Every finding on record at Hickory Creek at New Castle

Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 2 residents reviewed for abuse. (Resident B)Findings include:An interview was conducted with Resident B on 5/26/26 at 1:16 p.m. She indicated she was abused in the facility about a month ago. Resident D touched her breasts. It happened in her room. The door was shut, and Resident D came into the room to give her candy, and Resident D grabbed Resident B's breast. Resident B felt uneasy about it. Resident B had waited a couple of days to tell, but the Executive Director (ED) knew all about it. Resident B was unsure why she waited to tell. Resident B would not talk to or even look at Resident D any longer. The investigation into the above allegation was provided by the ED on 5/27/26 at 10:45 a.m. It included the follow-up incident report, an interview with Resident D, an interview with Resident B, staff interviews with no concerns, multiple resident interviews, and documentation of 15-minute checks on Resident B beginning 4/6/26.The follow-up incident report, dated 4/11/6, indicated Resident B informed the ED that Resident D came into her room and touched her chest inappropriately on top of clothing. An investigation was initiated.The documented interview with Resident B, conducted by the ED and dated 4/6/26, indicated, [Name of Resident B] stopped this writer on 4/6/26 by nurse station and informed me that over a week ago [name of Resident D] had come into her room and they were talking and he reached out and touched her inappropriately on the breast with her clothing on. Writer asked her if she was ok and she stated yes. Writer asked her if she had told anyone she stated 'No, I don't know why I didn't.' She then stated, 'I'm ok. I just didn't like it.' Writer encouraged her to not invite others in her room and she was in agreement.The clinical record for Resident B was reviewed on 5/26/26 at 1:05 p.m. Resident B's diagnoses included, but were not limited to, major depressive disorder (serious mental health disorder) and insomnia (inability to sleep).The documented interview with Resident D, conducted by the ED and dated 4/6/26, indicated, Writer was into speak with resident and he stated, 'Yes i did touch her boob on top of clothing.' When writer asked him what happened he stated that he went into her room and gave [name of Resident B's roommate] a sucker and I then gave [name of Resident B] a sucker and when I did she stood up and gave me a hug and they were right there. I didn't mean any ill. I just brushed it. Writer then informed Resident D that was inappropriate. Resident D indicated he knew and apologized. Writer informed Resident D to not go into others' rooms. He was in agreement.An interview was conducted with Resident D in his room on 5/27/26 at 11:56 a.m. Resident D indicated he did not talk to Resident B anymore, and she did not talk to him anymore either. Resident B claimed Resident D grabbed her breast, but Resident D indicated he just touched it. Resident B came up and hugged him and wasn't wearing a bra, and had her titties in my face, and I reached out and touched one. Resident D had never done that before. Then three or four days later, Resident B told the ED that Resident D grabbed her breast. Resident D thought Resident B was just mad at him that day over an earlier interaction involving another resident. Resident B lived two doors down from him, but they did not interact anymore. The ED told Resident D to not talk to her anymore, so Resident D didn't.The clinical record for Resident D was reviewed on 5/26/26 at 1:10 p.m. Resident D's diagnoses included, but were not limited to, depression (serious mental health disorder) and anxiety (intense worry or fear).An interview was conducted with the ED on 5/27/26 at 12:15 p.m. She indicated she substantiated abuse for the allegation, as Resident D admitted to touching Resident B's breast. The ED had never seen anything like that out of Resident D before this. The Abuse Prohibition and Investigating policy was provided by the ED on 5/19/26 at 11:46 a.m. It indicated, It is the policy of [name of facility] to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion. The definitions section of the policy defined abuse as, Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Abuse includes verbal, sexual, physical, and mental abuse facilitated by using technology. It defined sexual abuse as, Nonconsensual sexual contact of any type with a resident. Examples may include but not be limited to fondling, touching, rubbing, exposing, licking, kissing, gestures, sharing pornography, assault, rape, harassment, seduction, coercion, photographing a resident's rectal, genital, or breast areas, and/or exhibitionism.This citation relates to Intake 2975918. 410 IAC (Indiana Administrative Code) 3.1-27(a)(1)

Based on interview and record review, the facility failed to provide sufficient information to describe the results of an abuse investigation to the Indiana Department Of Health (IDOH) for 2 of 2 residents reviewed for abuse. (Residents B and D)Findings include:The clinical record for Resident B was reviewed on 5/26/26 at 1:05 p.m. Resident B's diagnoses included, but were not limited to, major depressive disorder (serious mood disorder) and insomnia (inability to sleep).The clinical record for Resident D was reviewed on 5/26/26 at 1:10 p.m. Resident D's diagnoses included, but were not limited to, depression (serious mood disorder) and anxiety (a feeling of fear and stress).An interview was conducted with Resident B on 5/26/26 at 1:16 p.m. She indicated she was abused in the facility about a month ago. Resident D touched her breasts. It happened in her room. The door was shut, and Resident D came into the room to give her candy, and Resident D grabbed Resident B's breast. Resident B felt uneasy about it. The Executive Director (ED) knew all about it. Resident B waited a couple of days to tell the ED about it. Resident B was unsure why she waited to tell. Resident B would not talk to or even look at Resident D any longer. The investigation into the above allegation was provided by the ED on 5/27/26 at 10:45 a.m. It included, but was not limited to, the follow-up incident report, an interview with Resident D, an interview with Resident B, and documentation of 15-minute checks on Resident B beginning 4/6/26.The documented interview with Resident B, conducted by the ED and dated 4/6/26, indicated, [Name of Resident B] stopped this writer on 4/6/26 by nurse station and informed me that over a week ago [name of Resident D] had come into her room and they were talking and he reached out and touched her inappropriately on the breast with her clothing on. Writer asked her if she was ok and she stated yes. Writer asked her if she had told anyone she stated 'No, I don't know why I didn't.' She then stated, 'I'm ok. I just didn't like it.' Writer encouraged her to not invite others in her room and she was in agreement.The documented interview with Resident D, conducted by the ED and dated 4/6/26, indicated, Writer was into speak with resident and he stated, 'Yes i did touch her boob on top of clothing.' When writer asked him what happened he stated that he went into her room and gave [name of Resident B's roommate] a sucker and I then gave [name of Resident B] a sucker and when I did she stood up and gave me a hug and they were right there. I didn't mean any ill. I just brushed it. Writer then informed Resident D that was inappropriate. Resident D indicated he knew and apologized. Writer informed Resident D to not go into others' rooms. He was in agreement.An interview was conducted with Resident D in his room on 5/27/26 at 11:56 a.m. Resident D indicated he did not talk to Resident B anymore, and she did not talk to him anymore either. Resident B claimed Resident D grabbed her breast, but Resident D indicated he just touched it. Resident B came up and hugged him and wasn't wearing a bra, and had her titties in my face, and I reached out and touched one. Resident D had never done that before. Then three or four days later, Resident B told the ED that Resident D grabbed her breast. Resident D thought Resident B was just mad at him that day over an earlier interaction involving another resident. Resident B lived two doors down from him, but they did not interact anymore. The ED told Resident D to not talk to her anymore, so Resident D didn't. Resident D's behavior care plan, dated 4/6/26, indicated he had an incident of inappropriately touching a peer. Two of the interventions were to keep him separated from the other resident during activities and meals, and for Resident D to not go into other resident's rooms uninvited. Resident D's care plan, dated 4/8/26, indicated he enjoyed passing out candy and treats to other residents. An intervention was for him to pass out candy and treats only in common areas, not to enter resident rooms.The follow-up section of the incident report, dated 4/11/26, indicated in its' entirety, Follow-up added -- 4/11/26 Staff and resident interviews completed with no concerns noted. Resident has been out of room per usual and showing no signs or symptoms of psychosocial distress. Residents are seen by psych services. Resident was educated on resident to resident interactions. The follow-up section did not indicate that Resident D admitted to touching Resident B's breast; that the allegation was substantiated; that Resident D had a care plan to address him inappropriately touching Resident B with interventions to keep Resident B and D separated during meals and activities and not go into other resident rooms uninvited; or that Resident D's care plan for passing out candy was created after the incident to include passing out in common areas only.An interview was conducted with the ED on 5/27/26 at 12:15 p.m. She indicated she substantiated abuse for the allegation, as Resident D admitted to touching Resident B's breast. She was unsure why she did not put in the follow-up report that Resident D admitted to touching Resident B's breast; that the abuse was substantiated; that Resident D had a care plan to address him inappropriately touching Resident B with interventions to keep Resident B and D separated during meals and activities and not go into other resident rooms uninvited; or that Resident D's care plan for passing out candy was created after the incident to include passing out in common areas only. When the ED put staff and resident interviews conducted with no concerns in the follow-up report, she meant there were no concerns with other residents or staff, not that there were no concerns with Resident D's interview. The Abuse Prohibition and Investigating policy was provided by the ED on 5/19/26 at 11:46 a.m. The Reporting/Response section of the policy indicated, Upon completion of the investigation, which will occur within 5 working days of the reporting of an occurrence, a report of the investigation will be forwarded to the Long-Term Care Division of the Indiana State Department of Health.This citation relates to Intake 2975918. 410 IAC (Indiana Administrative Code) 3.1-28(e)

Based on observation, interview and record review, the facility failed to implement a resident's comprehensive care plan interventions to prevent falls for 1 of 3 residents reviewed for accidents. (Resident 1) Findings include:The clinical record for Resident 1 was reviewed on 5/27/26 at 9:58 a.m. The diagnoses included, but were not limited to, osteoporosis (fragile bones), Lennox-Gastaut syndrome (rare, severe form of childhood-onset epilepsy [chronic neurological disorder characterized by recurrent, unprovoked seizures]), and anxiety (feelings of worry and tension). The Quarterly Minimum Data Set (MDS) assessment, dated 3/17/26, indicated Resident 1 was severely cognitively impaired, had no behaviors for rejecting care, had non-traumatic brain dysfunction, and was at risk for falls. During an observation on 5/26/26 at 12:46 p.m., and 5/27/26 at 11:31 a.m., and 1:36 p.m., Resident 1 was lying in bed without a helmet on their head and the bed was not in the lowest position. A progress note, dated 11/19/25 at 1:20 p.m. indicated Resident 1 had an unwitnessed fall out of their bed and included interventions that were in place, but did not include Resident 1 having a helmet on during or after the fall. During an interview with the Executive Director (ED) on 5/27/26 at 2:38 p.m., indicated they did not know if Resident 1 had their helmet when he fell out of bed on 11/9/25. A plan of care, dated 9/10/24, indicated Resident 1 was at risk for falls due to a history of falls, unsteady gait, and altered awareness of immediate physical environment. The interventions included, but were not limited to, bed in lowest position and helmet to be worn at all times, may remove for skin checks and hair washing. During an interview with Licensed Practical Nurse (LPN) 4 on 5/27/26 at 1:37 p.m., indicated they thought Resident 1 only needed their helmet on while out of bed and was unsure why it was not on while in bed or why the bed was not in the lowest position. During an interview with LPN 2 on 5/29/26 at 11:49 a.m., indicated sometimes Resident 1 would wear their helmet while in bed. During an interview with Certified Nursing Assistant (CNA) 3 on 5/29/26 at 11:49 a.m., indicated they usually would take Resident 1's helmet off when they got them into bed and put it back on when it was time to get out of bed. During an interview with the ED on 5/27/26 at 2:38 p.m., indicated Resident 1 should have had her helmet on at all times and the bed in the lowest position if that was what she was care planned for. Nursing staff was responsible to ensure that Resident 1's helmet was on and that her bed was in the lowest position. An IDT Comprehensive Care Plan Policy was provided by the ED on 5/28/26 at 9:00 a.m. It indicated .Policy:.each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented. 410 IAC (Indiana Administrative Code) 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a nebulizer was stored in a bag to promote infection control measures (Resident 23), failed to ensure oxygen tubing was dated (Resident 1), and failed to ensure ear protectors were implemented as ordered by the physician (Resident 1) for 2 of 3 residents reviewed for respiratory services. Findings include: 1, The clinical record for Resident 23 was reviewed on 5/29/2026 at 11:14 AM. The medical diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD). COPD (Chronic Obstructive Pulmonary Disease) is a long-term lung condition that damages and narrows your airways which makes it hard to breathe, especially when gases and mucus build up in your lungs.A quarterly Minimum Data Set Assessment, dated 3/24/2026, indicated Resident 23 was cognitively intact, received respiratory therapy for at least fifteen minutes each day, and was independent with upper body dressing without impairments to bilateral upper extremities. A care plan, dated 8/12/2024 and last revised 3/30/2026, indicated Resident 23 was at risk for impaired gas exchange due to her COPD. The interventions included, but were not limited to, administer medications as ordered and nebulizer treatments as ordered. A physician order, dated 12/30/2025, indicated for Resident 23 to receive nebulizer treatments three times a day routinely. During an observation, on 5/26/2026 at 1:01 PM, the mask for Resident 23's nebulized was hanging on the side of the compression without covering. During an observation, on 5/29/2026 at 10:50 AM, the nebulizer for Resident 23 was observed to have liquid still within the aerosol chamber. A policy entitled, AEROSOLIZED MEDICATION THERAPY HAND HELD NEBULIZER, was provided by the Executive Direction on 5/29/2026 at 1:30 PM. The policy indicated to administer the treatment until medication in the chamber is depleted as well as to disassemble the unit and store within a bag when not in use. 2.) The clinical record for Resident 1 was reviewed on 5/27/26 at 9:58 a.m. The diagnoses included, but were not limited to, chronic respiratory failure, heart failure, and generalized anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/17/26, indicated Resident 1 was severely cognitively impaired and received oxygen therapy. A physician's order for Resident 1, dated 4/15/25, indicated to change oxygen tubing once a day on Sunday. A physician's order for Resident 1, dated 4/15/25, indicated ear protectors to O2 (oxygen) tubing every shift. During an observation on 5/26/26 at 12:44 p.m., Resident 1 was lying in bed and did not have their oxygen tubing dated or ear protectors in place on their oxygen tubing. During an observation on 5/27/26 at 11:31 a.m. and 1:36 p.m., Resident 1 was lying in bed and did not have their oxygen tubing dated or ear protectors on. During an interview with Licensed Practical Nurse (LPN) 4 on 5/27/26 at 1:37 p.m., indicated they did not see a date on the oxygen tubing to indicate when it had been changed and did not know why Resident 1 did not have their ear protectors on. A plan of care, dated 10/14/25, indicated Resident 1 had symptoms of decreased oxygenation (shortness of breath, decreased oxygen saturation, change in mental status) that required continuous oxygen. During an interview with the Executive Director (ED) on 10/14/25 at 1:05 p.m., indicated it was nursing staff who were responsible to ensure that Resident 1 had their oxygen tubing dated when changed and that their ear protectors were on as ordered. 410 IAC (Indiana Administrative Code) 3.1-47(a)(6)

