Every finding on record at Hickory Creek at Scottsburg

Based on observation, interview and record review, the facility failed to ensure a resident's (Resident B) pain medication was available, in a timely manner, for 1 of 3 residents reviewed for pharmacy services.Findings include:The clinical record for Resident B was reviewed on 12/4/25 at 9:20 a.m. The resident's diagnoses included, but were not limited to, depression and pain. The quarterly MDS (Minimum Data Set) assessment, dated 10/7/25, indicated the resident's cognition was intact. The care plan, dated 6/10/23, indicated the resident was at risk for pain and staff were to administer the resident's pain medication as ordered. During an interview, on 12/3/25 at 6:20 p.m., Resident B was observed with a Fentanyl Duragesic patch (pain patch) to her right upper chest with a date of 12/3/25. Resident B indicated she had not had her pain patch for 2 days. It was due on 12/1/25 and she had just received it today. The physician's order, dated 10/29/25, indicated the resident was to receive a Fentanyl Duragesic patch 12 mcg (micrograms)/hr (hour) every 3 days in the morning. The November 2025 medication administration record indicated the resident received the medication patch on 11/28/25. The December 2025 medication administration indicated on 12/1/25, the resident's pain patch was due. The resident did not receive the medication on 12/1/25 as the drug item was marked unavailable. The progress noted, dated 12/2/25, indicated the prescription for the resident's Fentanyl Duragesic patches was sent to the pharmacy, the staff were awaiting approval from the pharmacist and the medication should be delivered this evening. The clinical record lacked any documentation of physician or pharmacy notification prior to 12/2/25, one day after the medication should have been given. During an interview, on 12/4/25, the Director of Nursing indicated it was the responsibility of the facility to ensure medications were available for the residents. On 12/4/25 at 3:24 p.m., the Executive Director provided a current copy of the document titled Medication Shortages/Unavailable Medications dated 8/1/24. It included, but was not limited to, Procedure.Upon discovery that Facility had an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the time of medication administration, Facility staff should immediately notify the Pharmacy. 3.1-25(a)

Based on interview and record review, the facility failed to ensure a resident's (Resident B) medication administration record accurately reflected the administration of as needed narcotic pain medication for 1 of 3 residents reviewed for medical records.Findings include: The clinical record for Resident B was reviewed on 12/4/25 at 9:20 a.m. The resident's diagnoses included, but were not limited to, depression and pain. The physician's order, dated 10/29/25, indicated the resident was to receive the narcotic pain medication, Percocet (oxycodone-acetaminophen) 5-325 mg (milligrams) every 6 hours as needed for pain. Review of the October 2025 and November 2025 controlled substance record indicated the resident received the medication on the following dates and times:-10/30/25 at 5:10 p.m.-10/30/25 at 11:00 p.m.-10/31/25 at 5:00 a.m.-10/31/25 at 11:00 a.m.-10/31/25 at 11:00 p.m.-11/01/25 at 5:00 a.m.-11/01/25 at 11:00 a.m.-11/04/25 at 5:00 p.m.-11/13/25 at 11:00 a.m.-11/20/25 at 11:00 p.m. The October 2025 and November 2025 medication administration records lacked documentation of the administration of the as needed narcotic pain medication. During an interview, on 12/4/25 at 2:41 p.m., Licensed Practical Nurse (LPN) 5 indicated when a narcotic pain medication was administered, both the medication administration record and the controlled substance record should be signed by the nurse. On 12/4/25 at 2:24 p.m., the Executive Director provided a current copy of the document titled General Dose Preparation and Medication Administration dated 11/15/24. It included, but was not limited to, Procedure.Document the administration of controlled substances in accordance with applicable law. 3,1-50(a)(2)

Based on record review and interview, the facility failed to ensure the physician was notified in a timely manner for 1 of 3 residents reviewed for a change in condition. (Resident 1) Findings include: The record for Resident 1 was reviewed on 4/24/25 at 1:37 p.m. The resident's diagnoses included but were not limited to chronic iron deficiency anemia secondary to blood loss, type 2 diabetes mellitus, schizoaffective disorder, bipolar disorder, epilepsy, functional dyspepsia, constipation, personal history of diseases of the digestive system, and atherosclerotic heart disease. The care plan, dated 8/17/20 and revised 4/24/25, indicated the resident was diabetic and at risk for hypoglycemic, hyperglycemic episodes related to the diagnosis. Possible negative outcomes of not following the prescribed diet. Consumes sugary snacks, ice cream, shakes, Pepsi and other items not on the resident's diet. Per the resident's preference, the resident kept these at her bedside and consumed through the day. The resident had a new diagnosis of a hernia with a recommendation to start 5 smaller meals starting November 2024. The interventions, dated 4/30/21, included, but were not limited to a diet per the medical doctor (MD) order for a regular diet of 3 small portion meals and 2 snacks, to honor preferences, and lab work as ordered with the results reported to the MD. Monitor blood sugars as needed for signs and symptoms of hypoglycemia or hyperglycemia. Nursing would notify the MD as needed, and provide medications as ordered. The physician's order, dated 9/21/23, indicated staff were to administer to the resident, 1 gram of carafate three times daily. The order was discontinued on 6/17/24. The physician's order, dated 9/25/23, indicated staff were to administer to the resident, 81 milligrams (mg) of chewable aspirin daily. The order was discontinued on 11/14/24. The nurse's note, dated 11/11/24 at 8:35 a.m., indicated Certified Nurse Aides (CNAs) reported the resident's vomiting to the Licensed Practical Nurse (LPN). Upon arriving to the resident's room, the resident had large brownish black emesis with little black spots in it. The resident complained of feeling bad, feeling sick and tired. The resident's vital signs were stable, however due to the appearance of possible blood in the emesis, the Nurse Practitioner (NP) gave an order to send the resident to a local hospital for evaluation and treatment. The physician's evaluation, dated 11/15/24 at 10:46 a.m., indicated an order to increase the protonix to twice daily and to add carafate. The resident had an upper endoscopy, which showed grade 4 esophagitis with a hiatal hernia. The resident had been on aspirin since 2023. The same thing happened 1 year ago, and the resident remained on aspirin. The physician took the resident off her carafate one month ago. For the future, the resident should stay off of aspirin without documented cerebrovascular or coronary artery disease. Nursing could try to take the resident off carafate again in a year, if the resident did not have any further bleeding. The resident was complaining of abdominal pain and nausea at that time. A recent upper gastrointestinal (GI) bleed appeared to be stabilized. The nurse's note, dated 11/27/24 at 10:02 p.m., indicated the resident had reported not feeling well and vomiting throughout the day after drinking ordered boost. The vomit was dark in color as if the resident had been eating and drinking something dark. The NP and Director of Nursing (DON) were made aware. The resident requested to be sent to the hospital at that time. The resident was not sent out to the hospital. The nurse's note, dated 11/28/24 at 12:07 a.m., indicated the resident requested to drink soda to attempt to settle her stomach and to prevent being sent out to the hospital. There were no signs or symptoms of vomiting for several hours. The resident was educated not to drink too many Boost protein drinks. Drinking too many Boost drinks caused the resident to not eat anything throughout the day. The resident was educated to let staff know if she vomited again. An order was given by the NP to send the resident out to the emergency room (ER) if needed. The physician's order, dated 11/15/24, indicated to provide small portions with regular meals and 2 snacks between meals. The order was discontinued on 12/20/24. The physician's order, dated 12/10/24, indicated staff were to administer to the resident, 100 milligrams (mg) iron-250 mg/5 milliliters (mL) 325 mg twice daily of Protect iron liquid (iron polysaccharide-vitamins C and B 12 complex). The order was discontinued on 12/17/24. The laboratory results, dated 12/18/24, indicated the resident had a Hemoglobin of 11.0 grams per deciliter (g/dL) and a Hematocrit of 34.6%. The normal range of Hemoglobin was 12.0 to 15.5 g/dl and the normal range of Hematocrit was 36 % to 48%) The nurse's note, dated 1/26/25 at 2:02 a.m., the resident reported pain that started in the stomach and radiated to her chest. The resident had requested as needed (PRN) pain medication at the medication pass. The resident was able to rest for a few hours after receiving the medication. The resident pressed her call light to notify staff she had vomited a large amount of emesis. The resident's blood pressure was 91/62 millimeters of mercury (mm Hg), a heart rate of 103 beats per minute (bpm), oxygen (O2) saturation at 93%, a temperature of 97.8 degrees Fahrenheit (F), and a respiratory rate (RR) of 18 breaths per minute. The resident requested to go to the ER. The NP, DON and Executive Director (ED) were notified. The resident continued to vomit. The vomit was dark with almost a look of coffee grounds to it. The resident then proceeded to demand to go to the ER related to feeling weak and continued vomiting. The NP, DON, and ED were notified, and the