents appearance change, and uploaded into the resident's electronic medical record for identification purposes. If the nurse has any doubt about the identification of the resident, he/she will confirm the resident's identity with another staff member. The immediate jeopardy, that began on [DATE], was removed on [DATE], when the facility completed the following: education of every nurse and QMA regarding the facility policy for accurate medication administration, including the 5 Rights of administration; every nurse and QMA were in-serviced regarding the facility policy for Resident Change of Condition, including the expectation that a resident's change in condition must be communicated by the nurse from shift-to-shift to allow for consistency in monitoring of the resident's condition; education regarding the facility policy for medication errors, Nurse consultant in-serviced the Director of Nursing regarding her role in actively directing the nurse when a medication error has occurred, including monitoring the resident, assessment of the resident's condition, and follow up care; Orientation of agency nurses to the facility to include medication error policy, resident change of condition policy; pictures of each resident were present with their Medication Administration Records for identification purposes; resident room changes will be dated and initialed of the person changing the room documentation on each page of documentation that carries the former room number; agency staff will receive and complete orientation packets prior to working their first shift; This Federal tag relates to Complaint IN 921. 3.,d+[DATE](a)

Based on observation, record review, and interview, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents 20, 13, 26, and 17) Findings include: 1. On 07/07/21 at 2:24 P.M., Resident 20 was observed sitting on a love seat in the hallway across from an entry door looking out the window. He was awake and alert and his speech was clear. A Quarterly MDS (Minimum Data Set) assessment, dated 05/26/21, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had received insulin injections for seven of the seven days during the assessment review period. The July MAR/TAR (Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked documentation of the morning blood sugar levels and insulin administration on the following days: - 07/01/21, - 07/02/21, - 07/03/21, - 07/04/21, and - 07/05/21. b. An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked documentation of the evening blood sugar levels and insulin administration on the following days: - 07/01/21, - 07/02/21, - 07/03/21, - 07/04/21, - 07/05/21, - 07/06/21 - 07/07/21, and - 07/08/21. 2. On 07/07/21 at 2:58 P.M., Resident 13 was observed in bed watching television. She was awake and alert. The clinical record was reviewed 07/12/21 at 2:25 P.M. An Admission MDS assessment, dated 05/15/21, indicated the resident was severely cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received insulin injections for six of the seven days during the assessment review period. The MAR/TAR was provided by the DON on 07/9/21 at 11:04 A.M. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and P.M.). The record lacked documentation of the evening blood sugar levels on the following days: - 07/02/21, - 07/07/21, and - 07/08/21. b. An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and P.M.). The record lacked documentation of the morning insulin administration on the following days: - 07/01/21, - 07/02/21, - 07/03/21, - 07/04/21, and - 07/05/21. The record lacked documentation of the evening insulin administration on the following days: - 07/01/21, - 07/02/21, - 07/03/21, - 07/04/21, - 07/05/21, - 07/06/21 - 07/07/21, and - 07/08/21. During an interview on 07/08/21 at 1:55 P.M., the DON indicated staff should document a blood sugar values on the MAR/TAR order. The Diabetes Care Plan was provided by the DON on 07/08/21 at 2:30 P.M. The Care Plan indicated blood sugar checks should be completed as ordered. 3. On 07/08/21 at 12:06 P.M., Resident 26 was propelling herself in her wheelchair in a common hallway. The resident was pleasant, and was talking to staff members. There were no signs of discomfort or distress observed. The resident's clinical record was reviewed on 07/08/21 at 2:09 P.M. An Annual MDS assessment, dated 06/09/21, indicated the resident was cognitively intact. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received insulin medication on 7 of 7 days of the assessment review period. The June 2021 MAR/TAR was provided by the DON on 07/12/21 at 11:35 A.M. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and P.M.). The record lacked documentation of the morning blood sugar levels on the following days: - 06/02/21, - 06/09/21, and - 06/10/21. The record lacked documentation of the evening blood sugar levels on the following days: - 06/05/21, - 06/06/21, and - 06/07/21. The resident was out of the facility on 06/11/21 and returned on 06/12/21. There was no indication the resident's blood sugar was checked after she returned to the facility on [DATE] for the remainder of the month of June. b. An open ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record lacked documentation the insulin was administered in the morning on the following days: - 06/01/21, - 06/02/21, - 06/09/21, and - 06/10/21. The record lacked documentation the insulin was administered in the evening on the following days: - 06/01/21, - 06/05/21, - 06/06/21, and - 06/07/21. During an interview on 07/08/21 at 2:38 P.M., the DON indicated there was some missing information on the June 2021 MAR for blood sugar checks and insulin administration. At times, the nurses initialed that they checked the resident's blood sugar, but they did not document the actual blood sugar reading. She was planning on inservicing the staff. 