Based on interview and record review, the facility failed to timely schedule an imaging appointment required for a pain specialist appointment for 1 of 2 residents reviewed for pain management. (Resident 8) Findings include:The clinical record for Resident 8 was reviewed on 5/26/26 at 2:37 p.m. The diagnoses included, but were not limited to, intervertebral disc degeneration (progressive breakdown of the rubbery cushions [discs] between the spine's vertebrae), lumbar region (lower back) with discogenic (originates from damaged discs) back pain and lower extremity pain and spinal stenosis (narrowing of the spaces within the spine, which puts pressure on the spinal cords and nerves). The quarterly Minimum Data Set (MDS) assessment, dated 4/7/26, indicated Resident 8 was cognitively intact, used a wheelchair, needed substantial/maximal assistance with sitting to stand and chair to bed transfers, and received scheduled pain medication. During an interview with Resident 8 on 5/26/26 at 1:12 p.m., Resident 8 indicated their back had been hurting really bad and they had been waiting to see the pain specialist for their back and needed a scan of their back prior to getting an appointment. Resident 8 indicated they had been waiting a long time to get the appointment for the back scan that was needed before they went to the pain specialist. Resident 8 indicated the Director of Nursing (DON) indicated the facility was waiting to hear back from the hospital for an appointment to be scheduled. A physician's order for Resident 8, dated 4/21/26, indicated to refer Resident 8 to the interventional pain and spine clinic for chronic back pain. A progress note for Resident 8, dated 4/23/26 at 10:14 a.m., indicated a message was left for the pain clinic to call the facility back regarding a referral appointment. A progress note Resident 8, dated 5/8/26 at 12:48 p.m., indicated a return call was received from pain management requesting a MRI (Magnetic Resonance Imaging) and 6 weeks of PT (Physical Therapy) prior to the initial appointment. A progress note, dated 5/12/26 at 9:42 a.m., indicated the clinical team attempted to schedule a MRI and were awaiting clinic scheduling from the hospital to respond with an appointment time. During an interview with Licensed Practical Nurse (LPN) 2 on 5/28/26 at 11:16 a.m., indicated they had called the hospital on 5/12/26 at 9:42 a.m. to schedule a MRI appointment for Resident 8 and was told they needed to get a referral (order) sent to them in order to schedule the MRI. LPN 2 indicated he notified the nurse practitioner after that and had not heard anymore about it. During an interview with the Director of Nursing (DON) on 5/28/26 at 11:10 a.m., indicated they had sent the order to central scheduling at the hospital for Resident 8 to have an MRI and was waiting to hear back from them on a time and day for the appointment. The DON indicated they had an appointment date of 6/5/26 written down on their desk calendar but it was not entered into the computer. The DON indicated she was unsure when it was scheduled because it was not entered into Resident 8's orders only on the desk calendar. The DON indicated whoever took the call for the appointment only wrote the date on the calendar and not in orders. The DON indicated they keep the appointment referral in a resident's orders to be reminded to call and make the appointment, then once the appointment was made, the order for the referral would be removed and a new order with the appointment is then put into the resident's EHR (Electronic Health Record). During an interview with Central Scheduling at the hospital on 5/28/26 at 11:32 a.m., indicated when a facility calls for a MRI appointment, they typically can get it scheduled within 1-2 days as long as they have an order. Central Scheduling indicated once the facility faxes them the information, the facility would then call to schedule an appointment and central scheduling did not call facilities back with an appointment, they have to be called in. They indicated the facility scheduled Resident 8's MRI appointment on 5/27/26. A plan of care Resident 8, dated 11/3/25, indicated Resident 8 was at risk for pain related to spinal stenosis, intervertebral disc degeneration, and discogenic back and lower extremity pain. During an interview with the Executive Director (ED) on 5/27/26 at 2:30 p.m., indicated nursing staff were responsible to ensure medical appointments were mad timely for residents. 410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on interview and record review, the facility failed to hold a resident's medication, as ordered, when their blood pressure results were out of parameters for administration for 1 of 5 residents reviewed for unnecessary medication. (Resident 23)Findings include:The clinical record for Resident 23 was reviewed on 5/29/26 at 11:20 a.m. Resident 23's diagnosis included, but were not limited to, hypertension.The at risk for ineffective tissue perfusion care plan, revised 3/30/26, indicated the goal was for Resident 23 to maintain adequate tissue perfusion as evidenced by blood pressure within normal limits, no change in mental status, and no complaints of dizziness/lightheadedness/syncope, and edema. Two of the interventions were to administer medications as ordered and to monitor vital signs.The physician's orders for Resident 23, dated May 2026, indicated to administer one 10 mg tablet of Amlodipine (medication to treat high blood pressure) once a day, and to hold if the systolic blood pressure result was less than 100 or if the diastolic blood pressure (bottom reading of the blood pressure) result was less than 60, effective 8/20/25. They indicated to administer one 25 mg tablet of Carvedilol (medication to treat high blood pressure) twice a day, and to hold if the systolic blood pressure (the top reading of the blood pressure) result was less than 110 or if the diastolic blood pressure result was less than 60, effective 8/1/24.The May 2025, medication administration record (MAR) for Resident 23 indicated the Amlodipine was administered on the following days with the following diastolic blood pressure results: 5/4/26 at 54, 5/6/26 at 54, 5/15/26 at 59, and 5/17/26 at 54. The Carvedilol was administered at the following times and days with the following diastolic blood pressure results: morning of 5/4/26 at 54, morning of 5/6/26 at 54, morning of 5/8/26 at 58, morning of 5/9/26 at 59, morning of 5/15/26 at 59, morning of 5/17/26 at 54, evening of 5/14/26 at 50, and the evening of 5/21/26 at 57.An interview was conducted with the Director of Nursing Services (DNS) on 5/29/26 at 12:10 p.m. She reviewed Resident 23's May, 2026 MAR and indicated the Amlodipine and Carvedilol were administered to Resident 23 on the above dates when they should have been held.The General Dose Preparation and Medication Administration policy was provided by the Executive Director (ED) on 5/29/26 at 1:44 p.m. It indicated, Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 3.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.3.5 If necessary, obtain vital signs.410 IAC (Indiana Administrative Code) 3.1-48(a)(1)