resident was sent to a local hospital. The nurse's note, dated 2/4/25 at 1:56 a.m., indicated the resident had an episode of vomiting, which was brown in color. The resident was on iron supplements, two times daily and had no history of ulcers or GI bleeds. The resident's vital signs were stable and within normal limits and the resident was alert and oriented. The resident denied the need for pain medication or any PRN medication. The record indicated the resident had a history of GI bleeding in November of 2024. The record lacked documentation of notification to the NP, DON, or ED of the resident's episode of dark brown emesis (vomiting) on 2/4/25 at 1:56 a.m. The NP, DON, or ED was not notified until 8:28 a.m. (6 hours and 24 minutes after the initial change in condition). The nurse's note, dated 2/4/25 at 8:28 a.m., indicated the resident had an elevated heart rate of 120 bpm and dark brown emesis. The resident refused her morning medications. The NP was notified, and a new order was received to send the resident to the ER for evaluation and treatment. The nurse's note, dated 2/4/25 at 8:50 a.m., indicated Emergency Medical Services (EMS) took the resident to a local hospital and left the building at 8:50 a.m. The nurse's note, dated 2/4/25 at 4:40 p.m., indicated the resident arrived back from the local hospital with diagnoses of gastroenteritis and acute cystitis without hematuria. A new order was placed in the computer for an antibiotic and antiemetic. The nurse's note, dated 2/4/25 at 5:24 p.m., indicated an order for Keflex from the ER was verified with the NP. The resident was currently on Augmentin for a UTI. The NP indicated to keep the Augmentin order and discontinue the Keflex order. The Minimum Data Set (MDS) Significant Change in Status assessment, dated 3/14/25, indicated the resident was cognitively intact. During an interview, on 4/28/25 at 9:53 a.m., RN 1 indicated the resident had been hospitalized on [DATE] for a gastrointestinal (GI) issue and was diagnosed with gastroenteritis and acute cystitis without hematuria. She was vomiting and had abdominal pain prior to hospitalization . The resident was vomiting brown emesis. She had complained of stomach pain at times in the past. It was one o'clock in the morning when the resident began vomiting and at 8:24 a.m., the same day, the resident was still vomiting and had an increased heart rate. The NP was notified and gave the order to send the resident to the ER. LPN 2 should have reached out to the Director of Nursing (DON), but LPN 2's note didn't reflect that he did that. During an interview, on 4/28/25 at 9:56 a.m., the DON indicated she was not contacted by the LPN on 2/4/25 about the resident vomiting brown emesis. The current Resident Change of Condition Policy, included, but was not limited to, . It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place . 3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to ensure staff hand sanitized during a medication pass and failed to ensure staff did not touch medications prior to medication administration for 6 of 6 residents reviewed for infection control. (Resident's B, C, E, F, G and H) Findings include: 1. The clinical record for Resident B was reviewed on 12/5/24 at 12:12 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic respiratory failure and gastroesophageal reflux disease (GERD). The December 2024 physician's orders indicated the resident was to receive the following morning medications: Anastrozole (cancer medication), Propranolol (hypertension), Folic acid (supplement), Isosorbide mononitrate (hypertension), Pimidone (tremors), Eliquis (blood thinner), Calcium carbonate (TUMS), Advair Diskus (COPD), Omeprazole (GERD), Claritin (allergies), Diltiazem (atrial fibrillation), Preservision (eye vitamin), Zoloft (depression), and Magnesium oxide (supplement). During a continuous medication administration observation on 12/6/24 at 9:17 a.m., QMA (Qualified Medication Aide) 4 was observed to remove 2 tablets from the bottle of calcium carbonate into her bare left hand and place in the medication cup. QMA 4 then removed the 2 tablets from the medication cup and placed in another medication cup with her bare fingers. Prior to this, QMA 4 had removed her medication cart keys from her pocket and unlocked the medication cart. She then opened the medication cart drawer with her right hand. She removed the medications from individualized package cards and touched her computer mouse after the removal of each medication from the cart. QMA 4 did not hand sanitize prior to or after the medication administration to the resident. On 12/6/24 at 9:25 a.m., QMA 4 indicated when passing medications staff were not suppose to touch the medications with their bare hands. During an interview on 12/6/24 at 11:26 a.m., LPN Licensed Practical Nurse) 5 indicated during a medication pass, hands should be sanitized before and after each resident. 2. The clinical record for Resident C was reviewed on 12/5/24 at 12:39 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease and diabetes. The December 2024 physician's orders indicated the resident was to receive the following morning medications: Myrbetriq (overactive bladder), Breo Ellipta (inhaled medication for COPD), Acetaminophen (pain), Hydroxychloroquine (rheumatoid arthritis), Isosorbide mononitrate (COPD), Levetiracetam (seizure medication), Spironolactone (heart failure), Cymbalta (depression), Paxil (depression), Clonazepam (seizures), Morphine (pain), Incruse Ellipta (COPD), Depakote (schizoaffective disorder), Seroquel (schizoaffective disorder), and Oxybutynin chloride (overactive bladder). During a continuous medication administration observation on 12/6/24 at 8:55 a.m., QMA 4 was observed to remove her medication cart keys from her pocket and unlocked the medication cart. She then opened the medication cart drawer with her right hand. She removed the medications from individualized package cards and touched her computer mouse after the removal of each medication from the cart. QMA 4 did not hand sanitize prior to or after the medication administration to the resident. 3. The clinical record for Resident E was reviewed on 12/6/24 at 10:30 a.m. The resident's diagnoses included, but were not limited to, malignant neoplasm of the pharynx and chronic obstructive pulmonary disease. The December 2024 physician's orders indicated the resident was to receive the following morning medications: Eliquis (blood thinner), Ondansetron (nausea), Docusate Sodium (constipation), Sodium Chloride (hyponatremia), Diphenhydramine (antihistamine), and Tramadol (pain medication). During a continuous medication administration observation on 12/6/24 at 7:29 a.m., QMA 4 was observed to remove her medication cart keys from her pocket and unlocked the medication cart. She then opened the medication cart drawer with her right hand. She removed the medications from individualized package cards and touched her computer mouse after the removal of each medication from the cart. QMA 4 did not hand sanitize after the medication administration to the resident. 4. The clinical record for Resident F was reviewed on 12/6/24 at 10:48 a.m. The resident's diagnoses included, but were not limited to, mild dementia with mood disturbance, endometriosis and stage 3 kidney disease. The December 2024 physician's orders indicated the resident was to receive the following morning medications: Vitamin B12 (supplement), Carvedilol (hypertension), Potassium Chloride (supplement), Omeprazole (GERD), and Alprazolam (anxiety). During the continuous medication administration observation on 12/6/24 at 7:35 a.m., QMA 4 entered the resident's room and obtained the resident's blood pressure. QMA 4 then walked back to the medication cart had removed her medication cart keys from her pocket and unlocked the medication cart. She then opened the medication cart drawer with her right hand. She removed the medications from individualized package cards and touched her computer mouse after the removal of each medication from the cart. QMA 4 did not sanitize her hands after she obtained the blood pressure or prior to or after the administration of the resident's medications. 5. The clinical record for Resident G was reviewed on 12/6/24 at 10:55 a.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease and iron deficiency anemia. The December 2024 physician's orders indicated the resident was to receive the following morning medications: Advair HFA aerosol inhaler (COPD), Lamotrigine (epilepsy), Fluoxetine (depression), Clozapine (schizoaffective disorder), Polyethylene glycol (constipation), Ferrous Sulfate (anemia), Levetiracetam (epilepsy), Xanax (anxiety), Gemfibrozil (hyperlipidemia), Linzess (constipation), Haloperidol (schizoaffective disorder), Potassium Chloride (supplement), Sucralfate (dyspepsia), Tylenol Extra Strength (pain), and Saline Nasal mist (allergies). During the continuous medication administration observation on 12/6/24 at 7:42 a.m., QMA 4 had removed her medication cart keys from her pocket and unlocked the medication cart. She then opened the medication cart drawer with her right hand. She removed the medications from individualized package cards and touched her computer mouse after the removal of each medication from the cart. QMA 4 did not sanitize her hands before or after the administration of the resident's medications. 6. The clinical record for Resident H was reviewed on 12/6/24 at 11:03 a.m. The resident's diagnoses included, but were not limited to, end stage liver disease and depression. The December 2024 physician's orders indicated the resident was to receive the following morning medications: Escitalopram oxalate (depression), Folic acid (supplement), Spironolactone (diuretic), Thiamine (supplement), Xifaxan (irritable bowel), Zinc sulfate (supplement), and Omeprazole (GERD). During a continuous medication administration observation on 12/6/24 at 8:50 a.m., QMA 4 was observed to remove her medication cart keys from her pocket and unlocked the medication cart. She then opened the medication cart drawer with her right hand. She removed the medications from individualized package cards and touched her computer mouse after the removal of each medication from the cart. QMA 4 did not hand sanitize after the medication administration to the resident. On 12/6/24 at 9:55 a.m., the Director of Nursing provided a current copy of the document titled General Dose Preparation and Medication Administration dated 4/30/24. It included, but was not limited to, Procedure .Appropriate hand hygiene should be performed before and after direct resident contact .Medications should not come into contact with any surface except for the medication cup .Facility staff should avoid touching the medication with bare hands This Citation relates to Complaints IN00447152 and IN00447339. 3.1-18(a)