4. On 07/08/21 at 2:52 P.M., Resident 17 was sitting in his wheelchair in the dining room working on a puzzle. There were no signs or symptoms of discomfort or distress observed. The resident's clinical record was reviewed on 07/08/21 at 11:35 A.M. A Quarterly MDS assessment, dated 05/19/21, indicated the resident was moderately cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's recent MARs were reviewed. A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/08/21 at 11:47 A.M., the DON indicated she thought the [MEDICATION(S)] medication was given to the resident every evening, but nursing staff did not sign off that it was administered in the month of June 2021. The current Diabetic Testing policy, with a revised date of 06/2021, was provided by the Administrator on 07/12/21 at 9:17 A.M. The policy indicated, .PURPOSE: To supply accurate determination of blood glucose level to assist resident in the control and daily management of diabetes .DOCUMENTATION: .Blood glucose level .including time and date of test . 3.1-48(a)(6)

Based on interview and record review, the facility failed to meet the needs of a resident related to bathing for 1 of 12 residents reviewed for activities of daily living. (Resident 29) Findings include: During an interview on 07/06/21 at 3:43 P.M., Resident 29's spouse indicated the resident received bed baths in the facility. With the bed baths, her skin was not exfoliated very well and there was a lot of dead skin. He was not sure why they didn't give her actual showers anymore, it may have been because the resident seemed more comfortable with bed baths. The clinical record for resident 29 was reviewed on 07/09/21 at 10:11 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/16/21, indicated the resident was severely cognitively impaired. The resident did not speak. The resident rarely understood others and was rarely understood herself. The resident required extensive assistance of staff with bed mobility, eating, and toileting. The resident was totally dependent on staff for transfers, locomotion, dressing, personal hygiene, and bathing. During an interview on 07/09/21 at 10:39 A.M., the DON (Director of Nursing) indicated the resident's husband requested she only receive bed baths, no showers. He thought it was more comfortable for her. The DON kept the shower sheets. The resident's husband often came in and bathed the resident during the week. During an interview on 07/12/21 at 2:28 P.M., CNA (Certified Nurse Aide) 5 indicated the resident's husband came in the facility regularly and provided a lot of the resident's care himself. Nursing staff still bathed the resident twice a week on her assigned shower day. They documented care on Shower Sheets. They would indicate the type of bathing provided (shower or bed bath), if they washed the resident's hair, and if they changed the resident's sheets. CNAs always provided the required care on shower days, regardless of whether the resident's husband provided resident care. The current facility shower schedule was provided by the Administrator on 07/12/21 at 3:25 P.M. Resident 29 was to receive showers on Mondays and Thursdays. The resident's shower sheets were provided by the DON on 07/09/21 at 11:04 A.M. For the week beginning 06/06/21 through 06/12/21, the resident only received one bed bath on 06/07/21. For the week beginning 06/13/21 through 06/19/21, the resident only received one bed bath on 06/13/21. For the week beginning 07/04/21 through 07/10/21, the resident had only received one bed bath on 07/05/21 as of 07/09/21. The current facility policy, titled Bath-Bed, Partial, Shower, Tub, with a revision date of 10/2004 was provided by the Administrator on 07/12/21, at 9:17 A.M. The policy indicated, .All residents who are bed bound should receive a complete bed bath at least twice a week . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure pressure ulcers were not acquired in the facility related to Stage 3 and Stage 4 pressure ulcers and interventions and treatments were in place for 2 of 4 residents reviewed for pressure ulcers. (Resident 32 and 26) Findings include: 1. The clinical record for Resident 32 was reviewed on 08/12/19 at 3:30 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 10/16/18, indicated the resident was severely cognitively impaired. [DIAGNOSES REDACTED]. The resident required extensive assistance with bed mobility, transferring, dressing, toileting, and personal hygiene. The resident was at risk for pressure ulcers and utilized a pressure reducing device for the bed and chair. Resident 32 did not have any pressure ulcers or wounds at the time of the assessment. A Care Plan, with an initiation date of 02/03/16 and revised on 11/13/18, indicated the resident required extensive assistance for bed mobility and was frequently incontinent of bladder due [MEDICAL CONDITION] resulted in a right [MEDICAL CONDITION] and was a risk for skin breakdown. During an interview on 08/09/19 at 11:53 [NAME]M., the DON (Director of Nursing) indicated the resident had acquired, while residing in the facility, stage 3 pressure ulcers (full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue was often present) on his coccyx, left heel, and right heel that were healed. The resident currently had an open surgical wound on his right buttock that had been treated in the facility. a. The resident's surgical wound was observed during a dressing change on 08/09/19 at 11:27 [NAME]M. The wound on the resident's right buttock was the size of a quarter, with well approximated edges. The skin around the wound was pale