Based on interview and record review, the facility failed to ensure a resident was free from verbal and mental abuse by a staff member to where the resident exhibited behaviors such as irritability and verbal disappointment in response to the staff member's presence for 1 of 3 residents reviewed for abuse. (Resident D)Findings include:The clinical record for Resident D was reviewed on 8/11/25 at 11:27 a.m. His diagnoses included, but were not limited to, depression, anxiety, pseudobulbar affect, hemiplegia, and hemiparesis. The 6/24/25 Quarterly MDS (Minimum Data Set) assessment indicated he was moderately cognitively impaired. A care plan, last reviewed/revised 7/7/25, indicated his cognition level could fluctuate throughout the day. A care plan, last reviewed/revised 7/7/25, indicated he was at risk for signs and symptoms of anxiety, and could have episodes of uncontrolled outbursts. The goal was for him to not have increased signs and symptoms of anxiety or uncontrolled outbursts. Approaches were to encourage him to verbalize fears and anxiety, and to offer validation and reassurance, and to maintain a calm environment. A care plan, last reviewed/revised 7/7/25, indicated he had a diagnosis of pseudobulbar affect and was known to exhibit angry outbursts related to extreme irritability, low frustration tolerance and a history of quick temper. The goal was for him to accept staff redirection/reassurance when angry. Approaches were for staff to always approach him calmly and in a non-confrontational manner; for staff to approach him only one at a time and not in a group; for staff to give him space and time to calm; and for staff to quietly ask him to stop his behavior. On 8/12/25 at 11:15 a.m., the Administrator provided the investigative file into an incident that occurred between Resident D and the Maintenance Director on 7/10/25 at 12:15 p.m. The file included the 7/15/25 follow-up incident report, the documented 7/10/25 CNA (Certified Nurse Aide) 3 interview, the documented 7/10/25 SSD (Social Services Director) interview, the undated written SSD statement, the documented 7/10/25 Resident C interview, and the documented 7/10/25 Resident D interview. The 7/15/25 follow-up incident report, completed by the Administrator, indicated a resident reported concerns with a staff member using harsh tones. An investigation was started, and the Maintenance Director was suspended pending investigation. The follow-up section of the report indicated the investigation was completed. Resident and staff interviews were conducted with no concerns noted. Resident D showed no signs or symptoms of psychosocial distress and denied staff using harsh tones. The Maintenance Director returned to work. The 7/10/25 CNA 3 interview, documented by the Administrator and signed by CNA 3, indicated CNA 3 was at the nurse's station when she heard Resident D yelling. Resident D sounded angry. CNA 3 went to Resident D's room. Resident D was sitting on the side of his bed, crying. Resident D informed CNA 3 he wanted to lay down, so CNA 3 covered him up in bed. The Maintenance Director and the SSD walked into the room, and Resident D started attempting to get out of bed. The Maintenance Director was standing at the foot of Resident D's bed, pointing his finger at Resident D and saying, You don't talk to me like that, in a loud voice. An interview was conducted with CNA 3 on 8/11/25 at 4:22 p.m. She indicated she worked at the facility for about a year as a CNA. About a week before her scheduled last day at the facility, due to transferring to a sister facility, she was sitting at the nurse's station and heard Resident D yelling. He sounded upset, so she went to check on him. When she walked toward Resident D's room, she saw the Maintenance Director walking down the hallway. When she entered the room, Resident D was crying and really upset. She calmed him down by changing the subject, talked about a local NFL (National Football League) team, and covered him up in bed. Then the Maintenance Director and SSD walked into the room. Resident D immediately freaks out, went into fight or flight. She remembered the Maintenance Director saying to Resident D, You don't f****** talk to me like that, while standing at the end of Resident D's bed, pointing his finger at Resident D. It was like a Walmart video. People yelling and crazy. It gives me chills. There were five people in the room at the time, including CNA 3, Resident D, Resident C who was Resident D's roommate, The Maintenance Director, and the SSD. The SSD ended up taking the Maintenance Director out of the room, and she followed. CNA 3 explained to the Maintenance Director that Resident D was cognitively impaired, and that he couldn't correct someone who was cognitively impaired like that. After explaining this the Maintenance Director, the Maintenance Director acted as if he didn't care. The Maintenance Director was mad and brushed it off. Resident C informed her that all Resident D wanted was for the Maintenance Director to take his lunch tray. Resident D had only one hand and one leg that worked, so if he saw anyone being lazy, it kind of pisses him off. CNA 3 had Resident D laid down, covered up, and calmed down, but as soon as the Maintenance Director came in the room, Resident D pulled his blankets off immediately, and got himself to the side of his bed, like he was trying to get at the Maintenance Director. Resident D normally needed assistance to get to the side of the bed. I would absolutely describe what I saw as verbal abuse. CNA 3 informed the Administrator of what she witnessed.An interview was conducted with the Administrator on 8/12/25 at 11:56 a.m. The Administrator reviewed CNA 3's documented interview and indicated that was how she recalled the interview. CNA 3 did not inform her that the Maintenance Director cussed at Resident D. If she had, she would have put that in the statement.The 7/10/25 SSD interview, documented by the Administrator and the SSD, indicated the SSD and Maintenance Director went into Resident D's room, because the Maintenance Director wanted the SSD to talk to Resident D. After entering the room, Resident D told the Maintenance Director to get out of his room. The Maintenance Director told the SSD that Resident D was not going to talk to him that way. Resident D was trying to get out of his bed to get at the Maintenance Director. Resident D basically just told the Maintenance Director to get out of his room. The SSD, CNA 3, and the Maintenance Director all left the room. The SSD informed the DON (Director of Nursing,) the Administrator, and nurse on duty of what happened. The SSD checked back in on Resident D.An interview was conducted with the SSD on 8/12/25 at 9:19 a.m. He indicated he worked at the facility for three and a half years as the SSD and Marketing Director. He was let go about a week ago. On 7/10/25, he was walking down the hallway, when the Maintenance Director asked him to go into Resident D's room. As soon as the SSD and Maintenance Director walked into the room, Resident D was screaming, Get this guy out my room, referencing the Maintenance Director. CNA 3 was present in the room as well. The SSD and CNA 3 were trying to prevent Resident D from getting out of bed, because he can't walk. The Maintenance Director was saying, This is what I'm talking about. The SSD witnessed how the Maintenance Director raised his voice, saying you're not going to talk to me like that, being confrontational. It was getting louder and louder. The SSD did not hear the Maintenance Director curse, just had a tone to his voice. When the SSD and the Maintenance Director first came to the room, the Maintenance Director stayed by the door, but by the end of the incident, he was at the end of Resident D's bed. The SSD was in between the Maintenance Director and Resident D, who was red in the face. The Maintenance Director was pointing at Resident D, saying, Look, this is what I'm talking about. The SSD thought the Maintenance Director verbally abused Resident D, based on what he witnessed. Resident D was screaming at the top of his lungs, and the Maintenance Director was matching his energy. The SSD was trying to calm down both Resident D and the Maintenance Director and keep Resident D safe. This went on for like ten minutes. The SSD saw the Maintenance Director in the hallway prior to entering Resident D's room with him, so there was clearly something that happened before then. Eventually the Maintenance Director left the room. The SSD remained in the room for a bit, to try and assist with calming Resident D down. Resident C, Resident D's roommate, informed him Resident D and the Maintenance Director were jaw jacking, raising their voices. The SSD informed the nurse on duty, the DON at the time, and the Administrator. The SSD informed the Administrator there was craziness going on down there. The SSD went back to check on Resident D, and things had calmed down. The SSD interviewed residents for the investigation later on, including Resident C. Resident C informed him Resident D and the Maintenance Director were going back and forth. Resident D yelled at the Maintenance Director. Then the Maintenance Director yelled at Resident D. The SSD did not know why the Maintenance Director went back into the room a second time, because he would not have done that. The Maintenance Director was sent home during the investigation, then called and told to come back. The Administrator asked the SSD back into her office and asked him if he thought Resident D was abused. The SSD wrote a statement to say Resident D was abused. The Administrator questioned his written statement, because it said abuse, so he changed his statement to say Resident D was not abused. The SSD indicated you could tell by looking at the statement that he originally wrote abuse and changed it to was not abused. The undated written statement by the SSD indicated, I believe that [name of Maintenance Director] was being firm with resident that his speech and tone was not acceptable and brought me in to be witness but was not abusive. The words was not were squeezed in between the words but and abusive, in smaller writing with the word was on top of the word not. An interview was conducted with the Administrator on 8/12/25 at 11:56 a.m. She indicated the SSD wrote his statement at the same time she interviewed him on 7/10/25. She asked the SSD if he thought it was abusive, and the SSD told her no. She absolutely did not have the SSD change his statement to reflect it was not abusive. The 7/10/25 Resident C interview, documented by the Administrator, indicated the Maintenance Director brought lunch trays into their room. Resident D said he did not want it and to take it away. Resident D cussed at the Maintenance Director. The Maintenance Director said don't talk to me like that. Resident C did not feel like the Maintenance Director was abusive at all.An interview was conducted with Resident C on 8/11/25 at 1:20 p.m. He indicated he witnessed an incident between Resident D and the Maintenance Director last month. Resident D became snippy and curses at people, and he cursed at the Maintenance Director. The Maintenance Director got huffy, when he realized he couldn't win, and left to get the SSD. They all came back into their room with another staff member. The Maintenance Director pointed his finger at Resident D, while standing towards the end of Resident D's bed. The Maintenance Director was not abusive, but he did yell.An interview was conducted with the Maintenance Director on 8/11/25 at 1:38 p.m. He indicated when he brought Resident D his lunch tray, Resident D asked him to remove an inhaler from his room. He did not feel comfortable removing the medication, and informed Resident D of that. Only he, Resident D, and Resident C were present in the room when he delivered the lunch trays. Resident D told him to get the f*** out of there, so the Maintenance Director left to get the SSD to handle it. The Maintenance Director also went back into the room with the SSD, but eventually left. CNA 3 was also present in the room. The Maintenance Director indicated he did not yell at or raise his voice at Resident D. He only asked if Resident D would please not cuss at him. I did not point my finger at him at all. The reason he went back into the room with the SSD was to explain what was going on, so he would get full picture, and so that everyone was on the same page as to what was going on. He explained it in the room in front of Resident D. He'd been trained on abuse upon hire, in April 2025, and again after this incident. He was told he handled the situation appropriately, that he backed out of the situation, because he wasn't helping.An interview was conducted with Resident D on 8/11/25 at 1:25 p.m. He indicated he did not recall an incident with the Maintenance Director. The 7/10/25 interview with Resident D, documented by the Administrator, indicated she spoke with Resident D at length regarding the incident between Resident D and the Maintenance Director. Resident D denied that the Maintenance Director yelled at him. Using the reasonable person concept, Resident D had the potential to experience ongoing anxiety, fear, agitation, and verbal outbursts in regards to the allegation involving the Maintenance Director. An interview was conducted with the Administrator on 8/11/25 at 2:15 p.m. and 8/12/25 at 11:56 a.m. She indicated when she spoke with Resident D and Resident C, neither of them said anything happened, so she unsubstantiated the allegation of abuse. Resident C said it was not abusive in any way. The Maintenance Director was trying to talk to Resident D, but when Resident D was upset, you couldn't talk to him. The Maintenance Director, being a newer employee, didn't know that about Resident D. The Maintenance Director just needed to walk away, instead of continuing to try to explain. The Maintenance Director was in-serviced on abuse, zero tolerance, and better ways to handle resident behaviors. The Abuse Prohibition, Reporting, and Investigation policy was provided by the Administrator on 8/11/25 at 1:50 p.m. It indicated, It is the policy of [name of facility] to provide each resident with an environment that is free from abuse, neglect, or misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion.Willful, used in the definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict injury or harm.Verbal Abuse-The use of oral, written, and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. This includes any episode of staff to resident.Mental Abuse-Verbal or nonverbal infliction of anguish, pain, or distress that results in psychological or emotional suffering. This includes any episode of staff to resident; and resident to resident if it appears to be willfully directed to a specific resident. Examples of mental abuse include but are not limited to: Harassing a resident.Yelling or hovering over a resident, with the intent to intimidate.This citation relates to Complaint 2568713. 3.1-27(a)(1)3.1-27(b)