Based on observation, interview and record review, the facility failed to ensure physician orders were followed for residents during medication administration for 3 of 5 residents reviewed for pharmacy services. (Resident's B, C, F and G) Findings included: 1. The clinical record for Resident B was reviewed on 12/5/24 at 12:12 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic respiratory failure and gastroesophageal reflux disease. The December 2024 physician's orders indicated the resident was to receive the following morning medications: - Calcium carbonate (TUMS), 500 mg tablets, give 2 1/2 tabs to equal 1,250 mg - Advair Diskus (COPD) 250-50 mcg (microgram)/dose, one puff via inhalation. Special instructions rinse mouth after use. During a medication administration observation on 12/6/24 at 9:17 a.m., QMA (Qualified Medication Aide) 4 was observed to remove 2 tablets from the bottle of calcium carbonate rather than 2 1/2 tabs and the QMA did not take the Advair Diskus into the resident's room during the medication administration observation. During an interview on 12/6/24 at 9:55 a.m., the Director of Nursing indicated the resident typically refused the Advair Diskus, however, QMA 4 should have taken the medication to the resident during the medication pass and offered the medication to the resident. During an interview on 12/6/24 at 11:26 a.m., LPN (Licensed Practical Nurse) 5 indicated all physician orders were to be followed. 2. The clinical record for Resident C was reviewed on 12/5/24 at 12:39 p.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease and diabetes. The December 2024 physician's orders indicated the resident was to receive the following morning medications: - Breo Ellipta (inhaled medication for COPD) 200-25 mcg/dose, one puff via inhalation. Special instructions: After use rinse mouth and spit. - Incruse Ellipta (COPD) 62.5 mcg, one puff via inhalation. Special Instructions: Rinse mouth after use. On 12/6/24 at 8:55 a.m., during the medication administration observation, QMA 4 did not have the resident rinse out her mouth after the use of both inhalers. 3. The clinical record for Resident G was reviewed on 12/6/24 at 10:55 a.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease and iron deficiency anemia. - Advair HFA aerosol inhaler (COPD) 115-21 mcg/actuation, 2 puffs via inhalation: Special instructions: Rinse mouth and spit. On 12/6/24 at 7:42 a.m., during the medication administration observation, QMA 4 did not have the resident rinse and spit after the administration of the Advair Diskus. On 12/6/24 R 9:55 a.m., the Director of Nursing provided a current copy of the document titled General Dose Preparation and Medication Administration dated 4/30/24. It included, but was not limited to, Procedure .Prior to Administration .Facility staff should take all measures required by facility policy and applicable law .Verify each time a medication is administered that is is the correct .dose .Follow manufacturer medication administration guidelines This Citation relates to Complaints IN00447152 and IN00447339. 3.1-25(b)

Based on interview and record review, the facility failed to ensure a resident's (Resident D) medication administration record reflected the administration of narcotic medication for 1 of 3 residents reviewed for medical records. Findings include: The clinical record for Resident D was reviewed on 12/5/24 at 1:29 p.m. The resident's diagnoses included, but were not limited to, irritable bowel syndrome, anxiety and pain. The physician's order, dated 2/8/22, indicated the resident was to receive Xanax (narcotic antianxiety medication) 0.5 mg (milligrams) twice daily for anxiety at 9:00 a.m. and 9:00 p.m. Review of the October 2024 controlled substance record indicated the resident received the medication on the following dates and times: - 10/04/24 at 8:00 p.m. - 10/07/24 at 8:00 p.m. - 10/08/24 at 8:00 p.m. - 10/10/24 at 8:00 a.m. - 10/18/24 at 8:00 p.m. - 10/21/24 at 8:00 p.m. The resident's October 2024 Medication Administration Record lacked documentation of the administration of the medication. The physician's order, dated 3/15/22, indicated the resident was to receive Viberzi 75 mg twice daily for irritable bowel syndrome at 9:00 a.m. and 9:00 p.m. Review of the October 2024 Controlled Substance Record indicated the resident received the medication on the following dates and times: - 10/04/24 at 8:00 p.m. - 10/07/24 at 8:00 p.m. - 10/08/24 at 8:00 p.m. - 10/10/24 at 8:00 a.m. - 10/18/24 at 8:00 p.m. - 10/21/24 at 8:00 p.m. The resident's October 2024 Medication Administration Record lacked documentation of the administration of the medication. The physician's order, dated 4/23/24, indicated the resident was to receive hydrocodone-acetaminophen (narcotic) 5-325 mg twice daily for pain at 9:00 a.m. and 9:00 p.m. Review of the October 2024 Controlled Substance Record indicated the resident received the medication on the following dates and times: - 10/04/24 at 8:00 p.m. - 10/07/24 at 8:00 p.m. - 10/08/24 at 8:00 p.m. - 10/10/24 at 8:00 a.m. - 10/18/24 at 8:00 p.m. - 10/21/24 at 8:00 p.m. The resident's October 2024 Medication Administration Record lacked documentation of the administration of the medication. During an interview on 12/6/24 at 11:26 a.m., LPN (Licensed Practical Nurse) 5 indicated when a narcotic medication had been administered, the nurse would sign the medication as administered on the medication administration record. On 12/6/24 at 9:55 a.m., the Director of Nursing provided a current copy of the document titled General Dose Preparation and Medication Administration dated 4/30/24. It included, but was not limited to Procedure .Document the administration of controlled substances in accordance with applicable law .After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to .Document necessary medication administration This Citation relates to Complaints IN00447152 and IN00447339 3.1-50(a)(2)

Based on interview and record review, the facility failed to act upon resident concerns of not answering the call lights in a timely manner; beds not made and rooms messy; urinals not emptied or put away; glove usage without handwashing; rooms not being deep cleaned; missing clothes after being sent to laundry; staff cursing and talking about other staff in front of residents; feeling rushed by housekeeping to eat and leave the dining room for 9 of 10 Resident Council meetings (August, September, October, November, and December 2023, January, February, March and April 2024). This deficient practice had the potential to affect 31 of 31 residents currently residing in the facility. Findings include: 1. The Resident Council meeting held on 8/11/23 indicated residents' concerns were not resolved or acted upon: - Call lights were taking 40 minutes to hours to be answered. - Beds were not being made and rooms were messy. - Urinals were not being emptied. - Staff were using gloves but no handwashing was observed. - Resident rooms were not being deep cleaned with everything moved out of the room to do so. On 8/11/23, the Director of Nursing (DON) responded that there would be staff education, daily rounds would be made on rooms to verify beds were made, urinals emptied and call lights answered. On 8/11/23, the Director of Maintenance/Housekeeping indicated he would educate staff on the deep clean schedule. The deep clean check list will be turned in to the Executive Director (ED) every Friday until compliance was achieved. 2. The Resident Council meeting held on 9/8/23 indicated residents' concerns were not resolved or acted upon: - Staff using foul language. - Call lights still taking awhile to be answered. - Still having issues with emptying urinals. - Clothing in the wrong closet even with the residents' names on the clothes. - Resident rooms still not being deep cleaned. On 9/13/23, the Director of Maintenance/Housekeeping indicated the ED would inservice all Housekeeping staff on 9/14/23. Each staff member will be given a copy of the deep cleaning schedule and policy. They will be given a copy of the deep cleaning checklist. The checklist would be given to their supervisor each day at the end of their shift. The ED will verify deep cleanings were being done daily. On 9/8/23, the DON indicated she and the ED would make rounds on all shifts. Concerns will be addressed at monthly inservices and the DON would follow up with residents to verify improvement with areas of concern. 3. The Resident Council meeting held on 10/13/23 indicated residents' concerns were not resolved or acted upon: - From 6:00 p.m. to 10:00 p.m., call lights were not answered. It took more than 25 minutes for them to be answered when staff did answer them. On 10/13/23, The DON indicated call light response time would be monitored by the charge nurses. Any issues would be addressed immediately and discussed with the DON. On 10/25/23, the ED developed and presented the Director of Maintenance with an Action Plan she developed for him due to the deep cleans not being completed by the Housekeeping department and the Housekeeping Director having failed to give the staff the deep clean schedule. The Root Cause Analysis indicated staff would be educated; the Housekeeping Director would make a monthly schedule and would verify the deep cleans were being completed daily. 