pink. The wound bed was dark red and was a half centimeter in depth. There was no slough or drainage; no foul odor was noted. The wound was cleansed, packed with antiseptic-soaked gauze, and covered with a foam dressing. During an interview on 08/12/19 at 2:07 P.M., the DON indicated the wound on the right buttock was an area that was first identified on 12/04/18. It was thought to be the beginning of a pressure area, then an unstageable pressure area, but was then determined to be an abscess. The initial treatment for [REDACTED]. Wound documentation prior to the wound's designation as a surgical wound could not be provided for the area on the resident's right buttock at the time of the survey. There was no record in the EMAR (Electronic Medication Administration Record) and ETAR (Electronic Treatment Administration Record) for (MONTH) (YEAR) of a treatment ordered or administered to Resident 32's right buttock. The physician orders [REDACTED]. A Health Status Note, dated 12/09/18 at 3:36 [NAME]M., indicated the resident had a new area on the lower coccyx. Antibiotic ointment and a dressing was applied to the area. The area was measured on day shift. The DON indicated this note referred to the area on the resident's right buttock. A Nutrition/Dietary Note, dated 12/26/18 at 10:52 [NAME]M., indicated the resident had pressure areas to the coccyx, right buttock, left heel, and right heel. A Health Status Note, dated 12/26/18 at 1:32 P.M., indicated the nurse informed the Nurse Practitioner of the resident's infection on the buttocks and the resident's complaint of nausea. Orders were received for an anti-nausea medication and the Nurse Practitioner would be in to see the resident in the morning. A Health Status Note, dated 12/26/18 at 6:48 P.M., indicated the resident told an aide that he wanted to go to the hospital. The resident was informed of a new order to start an antibiotic medication and asked if he would like to try the medication before going to the hospital. The resident indicated he wanted to go to the hospital. The resident had pressure areas to his coccyx, gluteal fold, and right heel. Vital signs were within normal limits except for an axillary temperature of 100.9 degrees Fahrenheit. The resident was sent to the local hospital emergency department. A Health Status Note, dated 12/27/18 at 1:41 [NAME]M., indicated the resident was being admitted for intravenous therapy due to possible [DIAGNOSES REDACTED] (inflammation of the fasciae of muscles or organs results in rapid destruction of overlying tissues). A Hospital Transcription Report, with a date of service of 12/28/18, indicated the resident was admitted to the hospital on [DATE]. The report indicated, .Operative Indications .patient .is a nursing home patient and was transferred to .hospital several days ago for a foul odor and several wounds. I took over the service and found him to have a sacral decubitus ulcer (bed sore), which was approximately stage I (1, Non-blanchable [DIAGNOSES REDACTED] (redness) of intact skin) to II (2, Partial thickness skin loss with exposed dermis), but had no obvious necrotic (dead) tissue, and a draining right ischial wound with copious (abundant) purulence (pus), [DIAGNOSES REDACTED], and necrotic skin, subcutaneous tissue (tissue under the skin) and fascia (a band or sheet of connective tissue beneath the skin that attaches, stabilizes, encloses, and separates muscles and other organs) requiring debridement (removal of devitalized/necrotic tissue) .Preoperative Diagnoses: [REDACTED].Deep right hip abscess .Postoperative Diagnoses: [REDACTED]. Deep right hip abscess .Operative findings: There was a deep abscess in the right hip tissues and there was a right ischial pressure ulcer with necrotic skin, subcutaneous tissue, and fascia. The wound ultimately measured 7 x (by) 5 x 2 cm (centimeters) at the conclusion of the debridement . During an interview on 08/12/19 at 01:51 P.M., the wound clinic nurse indicated the resident's initial visit to the wound clinic was on 01/24/19 for treatment of [REDACTED]. The wound was surgically debrided on 12/31/18, and had a wound vac (vacuum). The wound clinic treated Resident 32's wound until 03/28/19 when the resident refused further treatment at the clinic. The nursing home would have been providing treatment from then on. The wound treatment assessments for the resident's stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone) on his right buttock indicated the following: - Dated 01/01/19, the wound measured 9 cm x 3 cm x 1.5 cm, with tunneling at 2.5 cm. The wound bed was covered in brown slough. - Dated 01/15/19, the wound vac was intact. - Dated 02/07/19, the wound measured 4.5 cm x 4 cm x 1.7 cm at the deepest with tunneling at 2.5 cm. The wound bed was covered in brown slough. - Dated 02/15/19, the wound measured 4.2 cm x 4 cm. - Dated 02/26/19, the wound measured 3.8 cm x 2.8 cm and was worse in depth at 3 cm. The wound had been debrided at the wound clinic. - Dated 03/19/19, the wound measured 3 cm x 2.5 cm. Depth of the wound was 3 cm. - Dated 04/08/19, the wound measured 3 cm x 2 cm, with a depth of 1.6 cm. - Dated 07/12/19, the wound measured 1.4 cm x 1.4 cm x 0.4 cm. - Dated 07/19/19, the wound measured 1.2 cm x 1.2 cm x 0.4 cm. - Dated 08/03/19, the wound measured 1.7 cm x 2.4 cm x 0.4 cm. There was necrotic tissue, drainage, and odor noted. - Dated 08/09/19, the wound measured 1.6 cm x 2 cm x 0.4 cm. -The wound treatment documentation for the resident's right buttock with the assessment dates of 03/13/19, 04/01/19, 04/24/19, 06/14/19, 06/22/19, 06/28/19, 07/05/19, 07/12/19, and 07/31/19, lacked new wound measurements. b. The wound documentation for Resident 32 indicated he