Based on interview and record review, the facility failed to administer Resident B's psychotropic medications as ordered and failed to implement Resident D's behavioral care plan for management of behavioral outburst for 2 of 3 residents reviewed for behavioral care management. (Resident B and Resident D)Findings include: 1. The clinical record for Resident B was reviewed on 8/11/2025 at 1:10 p.m. The medical diagnoses included stroke and behavioral disturbances. A Quarterly Minimum Data Set assessment, dated 7/16/2025, indicated Resident B had moderate cognitive impairment and exhibited behaviors of verbal aggression towards others. A psychotropic medication care plan for Resident B, initiated on 8/1/2024 and revised 7/28/2025, indicated an intervention to administer medications as ordered. A physician's order, dated 6/25/2025, indicated to administer an antipsychotic medication via intramuscular injection every second month on the 25th of the month. Review of the Medication Administration Record for June of 2025, indicated that Resident B did not receive her dose of intramuscular antipsychotic medication. During an interview on 8/12/2025 at 11:56 a.m., the Psychiatric Nurse Practitioner (NP) indicated she had treated Resident B on and off for ten years. She resumed care for Resident B in July of 2025. During this time, she was concerned about Resident B not receiving her June dose of antipsychotic medication via intramuscular injection based on the escalating behaviors Resident B was exhibiting. During an interview on 8/12/2025 at 12:45 p.m., the Interim Director of Nursing Services (DNS) indicated it was the expectation for staff to follow physician orders as written unless clinically contraindicated. 2. The clinical record for Resident D was reviewed on 8/11/25 at 11:27 a.m. His diagnoses included, but were not limited to, depression, anxiety, pseudobulbar affect, hemiplegia, and hemiparesis. The 6/24/25 Quarterly MDS (Minimum Data Set) assessment indicated he was moderately cognitively impaired. A care plan, last reviewed/revised 7/7/25, indicated his cognition level could fluctuate throughout the day. A care plan, last reviewed/revised 7/7/25, indicated he was at risk for signs and symptoms of anxiety, and could have episodes of uncontrolled outbursts. The goal was for him to not have increased signs and symptoms of anxiety or uncontrolled outbursts. Approaches were to encourage him to verbalize fears and anxiety, and to offer validation and reassurance, and to maintain a calm environment. A care plan, last reviewed/revised 7/7/25, indicated he had a diagnosis of pseudobulbar affect and was known to exhibit angry outbursts related to extreme irritability, low frustration tolerance and a history of quick temper. The goal was for him to accept staff redirection/reassurance when angry. Approaches were for staff to always approach him calmly and in a non-confrontational manner; for staff to approach him only one at a time and not in a group; for staff to give him space and time to calm; and for staff to quietly ask him to stop his behavior. On 8/12/25 at 11:15 a.m., the Administrator provided the investigative file into an incident that occurred between Resident D and the Maintenance Director on 7/10/25 at 12:15 p.m. The 7/15/25 follow-up incident report, completed by the Administrator, indicated a resident reported concerns with a staff member using harsh tones. An investigation was started, and the Maintenance Director was suspended pending investigation. The follow-up section of the report indicated the investigation was completed. Resident and staff interviews were conducted with no concerns noted. Resident D showed no signs or symptoms of psychosocial distress and denied staff using harsh tones. The Maintenance Director returned to work. An interview was conducted with Certified Nurse Aide (CNA) 3 on 8/11/25 at 4:22 p.m. She indicated she worked at the facility for about a year as a CNA. About a week before her scheduled last day at the facility, due to transferring to a sister facility, she was sitting at the nurse’s station and heard Resident D yelling. He sounded upset, so she went to check on him. When she walked toward Resident D’s room, she saw the Maintenance Director walking down the hallway. When she entered the room, Resident D was crying and really upset. She calmed him down by changing the subject, talked about a local NFL (National Football League) team, and covered him up in bed. Then the Maintenance Director and SSD walked into the room. Resident D “immediately freaks out, went into fight or flight.” She remembered the Maintenance Director saying to Resident D, “You don’t f****** talk to me like that,” while standing at the end of Resident D’s bed, pointing his finger at Resident D. “It was like a Walmart video. People yelling and crazy. It gives me chills.” There were five people in the room at the time, including CNA 3, Resident D, Resident C who was Resident D’s roommate, The Maintenance Director, and the Social Services Director (SSD). The SSD ended up taking the Maintenance Director out of the room, and she followed. CNA 3 explained to the Maintenance Director that Resident D was cognitively impaired, and that he couldn’t correct someone who was cognitively impaired “like that.” After explaining this the Maintenance Director, the Maintenance Director acted as if “he didn’t care.” The Maintenance Director was mad and brushed it off. Resident C informed her that all Resident D wanted was for the Maintenance Director to take his lunch tray. Resident D had only one hand and one leg that worked, so if he saw anyone being lazy, it “kind of pisses him off.” CNA 3 had Resident D laid down, covered up, and calmed down, but as soon as the Maintenance Director came in the room, Resident D pulled his blankets off immediately, and got himself to the side of his bed, “like he was trying to get at” the Maintenance Director. Resident D normally needed assistance to get to the side of the bed. An interview was conducted with the SSD on 8/12/25 at 9:19 a.m. He indicated he worked at the facility for three and a half years as the SSD and Marketing Director. He was let go about a week ago. On 7/10/25, he was walking down the hallway, when the Maintenance Director asked him to go into Resident D’s room. As soon as the SSD and Maintenance Director walked into the room, Resident D was screaming, “Get this guy out my room,” referencing the Maintenance Director. CNA 3 was present in the room as well. The SSD and CNA 3 were trying to prevent Resident D from getting out of bed, because he can’t walk. The Maintenance Director was saying, “This is what I’m talking about.” The SSD witnessed how the Maintenance Director raised his voice, saying you’re not going to talk to me like that, being confrontational. It was getting louder and louder. The SSD did not hear the Maintenance Director curse, just had a tone to his voice. When the SSD and the Maintenance Director first came to the room, the Maintenance Director stayed by the door, but by the end of the incident, he was at the end of Resident D’s bed. The SSD was in between the Maintenance Director and Resident D, who was “red in the face.” The Maintenance Director was pointing at Resident D, saying, “Look, this is what I’m talking about.” Resident D was screaming at the top of his lungs, and the Maintenance Director was “matching his energy.” The SSD was trying to calm down both Resident D and the Maintenance Director, and keep Resident D safe. “This went on for like ten minutes.” The SSD saw the Maintenance Director in the hallway prior to entering Resident D’s room with him, “so there was clearly something that happened before then.” Eventually the Maintenance Director left the room. The SSD remained in the room for a bit, to try and assist with calming Resident D down. Resident C, Resident D’s roommate, informed him Resident D and the Maintenance Director were “jaw jacking,” raising their voices. The SSD informed the nurse on duty, the DON at the time, and the Administrator. The SSD informed the Administrator there was “craziness” going on down there. The SSD went back to check on Resident D, and things had calmed down. The SSD interviewed residents for the investigation later on, including Resident C. Resident C informed him Resident D and the Maintenance Director were going back and forth. Resident D yelled at the Maintenance Director. Then the Maintenance Director yelled at Resident D. The SSD did not know why the Maintenance Director went back into the room a second time, because he would not have done that. An interview was conducted with Resident C on 8/11/25 at 1:20 p.m. He indicated he witnessed an incident between Resident D and the Maintenance Director last month. Resident D became “snippy and curses at people,” and he cursed at the Maintenance Director. The Maintenance Director “got huffy,” when he realized he “couldn’t win,” and left to get the SSD. They all came back into their room with another staff member. The Maintenance Director pointed his finger at Resident D, while standing towards the end of Resident D’s bed. The Maintenance Director was not abusive, but he did yell. An interview was conducted with the Maintenance Director on 8/11/25 at 1:38 p.m. He indicated when he brought Resident D his lunch tray, Resident D asked him to remove an inhaler from his room. He did not feel comfortable removing the medication, and informed Resident D of that. Only he, Resident D, and Resident C were present in the room when he delivered the lunch trays. Resident D told him to get the f*** out of there, so the Maintenance Director left to get the SSD to handle it. The Maintenance Director also went back into the room with the SSD, but eventually left. CNA 3 was also present in the room. The Maintenance Director indicated he did not yell at or raise his voice at Resident D. He only asked if Resident D would please not cuss at him. “I did not point my finger at him at all.” The reason he went back into the room with the SSD was to explain what was going on, “so he would get full picture,” and so that “everyone was on the same page as to what was going on.” He explained it in the room in front of Resident D. He'd been trained on abuse upon hire, in April 2025, and again after this incident. He was told he handled the situation appropriately, that he backed out of the situation, because he wasn’t helping. An interview was conducted with Resident D on 8/11/25 at 1:25 p.m. He indicated he did not recall an incident with the Maintenance Director. An interview was conducted with the Administrator on 8/11/25 at 2:15 p.m. and 8/12/25 at 11:56 a.m. She indicated when she spoke with Resident D and Resident C, neither of them said anything happened, so she unsubstantiated the allegation of abuse. Resident C said it was not abusive in any way. The Maintenance Director was trying to talk to Resident D, but when Resident D was upset, you couldn’t talk to him. The Maintenance Director being a newer employee, didn’t know that about Resident D. The Maintenance Director just needed to walk away, instead of continuing to try to explain. The Maintenance Director was in-serviced on abuse, zero tolerance, and better ways to handle resident behaviors. The Behavior Management policy was provided by the Administrator on 8/11/25 at 1:50 p.m. It indicated, “It is the policy of [name of facility] to provide behavior interventions for resident with problematic or distressing behaviors. Interventions provided are both individualized and non-pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and/or accommodating a resident’s behavioral expressions….Direct care staff will be educated as to the interventions for residents reviewed by the IDT (Interdisciplinary Team.)” This citation relates to Complaint 2582411 and Complaint 2568713. 3.1-37(a)

Based on interview and record review, the facility failed to determine residents' ability to consent and establish individualized resident-centered care plans for a resident-to-resident relationships for 2 of 3 residents reviewed for resident-to-resident relationships. (Resident B and Resident C)Findings include: 1. The clinical record for Resident B was reviewed on 8/11/2025 at 1:10 p.m. The medical diagnoses included stroke and behavioral disturbances.A Quarterly Minimum Data Set assessment, dated 7/16/2025, indicated Resident B had moderate cognitive impairments.During an interview with Resident B on 8/11/2025 at 12:38 p.m., Resident B indicated she was in a relationship with Resident C. The relationship entailed her holding hands, playing cards, and kissing Resident C.Review of clinical record did not establish an assessment of Resident B's ability to consent nor care plans for Resident B's sexuality and relationship with Resident C.2. The clinical record for Resident C was reviewed on 8/11/2025 at 1:30 p.m. The medical diagnoses included chronic obstructive pulmonary disease and depression. A Quarterly Minimum Data Set assessment, dated 5/13/2025, indicated Resident C was cognitively intact.During an interview on 8/11/2025 at 12:52 p.m., Resident C indicated he was in a relationship with Resident B, but they had recently broken up. During the time they were together, they would spend time together, hold hands, and kiss each other. Resident C stated it did not go further than kissing in the mouth. Review of the clinical record did not establish an assessment for Resident C's ability to consent nor care plans for Resident C's sexuality and relationship with Resident B.An interview with the Executive Director, on 8/12/2025 at 12:20 p.m., indicated she was unable to find documentation of Resident B or C's capacity to consent and Resident B and C's care plans for resident-to-resident relationship. It was the responsibility of the Social Service Director to develop the care plans.A policy entitled, Resident Sexuality, was provided by the Executive Director on 8/11/2025 at 1:40 p.m. The policy indicated .A determination of the ability to consent to sexual activities must be made in conjunction with the IDT and physician.Determination of capacity to make decision regarding sexual activity will be documented by the physician in the medical record.This citation relates to Complaint 2582411.3.1-34(a)(1)

Based on interview and record review, the facility failed to provide eight consecutive hours of registered nurse (RN) coverage daily for 2 of 30 days reviewed. This deficient practice had the protentional to affect all 35 residents. Findings include: Preliminary review of the survey, completed on 5/4/2025 at 8:35 a.m., indicated the facility had a nurse-staffing waiver for RN coverage of eight consecutive hours every day. Review of the nursing schedule from April 4, 2025, through May 5, 2025, indicated the facility did not have RN coverage for the following days: April 20, 2025, and May 3, 2025. During an interview on 5/6/2025 at 12:45 p.m., the Executive Director (ED) indicated the facility will continue to utilize the RN waiver at that time. Overall, their staffing of RNs had improved, but not completely stabilized at that time. They are currently using as needed (PRN) RNs as well as their DON as the RN coverage, but it was mainly PRN RNs, and it was not consistent enough to get rid of the waiver currently. During an interview on 5/8/2025 at 11:35 a.m., the ED indicated there were no residents that needed RN specific care. The facility had a mitigation strategy to not admit any residents who would need RN specific care, to have an RN on-call, and an understanding with a local facility within the same corporation to have an RN come on-site in the case of need. During an interview on 5/8/2025 at 11:52 a.m., the ED indicated there was no policy regarding RN coverage, but the facility's expectation was to utilize the federal regulations. 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to promote dignity by ensuring residents were changed in a timely manner after episodes of incontinence for 2 of 2 residents reviewed for dignity. (Residents 7 & 11) Findings include: 1. The clinical record for Resident 11 was reviewed on 5/6/25 at 10:02 a.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, epilepsy, and major depressive disorder. The Annual Minimum Data Set (MDS) assessment, dated 2/4/25, indicated Resident 11 was cognitively intact, was always incontinent of bowel and bladder, and was dependent with toileting. An incontinence due to impaired mobility and overactive bladder care plan, dated 4/5/24, indicated to assist with incontinent care as needed and to check and change every two hours for incontinence. During an interview with Resident 11 on 5/5/25 at 10:44 a.m., they indicated they have to wait long periods at night to be changed when calling out that they have been incontinent. Resident 11 indicated night shift will not check her during the night, so by the time morning comes she was completely soaked in urine and required a complete bed change due to her linens being soaked in urine. Resident 11 indicated it made her frustrated, angry, and humiliated from having to lay in her urine. During an interview with Resident 11 on 5/6/25 at 11:08 a.m., she indicated staff had already been on her today for needing to be changed so much. She indicated it upset her, and she was crying, saying she can't help it. She indicated the staff does this to her every day when she was wet and waiting to be changed. During an observation with Licensed Practical Nurse (LPN) 2 on 5/6/25 at 11:29 a.m., LPN 2 was performing incontinent care to Resident 11. LPN 2 indicated her brief was wet when she removed it. During an interview with Resident 3 (Resident 11's roommate) on 5/7/25 at 12:40 p.m., she indicated she had seen Resident 11 wait several times for her call light to be answered when she calls out wet. Resident 3 indicated staff will come into the room, turn off the call light, and say they will be back, but then not return for a long time. Resident 3 had a Quarterly Minimum Data Set (MDS) assessment, on 2/11/25, indicating they were cognitively intact. During an interview with the Director of Nursing (DON) on 5/7/25 at 12:18 p.m. she indicated staff conduct every two hour checks with residents who are incontinent. The DON indicated Resident 11's bed was soaked a lot of times due to medications she was on and that could occur even an hour after being toileted. 45291 2. The clinical record for Resident 7 was reviewed on 5/6/2025 at 1:22 p.m. The medical diagnoses included bilateral lower limb amputations and major depression. An Annual MDS assessment, dated 3/18/2025, indicated Resident 7 needed assistance with transferring and toileting, was cognitively intact, and incontinent of bowel and bladder. An activities of daily living (ADL) care plan, revised 3/18/2025, indicated Resident 7 needed assistance with activities of daily living with an intervention to provide Resident 7 with toileting routinely. During an interview and observation on 5/5/2025 at 1:10 p.m., Resident 7 indicated she had to wait a long time, up to two hours, to get assistance after putting on her call light. The last time this happened was during the last week, and it was worse in the evening after supper. Due to the waiting times, she stated she had to sit in urine for a long time and it makes me [Resident 7] feel disgusting and humiliated. Resident 7's room was noted to smell of urine. Resident 7 stated she had accidents, and they do not clean her room on the weekends so it sometimes smells. A policy entitled Resident Rights was provided by the Executive Director on 5/7/2025 at 12:40 p.m. The policy indicated that residents have the right to be treated with consideration, respect, and full recognition of their dignity. 3.1-3(a) 3.1-3(t)