4. The Resident Council meeting held on 11/10/23 indicated residents' concerns were not resolved or acted upon: - Call lights not being answered timely. - Needy residents were bothering the nurses during medication pass and the medications were taking longer to get to the residents. - Deep cleaning not started. On 11/10/23, the ED indicated the DON or designee would observe call light response time on each shift until compliance was achieved. On 11/10/23, the Director of Maintenance/Housekeeping and the ED indicated the deep clean calendar would be made monthly. The Maintenance Director would ensure the deep cleans were completed and done properly daily. The ED would complete room rounds with the supervisor daily to ensure deep cleans were being completed. Failure to complete/follow deep clean schedule would result in disciplinary action for the responsible staff member. 5. The Resident Council meeting held on 12/8/23 indicated residents' concerns were not resolved or acted upon: - The call lights continued to be an issue. - The deep cleans were still not getting done. - Resident clothes were not coming back in a timely manner, sometimes it was taking weeks. On 12/8/23, the Director of Maintenance/Housekeeping indicated all housekeeping staff were re-educated on deep cleans. The ED developed the deep clean schedules. The ED and Maintenance Director would verify deep cleans were being completed daily. On 12/8/23, the ED indicated the Department Managers/Clinical staff were filling in between 6:00 p.m. and 10:00 p.m. if there was a shortage of nursing staff. The DON/designee would monitor call light response each shift. 6. The Resident Council meeting held on 1/12/24 indicated the resident concerns were not resolved or acted upon: - Staff talking about other staff during resident care and smoke breaks. - A lot of noise at bedtime; residents were loud in the hallway until early AM. - Staff not being courteous. - Aides placing urinals on the table tops; placing items on the roommate's side of the room; knocking things off and acting not to care. On 1/12/24, the DON indicated staff education regarding the concerns verbalized will be provided regarding the noise level at the all staff inservice on 1/16/24. She spoke to a certain resident regarding being respectful to others regarding the noise level. 7. The Resident Council meeting held on 3/8/24 indicated the residents' concerns were not resolved or acted upon: - The residents were feeling rushed at meal times from the housekeeping staff during lunch. - The deep cleaning was not getting done; beds were not being pulled out away from the wall to clean behind them; privacy curtains needed to be washed. - Resident 6 indicated her food was cold due to getting the meal last. She would like to rotate ways to serve meal trays for 6 months at a time. On 3/8/24, the DON addressed the resident concerns of customer service from the staff. She indicated customer service expectations would be discussed at the all staff inservice on 3/13/24. The ED would review customer service policy at the all staff inservice. On 3/11/24, the Dietary Manager inserviced the dietary and housekeeping staff on dinner times and to ensure all residents were out of the dining room before entering to clean. Resident 6 was spoken to who indicated the food was hot, but just wished to be served first. room [ROOM NUMBER] now moved to first trays on hallway service for all meals. On 3/12/24, the ED indicated all housekeeping staff would be inserviced at the all staff meeting on 3/13/24 regarding cleaning after meal times and deep cleans. Each staff would be given the deep clean policy and check list. The Maintenance/Housekeeping Supervisor was inserviced on verifying deep cleans were being completed daily. During an interview on 4/21/24 at 9:46 a.m., Resident 16 indicated he had often waited a half day to a day for his call light to be answered. He had to lay in a wet or soiled brief. During an interview on 4/21/24 at 9:52 a.m., Resident 23 indicated she has had to wait a half hour to an hour at times for her call light to be answered. During an interview on 4/22/24 at 8:11 a.m., Resident 6 indicated there wasn't enough staff especially on the night shift. She has had to wait up to an hour for the staff to help her to the bathroom. During an interview on 4/22/24 at 9:09 a.m., Resident 7 indicated she has had to wait so long for the staff to answer her light she wet the bed. 8. During the Resident Council meeting held on 4/24/24, the Activities Director indicated the 9 residents in attendance were alert and oriented. The following concerns were voiced: - Staff talking about each other while out on smoke break with the residents. - Missing laundry - residents talked to the staff, but they just told them they couldn't find it. Social services helped at times for some people, but usually the staff just told them they couldn't find it even though their names were in the clothes. - The phone was an issue. Sometimes it would ring and ring and no one would answer it when families called. Residents had heard the nurses sometimes say they were going to just refuse to answer it. Often the phone was not at the desk as it was in another resident's room or residents were answering it instead. - The CNAs (Certified Nurse Aides) frequently were seen just sitting at the desk and refused to answer the call lights - day shift was more of an issue. - Food was cold when they received it, all the meals were affected. The last room, room [ROOM NUMBER], was always getting cold food even after they had asked that the tray service rotation be switched up so they could be first for a change, but it didn't happen. - Certain things were brought up in Resident Council every month but nothing was ever taken care of like management said they would. Call lights and deep cleaning the rooms were a major issue. They don't seem to listen to us. The facility's current policy on Resident Council, dated 2/20, indicated Policy: The facility will promote and support the residents right to participate and organize resident council. The council will be used to communicate concerns, give suggestions for future programming and events, and otherwise participant in and guide facility life. Procedure: .6. Concerns or suggestions from the meeting will be addressed by the appropriate department. The Executive Director will review all minutes and concerns to ensure thorough resolution of concerns . Cross reference F804 3.1-3(l)

Based on observation and interview, the facility failed to provide meals that were palatable, appetizing and at appropriate temperatures. This deficient practice had the potential to affect 30 of 31 residents currently residing in the facility. Findings include: 1. During an observation on 4/21/24 at 11:55 a.m., a test tray was placed on the last cart for the hall trays. The cart arrived to the hall at 12:00 p.m. The staff began serving the trays at 12:00 p.m. and completed at 12:12 p.m. During a test tray on 4/21/24 at 12:14 p.m., the following food temperatures and observations were obtained: -The sliced turkey temperature was 124.9 degrees F. It had a processed flavor and texture, but was appetizing. -The Au gratin Potatoes temperature was 118 degrees F. The potatoes were undercooked and were cool to taste. The cheese sauce was thin and the flavor was not appetizing. -The brussels sprouts temperature was 117.8 degrees F. The flavor was appetizing. Salt was available. -The banana cream pie temperature was 21.3 degrees F. The pie was still partially frozen and as it melted, the flavor of the banana started to appear. 2. During an observation on 4/25/24 at 11:52 a.m., the following food temperatures were obtained: -The ham salad sandwich had a temperature of 37.7 degrees F. A seconds sandwich was obtained and had a temperature of 30.5 degrees F. The sandwich lacked an appetizing flavor and had hard ham pieces. There was a strong hint of mustard. -The apricots temperature was 34.5 degrees F. The apricot had a good color and were firm. The flavor was appetizing. -The broccoli soup temperature was 164 degrees F. The soup had a strong spicy pepper and a gravy mix flavor. -The bean salad temperature was 32 degrees F and was frozen with only the flavor of the cold green beans no seasoning. During an interview on 4/22/24 at 10:30 a.m., Resident 7 indicated the food was often cold. She was unable to eat some of it. She felt like the quality of the food had decreased. She thought the dietary budget had been cut. During an interview on 4/22/24 at 10:45 a.m., Resident 6 indicated she thought the turkey was ham on yesterday's lunch tray. The potatoes were so hard she could not eat them. She felt the food had really gone down hill. Most of the time her food was cold before she received her tray. 34309 During an interview on 4/21/24 at 11:26 a.m., Resident 32 indicated the food was terrible. It was the quality of the food and the way it was prepared. The food was sometimes cold. During an interview on 4/21/24 at 9:38 a.m., Resident 25 indicated the food was so, so on flavor and quality. It was sometimes cold when he received it. During an interview on 4/21/24 at 9:28 a.m., Resident 16 indicated the food was cold. He received his food in his room. T During an interview on 4/25/24 at 8:50 a.m., the Dietary Manager indicated she had resident requests for hot dogs and lunch meat sandwiches as alternates. They had soup as an alternate already. Breakfast cereals were also requested as an alternate. The residents were taken to the store and the residents would purchase snacks for themselves. The residents had requested for some