developed an unstageable wound to his right heel that was first identified on 11/12/18. During an interview on 08/12/19 at 11:15 [NAME]M., the DON indicated staff was helping Resident 32 with his socks and noticed a blister to his right heel on 11/12/18. The resident told them his new diabetic shoes were slipping up and down on his feet. The podiatrist came in, tried to adjust the shoes, and placed an insole in the shoe. A Health Status Note, dated 11/13/18 at 5:02 P.M., indicated the IDT (Interdisciplinary Team) met to review the blister to the resident's right heel. The resident received a new pair of diabetic shoes. The resident indicated the shoes rubbed his foot. The shoe would be adjusted. The wound treatment assessments for the resident's unstageable pressure ulcer (covered with slough or eschar / dead or devitalized tissue) on his right heel indicated the following: - Dated 11/12/18, the wound measured 4.0 cm x 5.0 cm x 0.0 cm. The wound bed was 15% (percent) eschar and 85% blister yellowing. There was no drainage. The treatment was to cleanse with normal saline, cover with a bordered dressing, and change the dressing every day and as needed for soilage or dislodgement. - Dated 11/22/18 , the wound measured 4.0 cm x 5.0 cm x 0.0 cm. The wound bed was 50% eschar and 50% pink tissue. There was scant, yellow drainage. The treatment was to cleanse with normal saline, cover with a bordered dressing, and change the dressing every day and as needed for soilage or dislodgement. - Dated 12/04/18 , the wound measured 4.0 cm x 5.0 cm x 0.0 cm. The wound bed was 50% eschar and 50% pink tissue. There was scant, yellow drainage. - Dated 12/11/18, the wound measured 3.8 cm x 4.7 cm x 0.0 cm. The wound bed was 50% eschar and 50% pink tissue. There was scant, yellow drainage. - Dated 12/18/18, the wound measured 3.8 cm x 4.1 cm x 0.0 cm. The wound bed was 50% eschar and 50% pink tissue. There was scant, yellow drainage. - Dated 12/24/18, the wound measured 3.8 cm x 3.8 cm x 0.0 cm. The wound bed was 50% eschar and 50% pink tissue. There was scant, yellow drainage. - Dated 12/31/18, the wound measured 3.1 cm x 2.8 cm x 0.0 cm. The wound bed was 100% pink tissue. There was scant, yellow drainage. - Dated 01/07/19, the wound measured 2.5 cm x 2.0 cm x 0.0 cm. The wound bed was 100% pink tissue with no drainage noted. The treatment listed was to cleanse with normal saline and cover with an absorbent foam dressing and float heels. - Dated 01/14/19 and 01/21/19, the wound measured 2.1 cm x 1.3 cm x 0.0 cm. The wound bed was 100% pink tissue with no drainage noted. The treatment listed was to cleanse with normal saline and cover with an absorbent foam dressing and float heels. - Dated 01/28/19, the wound to the right heel was closed. The (MONTH) and (MONTH) (YEAR) EMARs and ETARs were provided by the Corporate Nurse Consultant on 08/13/19 at 3:00 P.M. The resident had a physician's orders [REDACTED]. The clinical record lacked documentation of the skin prep being applied. A Health Status Note, dated 12/09/18 at 3:39 [NAME]M., indicated the resident's right heel was open, had light yellow drainage, and .continues to have black necrotic tissue at area A new order was received for Santyl (a [MEDICATION NAME] ointment) twice a day. A physician's orders [REDACTED]. The wound treatments dated 11/12, 11/22, and 12/04, 12/11, 12/18, and 12/24/2018, indicated the staff were to cleanse the wound with normal saline, cover with a bordered dressing, and change the dressing every day and as needed for soilage or dislodgement. The wound treatment documentations lacked the application of the skin prep or the Santyl to the resident's right heel as prescribed by the physician. The wound treatments dated 12/31/18, 01/07, 01/14, 01/21/19, indicated the treatment was to cleanse the wound with normal saline and cover with an absorbent foam dressing and float heels (position heels in such a way as to prevent contact with another surface). The wound treatment documentations lacked the Santyl being applied to the resident's right heel. During an interview on 08/13/19, at 10:40 [NAME]M., the DON indicated the order for Santyl was received, but when the order was put in the computer, it was entered in a way that did not include it on the ETAR. c. Wound treatment documentation for Resident 32 indicated he developed a stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis) on his left heel that was first identified on 11/27/18. During an interview on 08/12/19 at 11:15 [NAME]M., the DON indicated Resident 32 was having trouble with his diabetic shoes. He developed a blister on his right heel, they adjusted the shoes, and then he developed a blister on his left heel that was identified on 11/27/18. The resident ended up getting a different pair of shoes. The facility did an IDT review of the cause of the blister on the right foot. There was no indication in the EHR that the IDT team reviewed the cause of the blister on the left foot. The wound treatment assessments for the resident's pressure ulcer to his left heel indicated the following: - Dated 11/27/18, indicated a stage 2 pressure wound was identified. The wound measured 0.5 cm x 0.2 cm x 0.0 cm. The wound bed was identified as a clear blister. - Dated 12/04/18, indicated a stage 3 pressure wound was identified. The wound measured 0.5 cm x 0.2 cm x 0.0 cm. The wound bed was 15% slough and 85% blister resolving. - Dated 12/11/18, the wound measured 0.5 cm x 0.2 cm x 0.0 cm. The wound bed was 100% red granulation tissue. There was no treatment noted. - Dated 12/18/18, The wound measured 0.3 cm x 0.2 cm x 0.0 cm. The wound bed was 100% red granulation tissue. There was no treatment noted. - Dated 12/24/18, indicated