Based on observation, interview, and record review, the facility failed to provide showers as preferred for Resident 4 and failed to ensure Resident 21 had a pressure-reducing cushion in place as care planned for 2 of 2 residents reviewed for accommodation of needs (Resident 4 and Resident 21). Findings include: 1. During an interview with Resident 4 on 5/5/25 at 11:09 a.m., she indicated she was supposed to get a shower three times a week and the facility staff were not assisting her with showers. The resident indicated there was one CNA (Certified Nurse Aide) who would give her a shower, the other CNAs gave her bed baths because she had to use a mechanical lift to transfer. The resident indicated she preferred to have a shower instead of a bed bath. Review of the shower book, on 5/6/25 at 1:42 p.m., indicated Resident 4 was scheduled to have a shower three times a week on Tuesday, Wednesday, and Saturday. Review of the record of Resident 4, on 5/8/25 at 11:10 a.m., indicated the resident's diagnoses included, but were not limited to, cerebral palsy, diabetes, cerebral infarction with hemiplegia and hemiparesis affecting unspecified side, anxiety, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 4/8/25, indicated the resident was moderately impaired for daily decision making. The resident was dependent on the staff for showering. The plan of care for Resident 4, dated 4/14/25, indicated the resident required assistance with activities of daily living (ADLs) related to cerebral palsy and hemiplegia. The interventions included, but were not limited to, transfer resident with two staff with a mechanical lift and assist with bathing per residents' preference of showers. The preference for customary routine and activities for Resident 4, dated 5/7/24, indicated the resident preferred to have a shower. The shower report for Resident 4, dated March 2025, indicated the resident received a bed bath instead of a shower on 3/6/25, 3/8/25, 3/11/25, 3/13/25, 3/15/25, 3/25/25, 3/27/25, and 3/29/25. The shower report for Resident 4, dated April 2025, indicated the resident received a bed bath instead of a shower on 4/1/25, 4/2/25, 4/5/25, 4/19/25, 4/27/25 and 4/30/25. The preference for daily routine policy was provided by the Executive Director (ED) on 5/7/25 at 12:50 p.m. The policy indicated the purpose was to identify and develop a plan of care that reflects a resident's past and current daily customary routines. 45291 2. The clinical record for Resident 21 was reviewed on 5/6/2025 at 11:45 a.m. The medical diagnoses included schizophrenia and chronic kidney disease. A Quarterly MDS assessment, dated 3/11/2025, indicated Resident 21 was cognitively intact. A nursing assessment, dated 3/11/2025, indicated Resident 21 was not at risk for developing a pressure area. A skin care plan, revised 3/21/2025, indicated Resident 21 was at risk for skin breakdown and to utilize a pressure-reducing cushion while in the wheelchair. During an interview and observation, on 5/5/2025 at 12:53 p.m., Resident 21 was noted to be sitting in his wheelchair. Midway through the interview, Resident 21 stood up and transferred to bed. Resident 21's wheelchair was noted to have a cushion in place. Resident 21 indicated he had never used a cushion in his wheelchair. During an interview and observation, on 5/6/2025 at 1:09 p.m., Resident 21's wheelchair was noted to be without a cushion. During an interview with the Director of Nursing (DON) on 5/7/2025 at 12:32 p.m., she indicated Resident 21's cushion was in the second bathroom and drying after it was washed. The DON verified they have spare cushions that staff could utilize, but she was unsure why the staff did not utilize one. A policy entitled Resident Rights was provided by the ED on 5/4/2025 at 12:05 p.m. The policy indicated residents have the right to .receive services in the facility with reasonable accommodation of resident needs and preferences . 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to provide incontinent care in a timely manner for a resident dependent on staff for toileting needs for 1 of 4 residents reviewed for activities of daily living (ADLs). (Resident 22) Findings include: During an interview with Resident 22 on 5/5/25 at 12:48 p.m., she indicated last week or last weekend, she had to wait four hours in an incontinent brief that was wet with urine and had a bowel movement in it. The resident turned her call light on at 10:00 a.m., and they did not change her until 2:00 p.m. The roommate (Resident 17) indicated she was present when this happened and witnessed it. Resident 22 indicated she reported it to Licensed Practical Nurse (LPN) 6 and Certified Nurse Aide (CNA) 7 and various other nursing staff. The resident had a clock in her room with the correct time and indicated she had timed it the day it happened. The resident indicated her bottom was raw from laying in a dirty incontinent brief that long. During an observation on 5/7/25 at 11:45 a.m., CNA 3 and CNA 4 provided incontinent care for Resident 22. The resident's incontinent brief was soaked with urine and had also leaked through her jean shorts. LPN 5 applied magic butt paste to the resident's buttocks. The resident's buttocks were pink, shiny, and raw. Review of the record of Resident 22, on 5/7/25 at 1:08 p.m., indicated the resident's diagnoses included, but were not limited to, urinary tract infection, multiple sclerosis, chronic kidney disease, morbid obesity, neuromuscular dysfunction of bladder, and need for assistance with personal care. The Admission Minimum Data Set (MDS) assessment, dated 3/25/25, indicated the resident was cognitively intact for daily decision making. The resident was always incontinent of her bowels and bladder. The resident was dependent for toileting needs. The plan of care for Resident 22, dated 3/31/25, indicated the resident required assistance with ADLs related to multiple sclerosis, morbid obesity, and incontinence. The interventions included, but were not limited to, assistance with toileting and/or incontinent care as needed. The skin assessment for Resident 22, dated 5/3/25, indicated the resident was observed to have moisture associated dermatitis on her buttocks. The physician order for Resident 22, dated 5/5/25, indicated the resident was ordered magic butt paste to buttocks every shift for redness. The nursing skills competency provided by the Executive Director, on 5/8/25 at 11:45 a.m., indicated the procedure included, but were not limited to, assistance with toileting or perineal care as needed. 3.1-38(a)(3)(A)

Based on observation, interview, and record review, the facility failed to follow policy for a resident who utilized an electronic cigarette and was on oxygen for 1 of 1 resident reviewed for accidents. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 5/6/25 at 10:02 a.m. The diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, epilepsy, and schizoaffective disorder. The Annual Minimum Data Set (MDS) assessment indicated Resident 11 was cognitively intact for daily decision making and was dependent on laying to sitting up in bed. During an observation and interview with Resident 11 on 5/5/25 at 10:46 a.m., Resident 11 was sitting up in bed with oxygen on and using an electronic cigarette. During an interview with Resident 11 on 5/6/25 at 11:10 a.m., she indicated she did use their electronic cigarette while on oxygen. Resident 11 indicated she had been told by some staff it was okay to use the electronic cigarette while on oxygen, and then some staff have said it was not okay. Resident 11 indicated that the Executive Director (ED) came into her room yesterday and told her she had to turn her oxygen off when she used her electronic cigarette. Resident 11 indicated she was unable to turn the oxygen off herself because it was out of her reach while lying in bed. During an observation and interview on 5/7/25 at 10:45 a.m., Resident 11 was lying in bed with her oxygen concentrator behind her bed. She indicated she continues to use her electronic cigarette while on oxygen. Resident 11 indicated she cannot reach the oxygen to turn it off, so it stays on while she uses her electronic cigarette. She indicated she has used her electronic cigarette for over two years while wearing oxygen, and no one had said anything about it until the State came in. A use of electronic cigarette care plan, dated 4/1/24, indicated the electronic cigarette policy would be reviewed with the resident upon using and as needed During an interview with the Director of Nursing (DON) on 5/7/25 at 12:13 p.m., they indicated they were aware that Resident 11 uses an electronic cigarette in her room while on oxygen. The DON indicated Resident 11 does not have an order to self-administer her oxygen and has not been educated to manage her oxygen. The DON indicated Resident 11 could use her call light to have staff turn her oxygen on and off for her when she wanted to use her electronic cigarette. An Electronic Cigarettes policy was provided by the ED on 5/6/25 at 1:00 p.m. It indicated 9. Residents using oxygen are restricted from using electronic cigarettes when oxygen is in use. Oxygen must be shut off and removed prior to the resident using electronic cigarettes . 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure there was Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week for 14 of 31 days reviewed. This had the potential to affect 27 residents. Findings include: Review of the schedule and RN time sheets from 3/1/2024 to 4/1/2024, indicated that eight hours of RN coverage were not completed on 3/6/2024, 3/7/2024, 3/8/2024, 3/9/2024, 3/10/2024, 3/16/2024, 3/17/2024, 3/24/2024, 3/25/2024, 3/26/2024, 3/27/2024, 3/28/2024, 3/30/2024, and 3/31/2024. An interview with the Director of Nursing on 4/4/2024 at 11:25 a.m. verified that eight hours of RN coverage was not provided on the 14 aforementioned dates. An interview with the Director of Nursing on 4/4/2024 at 11:35 a.m. indicated that there was no specific policy to RN coverage, but the facility would follow the federal regulation of RN coverage of at least eight consecutive hours a day, seven days a week.

Based on interview and record review, the facility failed to develop and implement care plans for the utilization of oxybutynin and NicoDerm for Resident 7, dementia medication for Resident 13, and iron, Jardiance, and omeprazole for Resident 14. This affected 3 of 5 residents reviewed for medication management. Findings include: 1. The clinical record for Resident 7 was reviewed on 4/4/2024 at 11:45 a.m. The medical diagnosis included acute and chronic respiratory failure with hypoxia. A Significant Change Minimum Data Set (MDS) Assessment, dated 3/6/2024, for Resident 7 indicated she was cognitively intact. A physician order, dated 2/29/2024, indicated for Resident 7 to utilize Ditropan 5 milligrams (mg) daily. A physician order, started on 3/7/2024 and discontinued on 4/4/2024, indicated for Resident 7 to utilize a NicoDerm transdermal patch daily. No care plans were developed and implemented to address the utilization of the aforementioned medications for Resident 7. 2. The clinical record for Resident 13 was reviewed on 4/3/202 at 1:30 p.m. The medical diagnosis included dementia. A Quarterly MDS Assessment, dated 2/72/2024, indicated that Resident 13 was moderately cognitively impaired and had a progressive neurological condition. A physician order, dated 8/22/2023, indicated for Resident 13 to utilize donepezil 5 mg daily for dementia. A physician order, dated 8/22/2023, indicated for Resident 13 to utilize memantine 5 mg twice daily for dementia. A dementia care plan for Resident 13, dated 11/22/2022, did not indicate the utilization of medication. This dementia care plan was revised on 4/5/2024 at 10:34 a.m. 3. The clinical record for Resident 14 was reviewed on 4/3/2024 at 11:35 a.m. The medical diagnosis included gastro-esophageal reflux disease (GERD). A Quarterly MDS Assessment, dated 2/20/2024, indicated that Resident 14 was cognitively intact. A physician order, dated 10/14/2023, indicated for Resident 14 to utilize ferrous sulfate 325 mg daily. A physician order, dated 10/14/2023, indicated for Resident 14 to utilize Jardiance 10 mg daily. A physician order, dated 10/15/2023, indicated for Resident 14 to utilize omeprazole 20 mg daily. No care plans were developed and implemented to address the utilization and monitoring of the aforementioned medications for Resident 14. An interview with the Administration on 04/05/24 at 10:40 a.m. indicated that she had spoken with the MDS Coordinator regarding the care plans for Resident 7, 13, and 14. The facility did not have care plans in place for the utilization of oxybutynin and NicoDerm for Resident 7, dementia medication for Resident 13, nor for iron, Jardiance, and omeprazole for Resident 14, but the MDS coordinator would develop care plans for those medications for those residents. A policy, entitled IDT Comprehensive Care Plan Policy, was provided by the Administrator on 4/5/2024 at 10:45 a.m. The policy indicated, .The care plan must include measurable goals and resident specific interventions base on the resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental and psychological well-being . 3.1-35(a) 3.1-35(b)(1)