of the menu items to be changed recently, due to repeat meats during the week. She changed the menu for those requests. The menu alternated on a 4-week cycle and they had a spring menu to be started soon. It had been since October that the current menu was used. They had not changed the food company, but had used a different bread company recently. One resident complained about the food being cold in the morning, but he had slept late. The steam table was on the stove top. The staff delivered 4 trays at a time to the halls and to the dining room. All plates were covered. The plates were put on the stove sometimes to heat. This hadn't been done recently. If she had a suction device to pick up the hot plates from the oven that would help dietary staff to not burn their hands when picking up hot plates. She would keep the oven on a low temperature for the plates. The plates were kept on the back side of the kitchen and not kept warm in the oven. The kitchen didn't have enough room to have a plate warmer machine. The serving temperature of the food should be kept above 135 degrees F. She typically kept it between 165 and 170 degrees F. During an interview on 4/25/24 at 10:06 a.m., the Dietary Manager indicated she needed clarification on the palatability of food. Salt and pepper were offered at the tables, so she had trouble understanding why the food would be thought of as not palatable. All residents had weight gain. The only thing that was different was the brand of the food. Double portions were offered to residents. The residents would snack a lot and their weight was maintained. The residents' were taken out to the store and would purchase their own snacks. The Food Temperatures policy, revised last on June 2023, included, but was not limited to, . 2. Hot foods that are potentially hazardous will be held for service at or above 135 degrees F, and cold foods at or below 41 degrees F. 2. All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food . 9. Hot food will be held at or above 135 degrees F. If minimum temperature requirements are not maintained, food will need to be reheated to a minimum of 165 degree F for 15 seconds before serving . Cross reference F565 3.1-21(a)(2)

Based on observation, record review and interview, the facility failed to ensure appropriate assessment and monitoring skin impairments for 1 of 3 residents reviewed for Quality of Care. (Resident C) Findings include: During an observation of incontinent care on 9/20/23 at 10:30 a.m., Resident C had multiple large open and bleeding scratches on her buttock, lower back, and left buttock. She had multiple scabbed scratch marks on the area from her posterior left knee to her upper posterior left thigh. The resident started scratching her right buttock and lower back due to itching. The scratch marks started bleeding and the resident stated, Why can't they give me something for this itching. The blood from the scratching was dripping and running down the resident's buttocks. There was no visible remnants of any cream on the resident's skin. The CNA (Certified Nursing Aide) 1 went out to get the nurse so she could look at the resident's skin. The resident stated . They already know about it and haven't done a thing . The record for Resident B was reviewed on 9/29/23 at 9:30 a.m. The diagnoses included, but were not limited to, urinary tract infection, hypokalemia, the need for assistance with personal care, disorder of the urinary tract urinary system, and tubulo-interstitial nephritis. The Quarterly MDS (Minimal Data Set) assessment, dated 7/11/23, indicated the resident was cognitively intact. The physician's order, dated 7/13/23, indicated staff were to apply remedy calazime intensive skin (menthol-zinc oxide) OTC (over the counter) 0.44-20.6% (percent), to the resident's right buttock every shift and prn (as needed). The review of the skin assessments, dated 6/1/23 to 9/11/23, lacked documentation to indicate the resident had multiple open and bleeding scratches to her left thigh, lower back, coccyx, and right buttock. During an interview on 9/20/23 at 11:30 a.m., Resident C indicated her skin had been itching for about a year. During an interview on 9/20/23 at 11:35 a.m., CNA 6 indicated the nurse was aware of the resident's scratch marks from itching. The resident's skin had been itching for about a year. During an interview on 9/20/23 at 12:40 a.m., RN 5 indicated the resident's scratches to her right buttock was not open or bleeding when she seen them. She did not know if the scabbed over scratches on her left thigh were open and bleeding. She had not been there for 2 weeks. The treatment ordered was Calazime Intensive Skin and staff were to apply to her right buttock every shift and prn with a start date of 7/13/23. She was not sure how long the resident had the condition. She had not informed the NP (Nurse Practitioner) about the resident's skin condition before 9/20/23. During an interview on 9/20/23 at 1:15 p.m., Resident C's family member indicated he had complained about the resident's bleeding scratches on her skin for about a year and he could not get anyone to do anything about it. The resident's family member was observed to obtain his phone and show photos. He indicated the photos were taken by him on June 23, 2023 as was indicated on the date information on the photograph itself. The photographs showed the resident's lower body with multiple open and actively bleeding abrasions. The resident and her husband both indicated at this time it was due to self-inflicted wounds from the resident's excessive scratching due to itching. The family member also showed photos from September 2, 2023, where the issue continued with multiple areas of scratches from the resident's posterior thigh to her lower back and covering her buttocks with active bleeding dripping from the scratches. The resident's family member indicated he brought in pink cream for the resident from home for her to use. He had spoken with many people about his concerns, specifically naming the ED (Executive Director), the DON (Director of Nursing), and Social Services. He indicated he was concerned because the resident was in renal failure and asked them to talk to her doctor about the itching. No one had done anything except for occasionally applying cream. During an interview on 9/20/23 at 1:20 p.m. QMA 4 (Qualified Medication Aide) entered the room and indicated she was aware of the scratches. They had been there for months, and she thought greater than 3 months at least. Sometimes the nurse provided cream for the resident. It did not stop her from scratching, which was what caused the wounds. It did not improve much with what they treated her with. The Skin Management Program policy and procedure, dated 3/10, and last revised 5/22, provided on 9/21/23 at 9:00 a.m., indicated but was not limited to, . 6. Any skin alterations noted by direct care givers during daily care and or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin alterations by the direct caregivers on the shift reported. 7. Facility skin sweeps (head-to-toe assessment) are conducted to assess all residents' current skin condition and to ensure appropriate preventative measures are in place . This Federal tag relates to Complaint IN00416852. 3.1-47(a)

Based on record review and interview, the facility failed to schedule 8-hour RN coverage during the weekend day and night shifts for June and July 2023. This had the potential to affect all 31 residents residing in the facility. Findings include: On 7/6/23 between 9:30 a.m. and 2:30 p.m., the ED (Executive Director) provided a document indicating the facility had no staffing waivers. The June and July nursing schedule was reviewed on 7/11/23 at 9:02 a.m. 8-hour RN coverage was not documented on the following weekends: - On 6/3/23 no RN was scheduled for the day or night shift. - On 6/4/23 no RN was scheduled for the day or night shift. - On 6/10/23 no RN was scheduled for the day or night shift. - On 6/11/23 no RN was scheduled for the day or night shift. - On 6/17/23 no RN was scheduled for the day or night shift. - On 6/18/23 no RN was scheduled for the day or night shift. - On 6/24/23 no RN was scheduled for the day or night shift. - On 6/25/23 no RN was scheduled for the day or night shift. - On 7/1/23 no RN was scheduled for the day or night shift. - On 7/2/23 no RN was scheduled for the day or night shift. - On 7/9/23 no RN was scheduled for the day or night shift. During an interview on 7/11/23 at 8:45 a.m., the DON (Director of Nursing) indicated she would come in on the weekends for a few hours and sometimes for 8 hours, it depended on who was in the building and what was going on. If there was an LPN (Licensed Practical Nurse) on shift for the weekend, she would work for 3 to 4 hours on average. During an interview on 7/11/23 at 1:43 p.m., the ED indicated the facility did not have a policy for 8-hour RN coverage. They followed the State guidelines for daily 8-hour RN coverage. During an interview on 7/12/23 at 2:15 p.m., CNA (Certified Nurse Aide) 9 indicated the DON would work on weekends if she was needed. She would sometimes stay a few hours, or she would stay all day if needed. During an exit conference interview on 7/12/23 at 1:12 p.m., the ED and DON indicated they could not locate any documentation of 8-hour RN coverage on the weekends over the last month. 3.1-17(b)(3)