the wound to the left heel was closed. The (MONTH) and (MONTH) (YEAR) EMARs and ETARs were provided by the Corporate Nurse Consultant on 08/13/19 at 3:00 P.M. The clinical record lacked a treatment ordered or administered to the resident's left heel. During an interview on 08/12/19 at 11:52 [NAME]M., the DON indicated they did apply Skin Prep to the resident's left heel, but it was not documented in the clinical record. d. Wound treatment documentation for Resident 32 indicated he developed a stage 3 pressure wound to his coccyx that was first identified on 12/11/18. The (MONTH) (YEAR) EMAR and ETAR was provided by the Corporate Nurse Consultant on 08/13/19 at 3:00 P.M. A physician's orders [REDACTED]. The wound treatment assessments for the resident's pressure ulcer to his coccyx indicated the following: - Dated 12/12/18 and 12/19/18, the wound measured 3.0 cm x 2.8 cm x 0.1 cm. The wound bed was 100% slough with minimal sanguineous (bloody) drainage. There was no treatment noted. - Dated 12/25/18, the wound measured 2.9 cm x 2.6 cm x 0.1 cm. The wound bed was 100% slough with minimal sanguineous drainage. There was no treatment noted. - Dated 12/31/18, the wound measured 2.5 cm x 2.2 cm x 0.1 cm. The wound bed was 100% slough with minimal sanguineous drainage. There was no treatment noted. - Dated 01/07/19, the wound measured 2.3 cm x 1.9 cm x 0.1 cm. The wound bed was 100% slough with minimal sanguineous drainage. There was no treatment noted. - Dated 01/14/19 and 01/15/19, the wound measured 2.0 cm x 1.5 cm x 0.1 cm. The wound bed was 100% slough. There was no drainage noted. The current treatment was to cleanse with normal saline and cover with a dry dressing. - Dated 01/22/19, the wound measured 1.5 cm x 1.0 cm x 0.0 cm. The wound bed was 100% red granulation tissue. There was no drainage noted. - Dated 01/28/19, indicated the wound to the resident's coccyx was closed. During an interview on 08/12/19 at 11:15 [NAME]M., the DON indicated the resident had episodes of rejecting care and he had a care plan with a start date of 04/06/16. When a resident refused care or treatment, nursing staff would document in the Nurse's Notes or in the behavior book. If a resident refused care, there should be notes. The Behavior Monitoring Records and Behavior Monitoring Logs for the resident were provided by the Social Services Director on 08/12/19 at 3:00 P.M. Rejecting Care was listed as Behavior 2 on the Behavior Monitoring Records, with several interventions noted. There was no indication on the Behavior Logs for (MONTH) and (MONTH) (YEAR) that the resident exhibited any behaviors, including rejection of care. The current facility policy titled Discovering/Reporting New Pressure Ulcers, with a most recent revision date of 10/2011, was provided by the Corporate Nurse Consultant on 08/13/19 3:35 P.M. The policy indicated .pressure ulcer .verify existence and assess area .document findings on the resident's medical record .In order to heal pressure ulcers .must get a treatment order . 2. The clinical record for Resident 26 was reviewed on 08/09/19 at 12:00 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 07/11/19, indicated the resident was severely cognitively impaired. The resident's [DIAGNOSES REDACTED]. The resident was totally dependent on two physical staff members for assistance with bed mobility, transfers, personal hygiene, dressing, and toilet use. The resident was at risk for pressure ulcers and had no unhealed pressure ulcers at that time. The resident was completely immobile. On 08/08/19 at 11:35 [NAME]M., the resident was observed sitting in a high backed wheelchair in the main dining room. Both of her feet were touching and resting on a cushion on her wheelchair. On 08/09/19 at 2:03 P.M., the resident was observed sitting in a high backed wheelchair in the main dining room following an activity. Her feet were touching and resting on a pillow on her wheelchair. On 08/12/19 at 10:51 [NAME]M., the resident was observed being wheeled into the main dining room by a staff member. Her feet were touching and resting on a pad on her wheelchair. The administration of the prescribed treatment to the resident's pressure ulcer on her ankle was observed on 08/09/19 at 9:54 [NAME]M. LPN (Licensure Practical Nurse) 2 indicated Skin Prep, the treatment for [REDACTED]. The resident was resting in her high backed wheelchair with both feet resting on a pillow. The resident had contractures, and the left foot was turned and resting on the area with the pressure ulcer. The nurse indicated the resident had used a pillow under her feet for a long time. The resident had a round scabbed area slightly larger than a pencil eraser. The wound was on the inside of her left ankle, the side that was laying against the pillow. During an interview on 08/08/19 at 12:09 P.M., the DON indicated the resident had a scab on her left inner ankle, an unstageable, pressure wound. The wound was discovered on 07/18/19 and measured on 07/19/19. Initially the wound measured 0.3 cm x 0.3 cm. It was a dark crusty scab. The resident crossed her feet while in a wheelchair and wore socks. The current size of the wound was 0.2 cm x 0.2 cm. The resident crossed her left foot over her right foot while in a high backed wheelchair. A CNA discovered the wound when providing care for the resident. They were using Skin Prep on both of the ankles followed by lotion. The resident had a heels up device that they floated her heels on while she was in her wheelchair and in the bed. Staff had been educated to roll up a blanket and put it between her feet if they noticed her crossing her feet. During an interview on 08/12/19 at 3:42 P.M., LPN 2 indicated the resident's feet were pretty