Based on interview and record review the facility failed to maintain refrigerator/freezer temperature logs to ensure food was stored at a appropriate temperature and failed to maintain temperature logs for the dish machine to ensure dishes were sanitized for 7 out of 7 days, this had to potential effect 27 residents residing in the facility. Finding include: During initial tour of the kitchen on 3/20/23 at 6:55 p.m., Dietary Aide 3 provided the low temperature dish machine log, dated March 2023, the log was blank for lunch and supper from 3/13/23 to 3/19/23. The log indicated the facility was to check the water temperature and sanitation level of the dish machine when preparing to wash dishes for each meal; breakfast, lunch and supper. If the water temperature is below 120 STOP and notify the dietary manager. Any items washed when minimum standards are not met are to be held and re-washed when issue resolved. During initial tour of the kitchen on 3/20/23 at 6:55 p.m., Dietary Aide 3 provided the refrigerator/freezer temperature log, dated March 2023, the log was blank for evening from 3/13/23 to 3/19/23. During an interview with the Dietary Manager on 3/22/23 at 12:00 p.m., indicated it was the responsibility of cook to log refrigerator/freezer temperatures to ensure food was maintained at appropriate temperatures. The Dishwasher was responsible to log the dishwasher temperatures to ensure dishes were sanitized. The facility had not had any food borne illness outbreaks. The Dietary Manager was unsure why the refrigerator/freezer or dishwasher temperatures were not checked. During an interview with the Dietary Manager on 3/22/23 at 1:53 p.m., indicated all 27 residents residing in the facility ate meals from the facility kitchen. The dish machine temperature/sanitizer policy provided by the Dietary Manager on 3/22/23 at 1:50 p.m., indicated dishwashing staff would monitor and record dish machine temperatures to assure proper sanitizing of dishes. The food storage policy provided by the Dietary Manger on 3/22/23 at 1:50 p.m., indicated food would be stored at an appropriate temperature and by methods designed to prevent contamination. Refrigeration temperatures for refrigerators should be less than 41 degrees Fahrenheit and should be checked two times a day, if food is at above 41 degrees Fahrenheit, the food should be discarded. The freezer temperature should be at 0 degrees Fahrenheit and checked at least two times daily. 3.1-21(i)(3)

Based on observation, interview and record review the facility failed to maintain respiratory equipment in a bag for good infection control practices and failed to change oxygen tubing as ordered by the physician for 4 of 5 residents reviewed for respiratory care (Resident 20, Resident 23, Resident 12, and Resident 26). Finding include: 1.) During an observation on 3/21/23 at 10:53 a.m., Resident 20 a respiratory mask sitting on bedside table not in a bag and a nebulizer mouth piece laying on the edge of the raised floor not in a bag. During an observation on 3/22/23 at 11:50 a.m., Resident 20 laying in bed with oxygen on, a respiratory mask on nightstand not in a bag and nebulizer mouth piece laying on the edge of the raised floor not in a bag. Review of the record of Resident 20 on 3/22/23 at 11:03 a.m., indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, hypertensive heart disease, diabetes, muscle weakness and pneumonia. The physician recapitulation (recap) for Resident 7, dated March 2023, indicated the resident was order albuterol sulfate aerosol inhaler 90 micrograms (mcg), 2 puffs every four hours as needed for wheezing and shortness of breath. Albuterol sulfate solution for nebulization: 2.5 milligram (mg)/ 3 milliliter (ml) inhalation every 6 hours as needed for shortness of breath or wheezing. Ipratropium bromide solution: 0.02% for shortness of breath or wheezing. The resident was ordered a Trelegy Elipta (fluticasone-umeclidin-vilanter) (respiratory tract agent/anti-inflammatory agent) one puff one time a day COPD. During an observation on 3/22/23 at 2:00 p.m., Resident 20 was sitting on the side of his bed, oxygen on 3 liters, respiratory mask and nebulizer mouth piece was not in a bag laying on the raised floor. During an observation on 3/23/23 at 10:50 a.m., Resident 20 had a respiratory mask was laying on his nightstand not in a bag and his nebulizer mouthpiece laying on the edge of the raised floor not in a bag. During an observation on 3/23/23 at 11:20 a.m., Resident 20's respiratory mask was laying on his nightstand not in a bag, his nebulizer mouthpiece laying on the edge of the raised floor not in a bag. 45291 2. The clinical record for Resident 23 was reviewed on 3/22/2023 at 2:34 p.m. The medical diagnoses included dementia and chronic obstructive pulmonary disease. A Significant Change of Condition Assessment, dated 2/21/2023, indicated that Resident 23 was cognitively impaired, utilized oxygen therapy, and needed assistance with activities of daily living. A physician ordered for Resident 23, dated 7/17/2022, indicated to change oxygen tubing and humidification weekly. An observation on 3/20/2023 at 6:53 p.m. indicated oxygen tubing on the in-room concentrator was dated for 2/27/2023. An observation on 3/20/2023 at 7:10 p.m. with LPN 4 indicated the tubing was dated for 2/27/2023. 3. The clinical record for Resident 12 was reviewed on 3/23/2023 at 1:55 p.m. The medical diagnoses included pulmonary hypertension and muscle weakness. A Significant Change of Condition Assessment, dated 1/31/2023, indicated that Resident 12 was cognitively intact, used oxygen therapy, and needed assistance for activities of daily living. A physician order, dated 1/25/2023, indicated to change Resident 12's oxygen tubing and humidification every week. An observation on 3/20/2023 at 6:55 p.m. indicated oxygen tubing on the in-room concentrator was dated for 2/1/2023. An interview and observation on 3/20/2023 at 7:15 p.m. with LPN 4 indicated the tubing was dated for 2/1/2023. LPN 4 indicated she was not sure how often oxygen tubing should be changed. 4. The clinical record for Resident 26 was reviewed on 3/23/2023 at 1:55 p.m. The medical diagnoses included tremor and weakness. A Quarterly Minimum Data Set Assessment, dated 2/21/2023, indicated that Resident 26 was cognitively confused and needed assistance with activities of daily living. An observation on 3/21/2023 at 2:25 p.m., indicated Resident 26's nebulizer was in the top drawer of the bedside table with no storage bag. An observation on 3/22/2023 at 2:45 p.m. indicated Resident 26's nebulizer was in the top drawer of the bedside table with no storage bag. A policy entitled, Oxygen Therapy and Devices, was provided by the Administrator on 3/23/2023 at 3:45 p.m. The policy indicated to change oxygen tubing out weekly or as needed and to place in a labeled bag when not in use. A policy entitled, Aerosolized Medication Therapy, was provided by the Administrator on 3/23/2023 at 3:45 p.m. The policy indicated to change the nebulizer equipment weekly and to place in a labeled bag with patient's name when finished with nebulizer treatments. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure they accurately reported licensed nursing hours for 14 of 91 days of payroll based journal data reviewed. Findings include: Payroll Based Journal Staffing Data Report for Quarter 1 of Fiscal Year 2023 (10/1/22 to 12/31/22) indicated the facility did not report 24 hours of licensed nurse coverage on 10/1/22, 10/8/22, 10/9/22, 10/15/22, 10/23/22, 11/19/22, 11/20/22, 11/24/22, 12/3/22, 12/4/22, 12/18/22, 12/23/22, 12/25/22, and 12/29/22. Review of the as worked schedules indicated that agency or salary licensed staff was present on the aforementioned dates. An interview with Administrator on 3/23/2023 at 2:30 p.m. indicated she believed there was an issue with reporting agency staff members to the payroll-based journal. At the time agency and salaried staff would not clock in using the electronic time clock so the offsite reporter was not able to see those shifts as worked. Agency and salaried members would utilize paper time clocks for verification and payment. An interview with the Administrator on 3/24/2023 at 1:35 p.m. indicated there is no policy regarding payroll-based journal reporting but they would follow the CMS guideline.

Based on interview and record review the facility failed to maintain a dignified environment for a resident requested assistance with care for 1 of 2 residents reviewed for abuse (Resident 4). Finding include: During an interview with Resident 4 on 3/21/23 at 1:45 p.m., indicated CNA 1 yelled at her the other day on 3/17/23. The resident indicated she wanted to go to bed and CNA 1 yelled and told her that she had to wait her turn. The resident indicated she told her she wasn't going to treat her like a dog. The nurse heard CNA 1 yelling at me. The resident indicated it made her mad and she told CNA 1 she paid to live at the facility and she was not allowed to yell at me. Review of the record of Resident 4 on 3/23/23 at 1:05 p.m., Cerebral palsy, respiratory failure, cerebral infarction, personal history of transient ischemic attack, hypertensive heart disease, obstructive sleep apnea, diabetes, anxiety disorder, major depressive disorder and muscle weakness. The Quarterly Minimum Data Set (MDS) for Resident 4, dated 2/14/23, indicated the resident was moderately impaired for daily decision making. The resident had no behaviors. The resident required extensive assistance of two people for transfers and toileting. The resident utilized a wheelchair for mobility. The resident did not ambulate. The plan of care for Resident 4, dated 1/24/23, indicated the resident was at risk for signs and symptoms such as withdrawal, decreased appetite, tearfulness and insomnia. The interventions included, but were not limited allow resident to express feelings and frustrations; offer validation and support, emphasize and promote independence, encourage activities of interest. The plan of care for Resident 4, dated 1/24/23, indicated the resident was at risk for signs and symptoms of anxiety. The interventions included, but were not limited to, encourage the resident to verbalize fears and anxiety and offer validation and reassurance, maintain a calm environment and move to a quiet area. The witness statement for CNA 1, dated 3/21/23 (no time), indicated that on 3/17/23 Resident 4 and herself got into an argument regarding assisting the resident to bed. CNA 1 told the resident that she would get to her the first opportunity she could and then the resident indicated she needed to go to the bathroom, CNA 1 told the resident to go to the back hallway and she would come assist the resident. Resident 4 kept arguing with CNA 1, CNA 1 then told her there were 27 other residents besides her to take care of and the resident was not the queen of the building and she would have to learn to wait her turn. The resident began saying the staff were treating her like a dog and she was going to move to another facility. CNA 1 told the resident that was her choice if she wanted to go to another facility. LPN 2 then told CNA 1 to take a break and walk away from Resident 4. During an interview with the Administrator on 3/23/23 at 2:53 p.m., indicated the abuse allegations made by Resident 4 were not founded after the facility conducted an investigation. The facility suspended CNA 1 and brought her back after the investigation was completed. During an interview with CNA 1 on 3/23/23 at 3:09 p.m., indicated on 3/17/23 during the evening time Resident 4 was being demanding wanting to be put to bed. The resident stalks staff in her wheelchair and wants us to stop everything we are doing and take care of her. The resident started getting mouthy and back talking the CNA. The CNA told her she had to wait her turn. The nurse came and told me to take a break and not to provide care for the resident the rest of the night. The Director Of Nursing (DON) and the Assistant Director Of Nursing (ADON) did provide education to the CNA on 3/22/23 that if a resident starts an argument to walk away. During an interview with the DON on 3/23/23 at 3:26 p.m., indicated she did provide education to CNA 1 to be careful how she reacted to residents with behaviors and to get the charge nurse if a resident was making her feel uncomfortable. During an interview with LPN 2 on 3/23/23 at 3:40 p.m., indicated she was the nurse on 3/17/23 when CNA 1 and Resident 4 had the incident. LPN 2 indicated she intervened and told CNA 1 to walk away and take care of other residents. CNA 1 was being firm with Resident 4 but LPN 2 could tell it was going to escalate into an argument. The resident rights policy provided by the Administrator on 3/24/23 at 11:10 a.m., indicated All staff members recognize the rights of the residents at all times and residents assume responsibilities to enable personal dignity, well being, and proper delivery of care. 3.1-3(a)(1)(t)