Based on record review and interview, the facility failed to notify the physician when a pulmonology consult was not made as ordered by the hospital discharging physician (Resident 12); a resident experienced low blood sugars outside the physician ordered parameters (Resident 19); and a resident experienced a change in condition which required hospitalization and ordered labs were not completed (Resident 2) for 3 of 13 residents reviewed for physician notification. Findings include: 1. The record for Resident 12 was reviewed on 7/10/23 at 8:34 a.m. The diagnoses included, but were not limited to, acute exacerbation of chronic obstructive pulmonary disease (COPD) with hypoxia, type 2 Diabetes Mellitus with diabetic polyneuropathy, peripheral vascular disease (PVD) and hypertensive heart disease with heart failure. The Quarterly Minimum Data Set (MDS) assessments, dated 3/3/23 and 6/20/23, indicated the resident was cognitively intact. A nurse's note, dated 2/18/23 at 9:22 p.m., indicated that while arguing with his roommate, Resident 12 became red in the face with slurred speech. A new physician's order was received to send him to the hospital. A nurse's note, dated 2/19/23 at 4:44 a.m., indicated the resident was transferred from the local hospital to another hospital to be admitted for syncope and exacerbation of COPD. The hospital discharge orders, dated 2/24/23, included, but were not limited to, keep the follow up appointments; follow up with the primary care physician in 1 week; and follow up with the (name of pulmonologist) in 2 to 3 weeks related to the final bronchi culture which grew escherichia coli ESBL (Extended Spectrum Beta Lactamase). The NP's (Nurse Practitioner) note, dated 2/27/23 at 12:16 a.m., indicated the resident was being evaluated after a hospital stay for COPD exacerbation with hypoxia. The hospital chest X-ray showed right lower lobe pneumonia and had required tapering doses of O2 (oxygen) ranging from 15 liters to 8 liters, and was then weaned down to 5 liters. An order was given for the resident to see the pulmonologist in 2 to 3 weeks. The NP's note, dated 2/28/23 at 8:09 a.m., indicated she had been notified over the weekend of the resident having desaturation and drowsiness. Orders were given for the resident to be transferred back to the hospital if not improved. He did not improve and EMS (Emergency Medical Services) was called. The resident initially refused to go, but then agreed to go to a different hospital, and refused to go when EMS arrived at the facility. An order was written again for the resident to follow up with the pulmonologist in 2 to 3 weeks. The NP's note, dated 3/2/23 at 8:45 a.m., indicated there was no nursing note of the pulmonary follow up documented. The NP again gave orders for the resident to follow up with the pulmonologist in 2 to 3 weeks. A nurse's note, dated 3/2/23 at 4:16 p.m., indicated the nurse attempted to contact the pulmonologist's office to schedule an appointment without success. A message was left for the office to return the call to the facility. The record lacked documentation indicating the physician had been notified that the facility was having difficulty contacting the pulmonologist's office to set up the ordered appointment. The record lacked documentation of the pulmonologist office having been contacted for an appointment until 7 weeks after the order was initially received after returning from the hospital. During an interview with the Director of Nursing (DON) on 7/10/23 at 10:50 a.m., she indicated the hospital notes only indicated for the resident to follow up with either his primary physician or the pulmonologist and that since the resident's primary physician saw him on 4/5/23 and indicated his breathing was fine, no pulmonologist follow up appointment was needed to be scheduled. A NP note, dated 4/18/23 at 8:56 a.m. and recorded as a late entry on 7/10/23 at 10:58 a.m., indicated the resident was being evaluated this day for follow up to his pneumonia. She indicated that although the resident was scheduled to go to the pulmonologist, he declined to go and told the staff and NP that he would not go because he had been in the hospital too long and was tired. The NP gave a new order to not follow up with pulmonary and that there was no need to reschedule. During an interview with the DON on 7/11/23 at 11:00 a.m., the DON indicated that when the NP saw the resident on 4/18/23, the resident had refused to go the pulmonary appointment. She then canceled the need for any further follow up by the pulmonologist. 35732 2. The record for Resident 2 was reviewed on 7/6/23 at 11:37 a.m. The diagnoses included, but were not limited to, pneumonia, chronic respiratory failure with hypoxia, gastrostomy status and gastro-esophageal reflux disease with esophagitis. The Quarterly MDS assessment, dated 5/22/23, indicated the resident was severely cognitively impaired. The resident required a feeding tube for nutrition. The care plan, dated 5/8/23, indicated the resident required enteral nutrition to meet nutrient needs related to chronic pneumonia evidenced by silent aspiration. The interventions included, but were not limited to, refer the resident to the RD (Registered Dietician) and physician as needed, treatment per physician order, and the resident was NPO (nothing by mouth). The care plan, dated 3/24/23 and last revised on 5/23/23, indicated the resident was at risk for aspiration related to enteral nutrition with use of a PEG (Percutaneous Endoscopic Gastrostomy) tube. The interventions included, but were not limited to, refer the resident to speech therapy as needed, assess the resident's vital signs and lung sounds as needed, report abnormal findings to the physician, document abnormal findings and notify the physician, and observe the resident for symptoms of aspiration and choking. The physician's order, dated 6/14/23, indicated the resident was to receive Resource 2.0 (nutritional supplements) every 6 hours via the gastric tube, flush with 120 ml (milliliter) of water before and after each bolus for a total of 477 ml. Staff were to elevate the resident's HOB (head of bed) 30 to 45 degrees at all times and perform oral care every shift. The NP note, dated 4/4/23 at 7:52 a.m., indicated a chest x-ray was to be done at the hospital if possible. The resident was to be straight catharized for a UA (urinalysis) and sent to the hospital stat (immediately). A CBC (Complete Blood Count) was to be repeated on Thursday. The nurse's note, dated 4/4/23 at 12:18 p.m., indicated a report was given to the hospital ER (emergency room ) regarding a change in the resident's condition and decreased LOC (Level of Consciousness). The clinical record lacked documentation indicating the NP was notified for a change in condition, the UA was not collected for a stat order, and a CBC was not repeated. During an interview on 7/11/23 at 9:57 a.m., the NP indicated she had ordered a chest x-ray, UA stat and a CBC. She was aware of the resident going to the hospital for a chest x-ray and not for a change in condition. They should have let her know about the resident's change in condition and the labs should have been drawn. 3. The record for Resident 19 was reviewed on 7/10/23 at 10:10 a.m. The diagnosis included, but was not limited to, type 2 Diabetes Mellitus with hyperglycemia, The Significant Change MDS assessment, dated 5/6/23, indicated the resident was severely cognitively impaired. The care plan, dated 2/13/23 and last revised on 5/15/23, indicated the resident was at risk for adverse effects of hyperglycemia or hypoglycemia related to the use of glucose lowering medication and the diagnosis of diabetes mellitus. The interventions included, but were not limited, to document abnormal findings and notify the physician, observe for symptoms of hypoglycemia, observe for symptoms of hyperglycemia, diet as ordered and monitor intakes and offer replacements for 50% or less consumption, lab work and medications as ordered. The physician's order, dated 7/5/23, indicated the resident was to receive Basaglar KwikPen U-100 Insulin (insulin glargine) 30 units at bedtime subcutaneous. Notify the physician if the resident's blood sugar was less than 60 mg/dL mg (milligram per deciliter) or greater than 400. The vital signs record for blood sugars indicated the following: - On 6/18/23 at 5:02 a.m., the resident's blood sugar was low. - On 6/21/23 at 4:58 p.m., the resident's blood sugar was low. The clinical record lacked documentation indicating the physician was notified, treatment was provided, and the resident's blood sugar was rechecked. During an interview on 7/11/23 at 11:02 a.m., the NP indicated that if a resident had a low blood sugar reading, there were protocols in place for juice or something to be given, and if that didn't work then she should have been notified, and a change in insulin would be ordered. During an interview on 7/11/23 at 2:15 p.m., LPN (Licensed Practical Nurse) 5 indicated if a resident's blood sugar read low on the glucometer, she would retest the resident and use a different finger. She would do an assessment on the resident for any changes from their baseline. If the glucometer indicated the blood sugar was still low, she would give the resident some orange juice and a protein snack. She would notify the NP of the low blood sugar and retest the resident. During an interview on 7/12/23 at 8:39 a.m., the DON indicated she was aware of the lack of documentation of interventions and assessments by the nursing staff. The Policy and Procedure Blood Glucose Monitoring, dated 3/10 and revised on 2/15, provided on 7/11/23 at 2:30 p.m., by the DON included, but was not limited to, .If the resident has not received specific blood glucose call parameters the physician will be notified of any blood sugar less than 70 or if the resident is having signs or symptoms of high or low blood sugar. The physician will be notified when the resident's blood sugar is outside the physician stated parameters or if the resident is experiencing signs and symptoms of high or low blood sugar. A resident with blood glucose below 70 requires an assessment for symptoms of hypoglycemia. Document assessment in nursing progress notes. Immediate treatment of hypoglycemia will be completed as follows if there is not a resident specific physician order. Blood glucose below 70 and resident is able to consume PO intake will receive 4 ounces of juice. Recheck blood glucose in 15 minutes and