much in the same position all the time. The staff relieved the pressure off her ankles with pillows and with turning her from side to side. During an interview on 08/12/19 at 3:49 P.M., the DON indicated to keep pressure off the residents' heels they either have the blue cushions, which was a device designed for floating their heels, or they used pillows to float the residents' heels. The pillow or device should be positioned so the residents' heels were not touching the bed. The staff use them in the bigger wheelchairs as well. A Care Plan, with an initiation date of 07/17/19, indicated the resident had a scab, an unstageable ulcer, on her left ankle. An intervention listed indicated .Keep pressure off area as much as possible . A Care Plan, with a revision date of 01/31/19, indicated the resident was dependent on staff for bed mobility due to a [DIAGNOSES REDACTED]. An intervention, dated 10/21/11, indicated the resident was to be observed for areas of redness that did not resolve within 15 minutes. The wound assessments were provided by the MDS Coordinator on 08/12/19 at 3:04 P.M. and indicated the following: - Dated 07/19/19, the resident's pressure ulcer on the left ankle was identified as an unstageable pressure ulcer. The wound measured 0.3 cm x 0.2 cm. The treatment listed was Skin Prep to ankles and lotion to feet every shift. - Dated 07/24/19 , the wound measured 0.3 cm x 0.2 cm. - Dated 07/31/19, the wound measured 0.2 cm x 0.2 cm. - Dated 08/03/19, the wound measured 0.2 cm x 0.2 cm. - Dated 08/07/19, the wound measured 0.2 cm x 0.2 cm. The current Prevention of Pressure Ulcers policy, with a revision date of 11/08, indicated significantly contracted limbs are though to result in impaired blood supply to that limb - which should raise a red flag, since pressure ulcer development has its origins in impaired blood flow and resultant tissue ischemia . 3.1-40(a)(1)

Based on interview and record review, the facility failed to provide nursing assessments in a timely manner related to vital signs as indicated by the resident's condition, and physician notification of change in condition on 1 resident with [MEDICAL CONDITION] (abnormally low heart rate) and hypothermia (abnormally low temperature). This deficient practice resulted in harm in that Resident B developed septic shock, which required intubation (breathing tube/machine) and intensive care. (Resident B) Findings include: Resident B's closed clinical record was reviewed on 8/9/2016 at 12:05 p.m. [DIAGNOSES REDACTED]. Resident B was hospitalized for [REDACTED]. Resident B was transferred to the Hospital #1 Emergency Department due to hypothermia, [MEDICAL CONDITIONS], and altered mental status on 7/22/2016. Resident B's quarterly Minimum Data Set (MDS) assessment, dated 7/8/2016, indicated a Brief Interview for Mental Status (BIMS) score of 6; this indicated moderate cognitive impairment. The resident required extensive, 1-2 person assistance for all ADLs (activities of daily living) and had a Foley catheter. A Care Plan for Resident B, revised on 7/14/2016, indicated: Focus: I have a Foley cath (catheter) placed for elimination of my urine .I am at risk for a UTI .Interventions/Tasks: I need staff to alert MD ASAP (as soon as possible) of any abnormal findings .monitor me for any alterations in cognitive function and notify MD. A Care Plan for Resident B, initiated 2/29/2016, indicated: Focus: I take medication for high blood pressure .Interventions/Tasks: I need monitored for signs and symptoms of high/low blood pressure .blood pressure taken as ordered . A Care Plan for Resident B, initiated 2/29/2016, indicated: Focus: I am at risk to experience shortness of breath and/or low oxygen sats related to my [DIAGNOSES REDACTED].I need by (sic) O2 (oxygen) sats (saturations) monitored every shift and as needed . A Care Plan for Resident B, initiated 4/13/2016, indicated: Focus: I am at risk for blood clots and decreased cardiac output related to my [DIAGNOSES REDACTED].Staff will observe me for .decreased level of consciousness .Vital signs as ordered with abnormal results reported to MD . A Care Plan for Resident B, initiated 2/29/2016, indicated: Focus: I have chronic UTIs and am at risk for future infections .Interventions/Tasks: My nursing staff will observe my vital signs for s/s infection and notify MD if noted . There was no evidence in the physician's orders [REDACTED].>Documentation review indicated Resident B received an Admission Nursing Assessment on 7/13/2016. There was no evidence in the clinical record that Resident B received a nursing assessment after 7/13/2016. Resident B's vital signs, dated 7/19/2016 at 3:01 p.m., indicated, Temperature: 95.1 (degrees) F (Fahrenheit) (tympanic), Pulse: 50 bpm (beats per minute) - irregular - chronic, Blood Pressure: 122/60, O2 (oxygen) sats (saturation): 98% (Room air), Respiratory Rate: 18 breaths per minute. Review of Resident B's vital signs from 5/30/2016 through 7/19/2016 indicated the resident only experienced a pulse/heart rate of 50 or lower on 7/9/2016, when the resident was admitted to the hospital with [REDACTED]. There was no evidence anywhere in the clinical record that Resident B's pulse, blood pressure, O2 sats, or respiratory rate were evaluated between 7/19/2016 at 3:05 p.m. and 7/22/2016 at 8:50 a.m. Resident B's vital signs, dated 7/22/2016 at 8:50 a.m., indicated: Temperature: 93.9 (F) (Rectal), Pulse: 61 bpm - irregular - chronic, Blood Pressure: 95/60, O2 (oxygen) sats (saturation): 98% (Room air), Respiratory Rate: 16 breaths per minute. Resident B's Progress Notes, dated 7/20/2016 at 6:25 a.m., indicated: Temp 95.5 (F) .Foley catheter is draining clear yellow liquid Resident B's Progress