Based on interview and record review, the facility failed to ensure a urine specimen was transported to the laboratory, notify the physician timely of the failure to transport the urine specimen, and develop a thorough plan of care for a resident with vaginal or bladder area bleeding and an increased white blood cell (WBC) count, resulting [MEDICAL CONDITION], for 1 of 3 residents reviewed. (Resident #A) Findings include: Resident #A's record was reviewed on 5/2/16 at 11:52 a.m. Resident #A's [DIAGNOSES REDACTED]. Resident #A's quarterly Minimum Data Set (MDS) assessment dated ,[DATE], indicated she rarely/never understood others. She was severely impaired in her cognitive skills for daily decision making. Progress Notes for Resident #A indicated the following: 12/29/16 at 10:44 a.m. - She had large amounts of bright red blood from her vaginal or bladder area when staff toileted her. She also had 2 bed changes from large amounts of blood. 2/8/16 at 2:39 p.m. - She had bright red blood and several large clots in her brief. 2/10/16 at 2:31 p.m. - She had reddish brown drainage observed when she urinated. A physician's orders [REDACTED]. A Progress Note for Resident #A dated 2/11/16 at 8:13 p.m., indicated she had blood clots observed in her brief. A Progress Note for Resident #A dated 2/12/16 at 1:32 a.m., indicated two failed attempts were made to collect urine using a straight catheter technique. A Progress Note for Resident #A dated 2/12/16 at 4:27 a.m., indicated she had blood clots observed in her brief. A Progress Note for Resident #A, dated 2/13/16 at 6:10 a.m., indicated cloudy tan urine had been obtained using a straight catheter technique. A Progress Note for Resident #A dated 2/14/16 at 6:09 a.m., indicated the urine specimen collected on 2/13/16, had not been sent to the laboratory and had been thrown away. She was pale and more lethargic. No explanation was documented why the urine specimen had been thrown away. A Progress Note for Resident #A dated 2/14/11 at 2:11 p.m., indicated she had a small amount of blood observed in her brief. She was lethargic. A Progress Note for Resident #A dated 2/15/16 at 10:28 p.m., indicated she had a minimal amount of blood observed in her brief. A physician progress notes [REDACTED]. Her blood pressure was 90/40, respirations were 40, with [MEDICAL CONDITION]. Her status was discussed with her son and he was deciding how to proceed; comfort care verses emergency room . A Progress Note for Resident #A dated 2/16/16 at 10:14 a.m., indicated the physician had been in to see her. He recommended she be sent to the emergency room and Resident #A's son had not wanted her sent. A Progress Note for Resident #A dated 2/16/16 at 3:25 p.m., indicated Resident #A's respirations had ceased. A Certificate Of Death for Resident #A indicated she passed away on 2/16/16. Her Certificate of Death indicated the following: The immediate cause (final disease or condition resulting in death was septic shock. The underlying cause (disease or injury that initiated the events resulting in death) was abdominal or urinary bacterial infection. An interview with Resident #A's son on 5/2/16 at 1:40 p.m., indicated he had received different version from the facility related to the cause of his mother's bleeding. When his mother first began bleeding the CNA's had informed him the blood was coming from her urine. Other staff assumed the blood was from her vagina and he believed those staff were wrong. He believed the blood was coming from his mother's urine. He indicated the facility failed to follow the physician's orders [REDACTED]. He indicated his mother passed away and her Death Certificate indicated her cause of death was septic shock and secondary cause of death was bacterial urinary tract infection. An interview with the Director of Nursing (DON) on 5/2/16 at 5:40 p.m., indicated she did not know why the urine specimen collected from Resident #A on 2/13/16, had been thrown away and the staff involved in collecting and disposing the urine specimen were no longer employed at the facility. An interview with the Director of Nursing (DON) on 5/2/16 at 8:30 p.m., indicated Resident #A did not have a plan of care for bleeding in the vaginal or bladder area. A telephone interview with Resident #A's physician on 5/3/16 at 12:15 p.m., indicated he had not been notified by the facility of the two failed attempts to collect a urine specimen on 2/12/16, and had not been notified the urine specimen collected on 2/13/16, had been thrown away until Resident # A had become more ill. Resident #A had not shown any signs of infection except an increased WBC count. Resident #A's son had not wanted his mother sent to the emergency room . Resident #A had intermittent bleeding and had intermittent bleeding in the past. He believed Resident #A's bleeding was vaginal and would have required extensive work-up and testing to determine the cause of the bleeding. He believed the son had not wanted any of those interventions. Resident #A's bleeding probably had not contributed to her death. Resident #A's cause of death was probably [MEDICAL CONDITION]. He did not have Resident #A's record with him during the interview and could not confirm exact information or dates. This federal tag relates to Complaint IN 414. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to timely identify, accurately assess and document a stage 4 pressure ulcer, and failed to provide timely interventions with updated care plans for 1 of 2 residents who met the criteria for pressure ulcer development. (Resident #7) Findings include: Resident #7's record was reviewed on 10/29/2015 at 10:06 a.m. The record indicated Resident #7 had [DIAGNOSES REDACTED]. A Braden Scale for Predicting Pressure Sore Risk, dated 5/1/15, indicated a score of 14, and A score of 17 and below requires a weekly skin assessment and documentation in the medical record. A Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #7 had severe impairment in cognitively skills for daily decision making, was able to make herself understood, usually understands others, had no behaviors of rejecting care, had no long term memory or short term memory problems, was extensive assistance of one for bed mobility and personal hygiene, totally dependent of two staff physical assistance for transfers, did not walk, was always incontinent of bowel, had a Foley catheter, had no pressure ulcers but is at risk for pressure ulcer development, and had pressure reducing devices in her chair and bed. The area on the MDS that would have indicated she was on a turning and repositioning program was not checked. A Significant Change MDS, dated [DATE], indicated Resident #7 was moderately impaired in cognitive skills for daily decision making, was able to make herself understood, usually understands others, no long term or short term memory problems, required extensive assistance of one for bed mobility and personal hygiene, required extensive assistance of two for transfers, did not walk, was always incontinent of bowel, had a Foley catheter, had a stage 4 pressure area that was not present at a lesser stage . The area on the MDS that would have indicated Resident #7 was on a turning and repositioning program was not checked. During an interview, on 10/27/15 at 1:44 p.m., LPN # 8 indicated Resident #7 had a stage 3 pressure ulcer. A care plan, dated 6/23/14, indicated a Problem of: I am at high risk for pressure ulcers due to [DIAGNOSES REDACTED]. Goal and target date: I will remain free of skin breakdown thru 9/24/15, 12/14, 2/15, 5/15, 8/15. Approaches: Reposition me every 2 hours, place my pressure-reducing device/product on bed/chair, I sometimes need two persons to assist with repositioning to avoid skin friction/shearing, encourage my good nutritional intake, I need a daily observation of skin with routine care, I need a daily observation of skin with routine care, I need a full skin evaluation weekly with bath/shower, I need to float my heels off the bed, notify my MD if breakdown noted. A care plan, dated 6/23/14, indicated a problem of: I am unable to do my own care, (feeding, transfers, etc) and require staff assistance for all ADL's due to MS and spastic quad. I do have contractures. Goal and target date: I will have a neat clean appearance daily thru 9/24/15, 12/14, 2/15, 5/15, 8/15. Approaches: One person to assist me with bathing .Staff to do ROM to all my extremities during AM and PM care, give me a partial bath daily with either shower and shampoo or bed bath 2x weekly .mechanical lift for transfers. An Electronic Record Care Plan, dated 10/18/15, indicated: I have a pressure ulcer on my coccyx. Goal: Area will decrease in size by 0.5 cm (centimeters). Interventions: Do treatment as ordered. Keep all appointments with wound center. Keep my MD and family aware of any changes. Measure area weekly. Pressure reducing mattress on my bed and cushion in my wheelchair. Provide me pro-stat as ordered to aid with wound healing. Reposition me at least every 2 hours. On 11/02/2015 at 4:51 p.m., the Business Office Manager indicated Resident #7 received the air mattress on 6/18/15 and provided an invoice with that date. The air mattress was placed on the resident's bed 35 days after the initial observation of the stage 3 pressure ulcer. During an interview, on 11/02/2015 at 3:53 p.m., RN #3 indicated the new computer system doesn't have the dates that interventions were put in place. The mattress on Resident #7's bed before was a pressure redistributing mattress. She indicated the care plan has not been re-written that when she adds something new, she dates it, and there were no dates added. Nurse's notes dated 3/29/15 through 5/13/15 failed to indicate any documentation Resident #7 is turned and repositioned. Nurse's weekly summary notes, dated 2/28/15, 3/8/15, 3/15/15, 3/21/15, 3/28/15, 4/4/15, 4/12/15, 4/26/15, 5/3/15, and 5/10/15 did not have the box checked that would have indicated the resident would have been turned and repositioned. The Weekly Skin Assessments, dated 3/1/15, 3/8/15, 3/15/15, 3/21/15, 3/29/15, 4/5/15, 4/12/15, 4/26/15, 5/3/5, and 5/10/15, did not have any identified areas of skin breakdown. Nurse's Notes, dated 5/13/15 at 2:15 p.m., indicated: Open area on coccyx (tail bone area) measured 1.5 cm (centimeters) X 1.2 cm X 2.5 cm. Undermining from 9 - 3 2.3 cm, (no) drainage. MD faxed for tx order. A pressure ulcer healing chart for the coccyx, dated 5/13/15, indicated the area was found on 5/13/15, and was a stage 3 that was 1.5 cm in length, 1.2 cm width, and 2.5 cm depth, with no tunneling, no drainage, and a treatment was ordered to clean with normal saline then apply a wet to dry dressing twice a day until healed. On 10/30/2015 at 4:01 p.m., RN #1 indicated on 5/13/15, an aide came and got her to look at an area, on Resident #7's bottom, and those were the measurements when she found it. There were shower sheets that the CNA's documented skin conditions on, but no one had documented anything on them for Resident #7. She said she looked through a month's worth of shower sheets with the Director of Nursing at that time, and there wasn't anything documented. RN #1 indicated she couldn't find any thing to justify how the wound occurred or how it became a stage 3 before it was found. On 10/29/2015 at 1:08:27 p.m., Resident #7 was observed in her wheelchair in the dining room, and had been observed wheeling herself down the hallway with her right arm. On 1/28/15 at 3:05 p.m., Resident #7 was observed in her wheel chair in the dining room watching a pumpkin carving activity. On 10/29/2015 at 9:56 a.m., Resident #7 was observed in bed, supine with the head of the bed up 20 degrees, and had her blanket over her head. Resident #7 had an air mattress on her bed at that time. On 10/29/2015 at 10:54 a.m., the pressure area was observed with LPN #11. The wound was clean, no drainage, no redness, and it was deep, observed to be a stage III. On 10/30/2015 at 3:55 p.m., Resident #7 sat in her wheel chair in her room watching TV. She indicated staff didn't turn her in bed before she got the pressure ulcer, and said they didn't have a reason to and now they do turn her, but that area on her bottom doesn't hurt as much as it used to. On 11/02/2015 at 9:29 a.m., Resident #7 was observed in bed, laying supine, the head of her bed was raised 25 degrees. At 11:45 a.m., she had been gotten up for lunch and sat in her wheelchair. Resident #7 had physician's treatment orders for the pressure area that included, but were not limited to: 5/13/15: Wet to dry dressing to coccyx area twice a day until healed. 6/4/15: Cleanse wound with soap and water. Avoid using excessive force, pat dry completely. Apply silver alginate directly to wound bed. Apply [MEDICATION NAME] Gentle dressing over primary dressing. 6/23/15: physician's orders [REDACTED]. 7/17/15: Hyperbaric Oxygen treatments for 40 treatments at the wound clinic. Restart the wound vac at 125 mmHg pressure. Change 3X weekly M-W-F, apply calcium alginate to wound then wound vac. 9/9/15: Cleanse coccyx wound (with) soap & H2O. Pat dry. Apply wound vac - change 3X wkly. Apply thin duoderm to areas of excoriation on buttocks & leave in place. Change when soiled or comes off on own wound vac pressure 125. 9/26/15: DC Duoderm to buttocks - Causing further skin breakdown. 9/30/15 - 1) DC current tx to coccyx & wound vac. 2) Start - cleanse wound (with) soap (and) water. Avoid using excessive force. Pat dry completely. Saline wet to dry. Apply directly to wound bed. Avoid contact (with) surrounding skin, cover (with) [MEDICATION NAME] gentle (change every day). 10/14/15 - (1) D/C saline wet (to) dry drssg (dressing) to coccyx. (2) Cleanse coccyx with soap and water. Pat dry. Apply [MEDICATION NAME] gauze directly to wound bed. Cover (with) [MEDICATION NAME] (daily). 10/23/15 - Tx changed to Coccyx: Use Saline wet to dry directly on wound bed; Avoid contact with surrounding skin and cover primary dressing with [MEDICATION NAME] daily dressing changes. Supplements ordered to help aid in wound healing indicated: 7/9/15: Multi-vitamin tab 1 every day 7/13/15: Med pass 2.0, 60 milliliters twice a day for wound. 7/16/15 - Prostat (protein supplement) 30 milliliters daily to promote wound healing and increase protein. 9/3/15: Med pass was D/C'd. New order for Prostat 30 milliliters twice a day. Review of Medication Administration Records (MARs) dated July 2015 indicated the Prostat 30 milliliters daily was not initialed as given until 7/20/15, a lapse of 3 days after the order was obtained. Review of MARs dated August 2015, indicated the Prostat was initialed as not given from August 1 through August 7, with no explanation of the reason the Prostat was not given. During an interview, on 11/02/2015 at 3:53 p.m., RN #3 indicated she looked in the record and could not find a reason the Prostat had not been given. A History and Physical from a local hospital, dated 7/2/15, indicated, but was not limited to, The patient is a (age of resident) year-old-female with advanced [MEDICAL CONDITION], who is here with finding of osteo[DIAGNOSES REDACTED] in distal sacral and coccyx wound. She has been having this treated in the Wound Care Center, and a MRI performed 07/01/2015 showed osteo[DIAGNOSES REDACTED] in this area. The MRI also showed moderate bilateral hydro[DIAGNOSES REDACTED] with debris in the renal collecting systems, possibly blood or pus .She is very disabled from the [MEDICAL CONDITION] and reside at (name of nursing home). She is unable to care for herself. She is unable to transfer A progress note from a wound center at a local hospital, dated 7/16/15, indicated: .Coccyx is a stage 4 pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 2.5 cm length x 1.2 cm width x 1.8 cm depth, with an area of 3 sq cm and a volume of 5.4 cubic cm. There is muscle exposure. Tunneling has been noted at 12:00 with a maximum distance of 2.8 cm. There is additional tunneling and at 3:00 with a maximum distance of 3 cm. No undermining has been noted. There is a moderate amount of sero-sanguineous drainage noted which has a mild odor A progress note from a wound center at a local hospital, dated 10/21/15, indicated: .Integumentary (Hair, Skin) Depth same but opening decrease. Wound is clean with healthy tissue .Wound #1 status is open. Original cause of wound was pressure injury. The wound is currently classified as a category/stage IV wound with etiologies of pressure ulcer and acute osteo[DIAGNOSES REDACTED] (infection in the bone) and is located on the Coccyx. The wound measures 1 cm length x 0.4 cm width x 2 cm depth; 0.4 cm 2 area and 0.8 cm 3 volume. There are muscle exposed. There is no tunneling noted, however, there is undermining starting at 12:00 and ending at 4:00 with a maximum distance of 2.1 cm. There is a large amount of serosanguineous drainage noted. The wound margin is distinct with the outline attached to the wound base. There is medium (34-66%) pink granulation within the wound bed. There is a small (1-33%) amount of necrotic tissue within the wound bed including adherent slough A policy for Skin Integrity/Wound Care Program was provided by RN #3 on 11/2/15 at 4:53 p.m. The policy included, but was not limited to, All residents will be assessed for their risk of pressure ulcer development by a licensed nurse using the Braden Scale assessment form. All residents will be assessed as follows .quarterly, in accordance with the MDS schedule .with significant changes in health status. Residents with a Braden Scale score of 14 (moderate risk) or below (high risk) will receive preventive care. Residents with scores above 14 may have preventive care initiated as warranted by assessment .Purpose: To identify residents at risk for developing a pressure ulcer and to initiate preventive individualized interventions to address resident risk factors. Examples of risk factors include, but are not limited to: Impaired/ decreased mobility and decreased functional ability .cognitive impairment; exposure of skin to urinary and fecal incontinence .After conducting a risk assessment to identify risk factors, then focus the prevention program on minimizing their negative effects. When addressing pressure ulcers, prevention is the number one solution .Positioning: Frequent positioning of the resident is recommended to prevent capillary occlusion, which leads to tissue ischemia and pressure ulcers .Moisture and incontinence: Urinary incontinence results in overhydration or maceration of the perineal skin. In an overhydrated state, the skin is at greater risk for erosion and impairment of skin integrity. Maceration compromises the skin's ability to function as an effective barrier. Fecal incontinence is even more damaging because of the presence of bacteria and digestive enzymes .Documentation of the skin care plan: Once the nurse has determined the resident's risk factors and has used the Risk Management Protocol and Pressure Ulcer Prevention Tool to select and institute appropriate interventions, he/she documents the skin/wound plan of care on the Initial Care Plan .Interdisciplinary Care Plan or Episodic Care Plan Open Area .By using the care plan forms available, the nurse should document: The date the plan is initiated, a list of selected approaches and interventions, the goal(s) and the date on which the goal will be reviewed, the responsible disciplines .Review of the prevention plan: Each week the nursing assistant performs a skin audit of each resident on his/her shower or bath days. The nursing assistant documents the findings on the Shower Day Skin Audit form .signs it, and turns it in to the licensed nurse. If there are any skin areas noted, the nurse observes the areas, contacts the physician, and begins treatment as ordered. The nurse signs the audit form .The completed forms are forwarded to the Director of Nursing for his/her review before filing. Additionally, the licensed nurse performs a hear-to-toe assessment of all residents weekly. The results of these assessments are documented on the Nurses' Weekly Summary Note form (HC-N-7) with detailed information written in the nurses' notes. Whenever a nurse or other team member decides that a new intervention is more appropriate, that person updates the resident's care plan and notes the change on the nursing assistant assignment sheet .The four stages of pressure ulcers are .Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to , but not through, underlying fascia. The ulcer presents clinically as a deep crater, with or without undermining of the adjacent tissue. Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, such as tendon or joint capsule 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview and record review the facility failed to do skin assessments on one resident resulting in the resident acquiring a stage four pressure ulcer (full thickness tissue loss) and an unstageable pressure ulcer (necrotic tissue) that the facility was unaware of for 1 of 2 residents reviewed for pressure ulcers for 2 who met the criteria for pressure ulcers (Resident #20). Finding include: 1.) Interview with LPN #3 on 8-20-13 at 10:41 a.m. indicated Resident #20 had an unstageable pressure ulcer on his right foot that he acquired at the facility. Review of the record of Resident #20 on 8-21-13 at 10:15 a.m. indicated the resident's [DIAGNOSES REDACTED]. The record of Resident #20 indicated he began receiving hospice care on 7-23-13. The Braden scale for predicting pressure sore risk for Resident #20 dated, 6-6-13 indicated the resident had a score of 15. A score of 17 and below requires a weekly skin assessment and documentation in the medical record. The Minimum Data Set (MDS) annual assessment for Resident #20 dated, June 14, 2013 indicated the following: bed mobility- extensive assistance of one person, transfer- extensive assistance of two people, walk in room - did not occur and toilet use extensive assistance of two people. The MDS indicated the resident was at risk for pressure ulcers and had an infection of the foot. The physician order [REDACTED]. Interview with the Director Of Nursing (DON) on 8-21-13 at 10:41 a.m. indicated the order for the [MEDICATION NAME] was from hospice as a preventive measure for pressure ulcers not because the resident had a pressure ulcer. During an observation on 8-21-13 at 11:17 a.m. with CNA #1 and CNA #2 Resident #20 had a black and brown pressure ulcer on his left heel. CNA #1 and CNA #2 indicated they were not aware the resident had a pressure ulcer on his left heel. CNA #1 and CNA #2 rolled resident #20 on his side and the resident had a black pressure ulcer on the left lower buttock and thigh area with red and yellow surrounding the wound. The area was draining serosanguineous fluid (consisting of both blood and serous fluid). The resident began having a bowel movement at this time. When CNA #2 attempted to clean the resident up, the resident began moaning and yelling out in pain. CNA #2 indicated hospice had been putting a foam piece on the area on his bottom but she did not know why the resident did not have one on now. CNA #1 got the resident's nurse. LPN #3 came in the room and indicated she was not aware of Resident #20 having a pressure ulcer on his left heel. Interview with the DON on 8-21-13 at 11:30 a.m. indicated the day shift nurse was suppose to be doing skin assessments on Resident #20 every week. The DON indicated the last weekly skin assessment she could find was done on 7-13-13. Interview with LPN #3 on 8-21-13 at 11:40 a.m. indicated she was aware of the area on Resident #20's buttocks. LPN #3 indicated the hospice nurse put a [MEDICATION NAME] dressing on the area on 8-15-13. LPN #3 indicated when she saw the area on 8-15-13 it was purple and it was not black or open. LPN #3 indicated she had not been assessing the area because she thought hospice staff was doing the assessments. LPN #3 indicated she was unaware the [MEDICATION NAME] dressing was not in place. LPN #3 looked for skin assessments for Resident #20 and was not able to find any besides the one done on 7-13-13. LPN #3 indicated the facility was relying on the hospice staff too much. Interview with the Resident #20's hospice nurse on 8-21-13 at 3:04 p.m. indicated the last skin assessment he had done on the resident was on 8-15-13 when he applied the [MEDICATION NAME] dressing to the resident's left lower buttocks. The hospice nurse indicated on 8-15-13 the area was bright pink. The hospice nurse indicated the pressure ulcer was a stage one. The weekly pressure ulcer/deep tissue injury assessment for Resident #20 dated, 8-21-13 indicated the resident had a stage four and unstageable pressure ulcer on his left lower buttocks. The area measured 5 centimeters (cm) by 3 cm. The area was black with outer edge yellow slough. The area was acquired in the facility. The weekly pressure ulcer/deep tissue injury assessment for Resident #20 dated, 8-21-13 indicated the resident had an unstageable pressure ulcer on his left heel. The area measured 2 cm by 2.3 cm. The area was soft black with a dry center. The area was acquired in the facility. The "Skin Integrity/Wound program" provided by the Administrator on 8-21-13 at 12:20 p.m. indicated "to prevent deep tissue injury for occurring, it is important for frequent, if not daily, skin assessments, particularly checking for any changes in the skin's appearance, especially in residents who have diabetes or some type of arterial disease." 3.1-40(a)(2)