document. After 15 minutes proceed to the next step. If no symptoms of hypoglycemia and glucose is greater than 70 no further action is required. If symptomatic or blood sugar is less than 70 after 2 treatments, notify physician of resident status. Document MD notification and ongoing assessment and treatment. Blood glucose less than 70 and resident is unable to consume PO intake: Administer PRN IM or glucose as ordered. Recheck blood glucose in 15 minutes, document findings and current resident status and notify MD. If there is no PRN order notify MD immediately. Document notification, resident status and treatment interventions. Blood glucose results will be documented on the Capillary Blood Glucose Monitoring Tool or on the medication administration record. On 7/10/23 at 11:20 a.m., the Executive Director (ED) presented a copy of the facility's current policy titled Resident Change of Condition Policy dated effective 11/2018. Review of this included, but was not limited to, Policy: It is the policy of this facility that all changes in resident condition will be communicated to the physician .and that appropriate, timely, and effective intervention takes place. Procedure: .2. Acute Medical Change: a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. b. If unable to contact the attending physician or alternate physician in a timely manner, notify the Medical Director for medical intervention .d. All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met. 3. Non-Urgent Medical Change: a. All symptoms and unusual signs will be documented in the medical record and communicate to the attending physician promptly. Non-urgent changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. b. The nurse in charge is responsible for notification of the physician .prior to the end of assigned shift when a significant change in the resident's condition is noted. c. If unable to reach the physician ., all calls to the physician or exchanges .requesting callbacks will be documented. d. If the physician has not called back by the end of the shift, the oncoming nurse will be notified for follow up. e. If unable to contact the attending physician or alternate timely, the Medical Director will be notified for response and intervention for the resident change of condition. f. Document resident change of condition and response in the medical record. Documentation will include time and .physician response . 3.1-5(a)(2) 3.1-5(a)(3)

Based on observation, record review, and interview, the facility failed to ensure residents received the appropriate perineal care related to infection control guide lines to prevent urinary tract infections for 2 of 3 residents reviewed for bowel and bladder. (Residents 17 and 29) Findings include: 1. During an observation of incontinence care for Resident 17 on 7/12/23 at 10:37 a.m., CNAs (Certified Nurse Aides) 9 and 10 performed hand hygiene and applied gloves. The 2 basins were filled with warm water and the resident's brief was removed. A wet washcloth was obtained, and soap was added. CNA 10 used 6 swipes of the same area of the washcloth to clean the creases. The washcloth was folded and with 5 swipes of the same area of the washcloth she cleaned the penis with a back and forth motion down the shaft. She obtained another soapy washcloth and with 10 swipes of the same area of the washcloth she rinsed the penis and creases. The washcloth was folded and with 3 swipes of the same area of the washcloth she rinsed the creases. She folded the washcloth and with 4 swipes of the same area of the wipe she rinsed down the penis. She obtained a towel and with 7 swipes of the same area of the towel she dried the penis and creases. The resident was rolled onto his right side. The wound dressing was removed. It was dated 7/11/23. CNA 10 obtained a wet washcloth and applied soap. Using 13 swipes of the same area of the washcloth she cleaned the resident's buttock and rectal area. She folded the washcloth and with 4 swipes of the same area of the washcloth she cleaned the scrotum and visible stool from the rectum. A new soapy washcloth was obtained and with 3 swipes of the same area of the washcloth she cleaned the buttocks and some stool was removed from the rectum. The washcloth was folded and with 3 swipes of the same area of the washcloth she cleaned the buttocks and the rectum area. The resident continued to have a bowel movement. A new soapy washcloth was obtained and with 4 swipes of the same area of the washcloth the stool was cleaned from the rectum. The washcloth was folded and with 2 swipes of the same area of the washcloth the stool was cleaned from the rectum. A new soapy washcloth was obtained and with 2 swipes of the same area of the washcloth the stool was cleaned from the rectum. The washcloth was folded and with 2 swipes of the same area of the washcloth the stool was cleaned from the rectum. The washcloth was folded and with 4 swipes of the same area of the washcloth she cleaned the stool from the rectum. A fresh wet washcloth was obtained and the rectal area was rinsed using 7 swipes of the same area of the washcloth. It was folded and with 4 swipes of the same area of the washcloth she rinsed the rectal area. She folded the washcloth and with 5 swipes of the same area of the washcloth she rinsed the rectal area. She obtained a towel and with 5 swipes of the same area of the towel she dried the rectal area. She folded the towel and with 2 swipes she dried the rectal area. She folded the towel and with 4 swipes of the same area of the towel she dried the rectal area. The brief was applied. During an interview on 7/12/23 at 10:55 a.m., CNA 10 indicated she would clean the head of the penis first with using a front to back motion. She would rinse then dry the area. She would then clean the rectal area using a front the back motion, rinse, and then dry the area. She would use a clean area of the washcloth with each swipe. The record for Resident 17 was reviewed on 7/10/23 at 1:01 p.m. The diagnoses included, but were not limited to chronic kidney disease, BPH (benign prostatic hyperplasia) with lower urinary tract symptoms, dementia, personal history of UTIs (urinary tract infections), obstructive and reflux uropathy, retention of urine, and the need for assistance with personal care. The care plan, dated 7/13/22 and last revised on 5/30/23, indicated the resident was at risk for a UTI related to a history of recurrent UTIs, a history of a TURP (transurethral resection of the prostate) procedure, obstructive uropathy, a diagnosis of BPH, and urine retention. The interventions, dated 7/13/22, included but was not limited to assist with incontinence care. The Significant Change MDS (Minimum Data Set) assessment, dated 6/10/23 indicated the resident was severely cognitively impaired. The NP note, dated 7/6/23 at 8:21 a.m., indicated the resident was evaluated today for a UTI. The culture resulted from one of his recent emergency department visits with probable ESBL. He was started on ertapenem 1 gram daily for 7 days. The physician's order, dated 7/6/23, indicated to administer ertapenem 1 gram every 24 hours for 7 days until 7/12/23. 2. During an observation of catheter care for Resident 29 on 7/12/23 at 11:12 a.m., by CNA 10 and QMA (Qualified Medication Aide) 11, the catheter tubing was on the floor under the resident's wheelchair. Both staff performed hand hygiene and applied gloves. QMA 11 placed the catheter bag on the side of the bed. CNA 10 started to hang the catheter bag on her clothes and QMA 11 indicated to her to not hang it on her clothes. The resident was placed in the bed. The resident's pants were lowered, and CNA 10 obtained a wet washcloth. Using 3 swipes with the same area of the washcloth she rinsed the creases and the penis shaft. She folded the washcloth and with 5 swipes of the same area of the washcloth she rinsed the creases and penis with a back and forth motion. She folded the washcloth and with 4 swipes of the same area of the washcloth she rinsed the creases and groin. She obtained a soapy washcloth and with 7 swipes of the same area of the washcloth she cleaned the creases and the penis shaft using a back and forth motion. She folded the washcloth and with 6 swipes of the same area of the washcloth she cleaned the penis shaft. She did not clean the meatus of the penis. She obtained a fresh soapy washcloth and holding the tubing at the meatus she cleaned down the tubing. She folded the washcloth and with 3 swipes of the same area of the washcloth she cleaned the creases. She folded the washcloth and with 3 swipes of the same area of the washcloth she cleaned the shaft of the penis. She obtained a wet washcloth and the creases and penis were rinsed. She folded the washcloth and with 6 swipes of the same area of the washcloth she rinsed the creases and penis again. She obtained a dry towel and with 5 swipes of the same area of the towel the creases and penis were dried. She folded the towel and with 5 swipes of the same area of the towel she dried the area again. She folded the towel and dried the tip of the penis. She folded the towel and with 5 swipes of the same area of the towel she dried the tubing. The resident was rolled onto his left side and QMA 11 obtained a soapy washcloth. Using 2 swipes of the same area of the washcloth, using a circular motion, she cleaned the right buttock. She folded the washcloth and with 2 swipes of the same area of the washcloth, using a circular motion, she cleaned the left buttock back to front to the rectal area. She folded the washcloth and using 4 swipes of the same area of the washcloth she cleaned the rectal area. She obtained a new soapy washcloth she swiped the buttocks and rectal area 9 times with the same area of the washcloth going toward the scrotum. She obtained a new washcloth and using 3 swipes with the same area of the washcloth she cleaned the buttocks. She folded the washcloth and with 3 swipes of