Notes, dated 7/21/2016 at 6:30 a.m., indicated, .F/C (Foley catheter) patent draining dark yellow concentrated urine with scanty (sic) amount of blood noted. Temp 95.8 (F) . Resident B's Progress Notes, dated 7/22/2016 at 4:15 a.m., indicated: Temp 94.8 (F). F/C patent draining tea colored urine decreased output noted .Resident BLE (bilateral lower extremities) noted weeping legs wrapped with Kerlix and ACE wraps. Resident B's Progress Notes, dated 7/22/2016 at 8:52 a.m., indicated: res (resident) lethargic, weak, shaky, cold to touch, temporal temp 86.5 (F) rectal temp 93.9 (F); BP 95/60, P (pulse) 61, RR 16 .BLE with weeping [MEDICAL CONDITION] with generalized non pit (pitting) [MEDICAL CONDITION]; disoriented from baseline .F/C patent with tea colored cloudy urine with decreased output .NP (Nurse Practitioner) paged for further orders. Resident B's Progress Notes, dated 7/22/2016 at 9:09 a.m., indicated: .send to ER (emergency room ) for eval (evaluation) and treat (treatment). Resident B's Progress Notes, dated 7/22/2016 at 9:20 a.m., indicated: Transfer to hospital by (ambulance) d/t (due to) [MEDICAL CONDITION], hypothermia, lethargic, confusion . Resident B's Hospital #1 EMS (Emergency Medical Services/Ambulance) Report, dated 7/22/2016, indicated EMS arrived to the facility at 9:20 a.m. Vital signs and cardiac monitor indicated a heart rate in the 30's and no palpable blood pressure. EMS Narrative indicated: .Upon arrival, the crew was advised by nursing staff that the patient is hypotensive and hypothermic. The patient presented alert and oriented .states she is sleepy and her belly hurts. The patient presented with a PICC (peripherally inserted central catheter) line in her R (right) arm and a Foley catheter in place . The resident received two doses of [MEDICATION NAME] (medication used to treat abnormally low heart rate in an emergency) en route to the Emergency Department (ED) at Hospital #1. Resident B's Hospital #1 Emergency Physician Record, dated 7/22/2016 at 9:46 a.m., indicated: .chief complaint: ?[MEDICAL CONDITION] - low temp at ECF (extended care facility) .EMS had [MEDICAL CONDITION] (abnormally slow heart rate), (no palpable) BP (blood pressure). Pt has been awake and alert and responsive however .hospitalized : recent UTI/sepsis .Extremities: (positive sign) weeping wounds to RLE .(Cardiology Consult) - transcutaneous pacing. Suspect brady ([MEDICAL CONDITION]) 2/2 (secondary to) infection/sepsis . Resident B's Hospital #1 ED Clinical Summary, dated 7/22/2016 at 9:57 a.m., indicated: Temp Rectal: 34.8 Deg C. O2 Sat 89%. Respiratory Rate: 21 br/min (breaths per minute). Peripheral Pulse Rate: 37 bpm (beats per minute). Blood Pressure: 70/40 . The resident was transferred to Hospital #2 for ICU (Intensive Care Unit) admission 7/22/2016 at 3:00 p.m. Resident B's Hospital #2 Critical Care Admission History and Physical, dated 7/22/2016 at 7:57 p.m., indicated, .History of Present Illness: (Resident B) presenting from (Hospital #1) as a transfer for further management. (Resident B) was hypothermic (low temperature) , bradycardic (low heart rate) in the 30's ., hypoTN (low blood pressure) at 70/40, hyperK (abnormally high potassium) at 6.5, [MEDICATION NAME] 1.9 .Upon arrival to our facility .PICC line was removed was (sic) showed concern for infection .Impression and Plan: 1. HyperK .2. [MEDICAL CONDITION] .3. SIRS (Systemic [MEDICAL CONDITION] Response Syndrome; criteria include hypothermia and elevated white count) - hypothermia, hypoTN, WBC (white blood cell count) elevated (indicates infection) .giving [MEDICATION NAME] and [MEDICATION NAME] infusions .5. Acute [MEDICAL CONDITION] - intubated (breathing tube/machine) for [MEDICAL CONDITION] and failure to protect airway in setting of ams (altered mental status) . Resident B's Hospital #2 Discharge Summary, dated 7/29/2016, indicated, .Discharge Diagnoses: [REDACTED]. 2. [MEDICATION NAME] faecalis bacteremia from peripherally inserted central catheter line. 3. [MEDICAL CONDITION]/[MEDICAL CONDITION]. 4. Acute [MEDICAL CONDITION] . The facility Nurse Practitioner (NP) was interviewed on 8/9/2016 at 3:40 p.m. She indicated her records indicated she last saw Resident B on 6/30/2016. The NP indicated she was not notified of the resident's decreased heart rate on 7/19/2016. The resident's vital signs and condition could fluctuate rapidly, indicating, (It's) based on good assessment and what else is going on with (Resident B) .not just (Resident B's) numbers (vital signs). The NP indicated she would expect the abnormal heart rate of 50, documented on 7/19/2016, to be re-checked and followed up on. The NP indicated she would expect abnormal findings to prompt a nursing assessment and to be notified of any significant changes. The NP indicated, Vital signs should be completed every shift until it's cleared up . if it's a UTI, pneumonia . The Director of Nursing (DON) was interviewed on 8/9/2016 at 3:59 p.m. She indicated Resident B's last weekly nursing assessment was 7/13/2016 and the resident should have received a weekly nursing assessment on 7/19/2016. The DON indicated she was made aware via written communication from the nurse on 7/19/2016 that the assessment was not completed and that she normally would follow up. The DON indicated: They (nurses) all know abnormal one's (vital signs) need to be reported to the MD. The DON indicated there was no policy and procedure related to nursing assessments or abnormal vital signs. The DON indicated the expectation was that residents received a weekly nursing assessment and additional assessments were based on nursing judgement. The Executive Director (ED) was interviewed on 8/9/2016 at 4:34 p.m. She indicated, Corporate said if the doc (doctor) didn't give parameters, our policy (regarding vital signs and nursing assessments) was nursing judgement. On 8/10/2016 at 1:42 p.m., the ED indicated: (Resident B) should have had vital signs those two days. On 8/10/2016 at 1:50 p.m., the DON indicated: (Resident B's) recorded baseline temperature was 97.9' (F). A copy of the current Vital Signs Nursing Policy and Procedure was provided by the DON on 8/9/2016 at 4:25 p.m. The policy indicated: Vital signs will be taken as per physician's orders [REDACTED].D. Establishing a Baseline Temperature: .3. Average .7 days worth of temperatures to determine the baseline temperature. 