Based on interview and record review, the facility failed to administer 9 doses of [MEDICATION NAME] (anticoagulant medication to prevent [MEDICAL CONDITION] for 1 resident, resulting in the resident being hospitalized with a [MEDICAL CONDITION] ([MEDICAL CONDITION], for 1 of 3 residents reviewed for medications in a sample of 3. (Resident #A) Findings include: The record of Resident #A was reviewed on 12/4/12 at 10:30 a.m. Resident #A's [DIAGNOSES REDACTED]. Resident #A's MDS (Minimum Data Set), assessment, dated 11/12/12, indicated BIMS (Brief Interview for Mental Status) was a 6, with a score of 0-7 indicating severe impairment of cognition. The MDS also indicated, medications received, anticoagulant, 7 times during the last 7 days. Resident #A's physician's orders [REDACTED].Q. (Subcutaneous) every day." Resident #A's nursing notes, dated 11/13/12 at 2:00 a.m., indicated "Resident's left foot very cold and purple in some spots. Outside blankets upon arrival to room. Faint pedal pulse, both feet cold, left colder than right. Some mottling (skin discolored in irregular patches) of left leg." Resident #A's nursing notes, dated 11/14/12 at 2:20 p.m., indicated "...Left lower leg is swollen but cool to touch. (Family member) is aware and would like doctor to see her soon...." Resident #A's nursing notes, dated 11/14/12 at 10:00 p.m., indicated "... Left foot 5 plus [MEDICAL CONDITION], pale with what appears to be mottling and has slight pedal pulse. (Family member) very concerned. Faxed physician." Resident #A's nursing notes, dated 11/15/12 at 10:00 p.m., indicated "...Obtain Doppler for left lower extremity to rule out clot. Schedule for 11/16/12 at 12:30 p.m." Resident #A's physician's orders [REDACTED]." Resident #A's nursing notes, dated 11/16/12 at 12:10 p.m., indicated "Resident transported by (local ambulance service) to (local hospital) for left leg Doppler." Resident #A's nursing notes, dated 11/16/12 at 1:10 p.m., indicated "Received call from (local hospital radiology) Resident diagnosed with [REDACTED]. Requested that they send resident to emergency room ." An interview with the DON (Director of Nursing) on 12/4/12 at 12:15 p.m., indicated looking back on Resident #A's left leg being cold, discolored with [MEDICAL CONDITION] and the nurse not calling the physician right away might be because the nurse practitioner put in her progress notes she wanted to make Resident #A palliative care only. During an interview on 12/4/12 at 1:45 p.m., the DON (Director of Nursing) indicated after Resident #A was admitted to the hospital, the hospital called the facility and indicated they had reviewed Resident #A's MAR (Medication Administration Record) sent with her on admission, and there was a concern that Resident #A had not received her [MEDICATION NAME] as ordered at the facility. The MAR faxed from the hospital indicated the [MEDICATION NAME] was not given from 11/11/12 to 11/16/12. After investigating the concern from the hospital, it was determined Resident #A had not received her [MEDICATION NAME] as ordered. The facility received 10 doses of the [MEDICATION NAME] from the pharmacy on 11/3/12, and the pharmacy verified the 10 doses were the only [MEDICATION NAME] sent to the facility. Four doses were administered, and there were 5 doses of [MEDICATION NAME] remaining in Resident #A's medication drawer after she was sent to the hospital. Resident #A missed a total of 9 doses. The DON also indicated the hospital had completed lab work, and the lab work did not reflect levels of [MEDICATION NAME] in Resident #A's blood work consistent with the physician's orders [REDACTED]. Resident #A's MAR, which was sent to the hospital, was requested on 12/4/12 at 2:00 p.m., but was not provided. This federal tag relates to complaint IN 976. 3.1-37(a)