4. Document baseline temperature . A copy of the current Change of Condition Nursing Policy and Procedure was provided by the DON on 8/9/2016 at 2:30 p.m. The Policy indicated: .The resident's primary physician or designated alternate will be notified immediately of any change in the resident's physical or mental condition .will be documented in the resident's clinical record .Guidelines: Documentation in the nurses' notes is required each shift on any resident who experiences a problem, demonstrates a symptom, or any change of status. Documentation must continue each shift for at least 24 hours, and usually 72 hours, after the problem is identified, then daily until the problem is noted as resolved. Examples of significant change include, but are not limited to: .change in level of consciousness, signs and symptoms of infection, change in temperature, antibiotic therapy .Procedure: .Nurses' notes will identify the condition change and will describe any pertinent nursing assessment indicators and interventions taken. 3. Vital signs will be taken every shift until the resident is stable. 4. Physician and family will be notified. 5. Follow up charting will continue every shift until the problem has resolved . This Federal tag relates to Complaint IN 231. 3.1-37 (a)

Based on observation, record review and interview, the facility failed to protect a resident from a hip fracture and head laceration during a hoyer transfer for 1 of 1 residents in a sample of 3 residents reviewed for accidents. (Resident C) Findings include: Social Services Director was interviewed on 2/11/14 at 3 p.m. She indicated Resident C had suffered a femur fracture in December, 2013. The fracture had been reported to the state agency. The clinical record for Resident C was reviewed on 2/12/14 at 2:30 p.m. The resident's [DIAGNOSES REDACTED]. The physician orders, dated 2/4/13, indicated the resident was to be up with assist of two people in a geri chair via hoyer lift, up only for meals sitting and may participate in activities as tolerated. There was an order, dated 12/11/13, to x-ray both hips, knees, and left forearm. A nursing note, dated 12/10/13 at 8:15 p.m. read as follows: "cna transferring res per hoyer lift, strap came off of hook and res fell out of lift and landed face down on the floor of her room. Assessed res for injury, goose egg mid forehead, redness bilateral knees and left forearm. Neuro checks initiated and wnl (within normal limits). Transferred floor to bed with hoyer lift and 2 staff. MAE (moving all extremities) as prior to fall. c/o headache, prn tylenol given. b/p 108/62, t 97.9, p 65, r 20, MD and mother notified." The fall risk assessment, dated 11/1/13, indicated a score of 10 ( >10 = high risk of falls) The fall risk assessment, dated 12/11/13, indicated a score of 12. A fall risk assessment, dated 12/27/13, was a score of 14. Observation of the resident being transferred by the hoyer lift was done on 2/13/14 at 9:30 a.m. CNA # 3 and & CNA #4 transferred the resident without any difficulty. There were no complaints from the resident. The Maintenance Director was interviewed on 2/13/14 at 9:00 a.m. He indicated he had checked over the hoyer after the resident had fallen and found no breaks or loose nuts or bolts. He indicated there was nothing wrong with mechanics of the lift. The facility provided an investigation of the fall incident on 2/13/14 at 8:30 a.m. The investigation included a statement by CNA # 5., dated 12/11/13 at 2:50 p.m. It indicated the CNA "'states she was transferring resident from her Jeri (sic) chair to her bed. CNA states that she was using the hoyer by herself. When asked why she did not have another staff member present with her the CNA states I didn't think about it, everyone was busy, I just transferred her.' Asked CNA if she was aware of our facility policy regarding the hoyer lift, cna stated yes. When asked CNA how resident fell , CNA stated she was unaware. She states she checked the hoyer lift pad and it was in good condition. She placed the 4 straps on the hoyer lift and began lifting her. She states she had her raised from the chair, she had not moved the hoyer lift yet and the resident fell to the floor. She states she heard a 'click, click' but is unaware what caused that. She states resident fell forward to her knees and then fell completed forward to the floor...." She also indicated that all four straps were connected. Other staff were interviewed by phone and indicated they had not been involved in the transfer because CNA #5 had not asked for help. The CNA was terminated for not following the policy according to an interview with the Administrator on 2/13/14 at 9:45 am. The facility policy, titled "Hoyer Lift", dated 9/04 and revised 6/06, was provided by the Administrator on 2/14/2:00 p.m. It indicated the following: "All resident transfers that are done by means of a mechanical lift will be done with 2 nursing staff members (nursing assistants or nurses) in attendance at all times." This Federal tag relates to Complaint # IN 249. 3.1-45(a)(2)