the same area she cleaned the buttocks. She obtained a new washcloth and with 3 swipes of the same area of the washcloth she cleaned the buttocks toward the scrotum. She folded the washcloth and with 3 swipes of the same area of the washcloth she cleaned the scrotum. The catheter bag was raised over the resident and held above the level of the bladder. The resident was dried using the same area for 4 swipes then folded, 3 swipes with the same area then folded, and 3 swipes of the same area over the rectal area. The resident was rolled onto his back and the brief was fastened. The resident's urine was a dark yellow and he indicated he had a burning stinging feeling. During an interview on 7/12/23 at 11:39 a.m., QMA 11 indicated for catheter and incontinence care, she would use a circular motion to clean around the penis and from the inside out. She would use a different area of the washcloth for each swipe. She would then clean the tubing. The resident would be rolled, and the backside would be cleaned. She used a circular motion from the outer area, then the inner. The bag doesn't go above the bladder and the tubing should not be pulled or stretched. The record for Resident 29 was reviewed on 7/10/23 at 10:15 a.m. The diagnoses included but were not limited to acute kidney failure with tubular necrosis, BPH, and obstructive and reflux uropathy. The care plan, dated 3/26/23, indicated the resident required an indwelling urinary catheter due to obstructive uropathy, BPH, and acute kidney failure with tubular necrosis. The interventions, dated 3/26/23, included, but were not limited to, do not allow tubing or any part of the drainage system to touch the floor, position the catheter bag below the level of the bladder, and provide assistance with catheter care. The Significant Change MDS assessment, dated 5/10/23 indicated the resident was moderately cognitively intact. The nurse's note, dated 5/23/23 at 7:47 a.m., indicated the resident's urine was yellow with sediment. The nurse's note, dated 6/10/23 at 3:50 p.m., indicated the resident required extensive assistance of 1 to 2 staff with toileting. A Foley catheter was in place for urinary retention. He was continent of bowel and staff provided peri care and Foley catheter care. The Catheter Care policy, last revised on May 2023, was provided by the ED (Executive Director) on 7/12/23 at 12:46 p.m. The policy included, but was not limited to, . 10. Change the area of the washcloth or retrieve a new washcloth for consecutive passes along the catheter tubing. Do not rewipe the drainage tube . The Perineal Care with Disposable Wipes policy, last reviewed in March 2023, was provided by the Executive Director on 7/12/23 at 12:46 p.m. The policy included, but was not limited to, . Do not rewipe catheter . 14. Wash tip of penis in circular motion, starting at urethra moving outward . 15. Use a clean disposable wipe with each wipe. Do not rewipe area, unless using a clean disposable wipe. 16. Continue washing down the penis to the scrotum outward. 17. Gently pat dry area in same direction as washing . 19. Clean anal area from front to back, using a clean disposable wipe. Do not rewipe area, unless using a clean disposable wipe . 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to ensure appropriate interventions were implemented to prevent aspiration for a resident with a g-tube (gastrointestinal tube) for 1 of 4 residents reviewed for g-tubes. (Resident 2) Findings include: The record for Resident 2 was reviewed on 7/6/23 at 11:37 a.m. The diagnoses included, but were not limited to, pneumonia, chronic respiratory failure with hypoxia, gastrostomy status and gastro-esophageal reflux disease with esophagitis. The Quarterly MDS (Minimum Data Set) assessment, dated 5/22/23, indicated the resident was severely cognitively impaired. The resident required a feeding tube for nutrition. The care plan, dated 5/23/23, indicated the resident required enteral nutrition to meet nutrient needs related to chronic pneumonia evidenced by silent aspiration. The interventions included, but were not limited to, The resident was to be referred to the RD (Registered Dietician) and physician as needed, treatment per physician order, and the resident was NPO (nothing by mouth). The care plan, dated 3/24/23 and last revised on 5/23/23, indicated the resident was at risk for aspiration related to enteral nutrition with use of a PEG (Percutaneous Endoscopic Gastrostomy) tube. The resident would be free from symptoms of aspiration. The interventions included, but were not limited to, refer the resident to speech therapy as needed, assess the resident's vital signs and lung sounds as needed, report abnormal findings to the physician, document abnormal findings and notify the physician, and observe the resident for symptoms of aspiration and choking. The physician order, dated 6/14/23, indicated the resident was to receive Resource 2.0 (nutritional supplements) every 6 hours via the gastric tube, flush with 120 ml (milliliter) of water before and after each bolus for total of 477 ml. Staff were to elevate the resident's HOB (head of bed) 30 to 45 degrees at all times and perform oral care every shift. The clinical record lacked documentation to indicated the nursing staff were checking for residual of the g-tube and lacked the documented residual amounts. The nurse's note, dated 4/21/23 at 3:25 p.m., indicated the resident received bolus feedings every 6 hours via his g-tube. The nurse's note, dated 5/9/23 at 3:01 p.m., indicated staff alerted the nurse that the resident had been vomiting. The resident was observed by the nurse and had light brownish or tan vomit on his clothing and bed, no active vomiting was observed. He was assisted onto his side; the HOB was elevated per protocol. The resident had removed his nasal cannula and his 02 (oxygen saturations) was 80 to 82% via NC (nasal cannula) and remained at that level after his oxygen was reapplied. His heart rate was elevated in the 140s, and his lung sounds had wheezing present. Orders were received to send the resident to the hospital for evaluation and treatment. The nurse's note, dated 5/9/23 at 10:37 p.m., indicated the resident was admitted to the hospital for possible aspiration. The nurse's note, dated 5/18/23 at 7:44 a.m., indicated the resident was evaluated for abnormal breath sounds. The resident sounded junky. He had been removing his supplemental oxygen and his 02 saturations were dropping. He was recently in the hospital with a diagnosis of pneumonia due to silent aspiration. He also had a history of COPD (Chronic Obstruction Pulmonary Disease) and chronic respiratory failure with hypoxia. The nurse's note, dated 6/25/23 at 12:00 p.m., indicated the nurse was called to the resident's room by the CNA (Certified Nursing Aide). He was observed to have emesis on his shirt and face. As staff were changing the resident, he began vomiting up a moderate amount of milk colored emesis with white clumps. The HOB was elevated throughout. The resident's lungs had expiratory wheezes and rhonchi. His O2 saturation was at 90% on 3L (liters) per nasal cannula. The NP (Nurse Practitoner) and DNS (Director of Nursing Services) were made aware of the findings and a new order was received to send the resident to the hospital for evaluation and treatment. During an observation on 7/6/23 at 11:37 a.m., the facility did not have signage posted indicating keep the head of the bed up 30 to 45 degrees at all times. During an interview on 7/11/23 at 8:49 a.m., the DON indicated the nursing staff should be checking residual for any resident that had a g-tube. That was the standard nursing protocol. She indicated she could not find any documentation indicating the nursing staff were checking and documenting the resident's residual. During an interview on 7/11/23 at 9:57 a.m., NP 3 indicated Resident 2 came from another facility with a history of aspiration. She was not aware the facility was not checking the residual from the g-tube. It was a standard nursing practice for a g-tube. The nurse's note, dated 7/11/23 at 5:07 a.m., indicated the resident was sent to the hospital for aspiration. During an interview on 7/11/23 11:15 a.m., RN 4 indicated the resident was sent to the hospital that morning for aspiration. During shift report the night shift nurse reported Laboratory Technician 8 came to draw the resident's blood and lowered the resident's head of the bed flat to draw blood. During an observation on 7/11/23 at 12:49 p.m., no signage was observed to be posted in the resident's room indicating to keep the head of the bed elevated 30 to 45 degrees at all times due to the g-tube feeding. During an interview on 7/11/23 at 12:50 p.m., LPN 5 (Licensed Practical Nurse) indicated she would check a g-tube residual before and after feedings, before giving medications, changing feeding bags, or any time she did anything with the feedings. She would check the residual at least a couple times her shift to make sure the feeding was doing okay. The residual was not documented in the clinical record. The resident's head of the bed should always be up at least 30 degrees. There would be no reason for the head of the bed to be lowered just to draw blood. The g-tube residual was checked but not documented in the clinical record. During an interview 7/11/23 at 1:12 p.m., LPN 6 indicated she was the nurse caring for the resident on the night shift. The lab technician came in that morning to draw the resident's blood for a CBC (Complete Blood Count). She wasn't sure how long the laboratory technician had been in the room. The labortary technician turned on the resident's call light and when she went to answer the light, she observed the resident's head of the bed was lowered in a flat position. She indicated the resident looked pale, so she called her DON and the resident was sent to the hospital for aspiration. During an interview on 7/12/23 at 8:39 a.m., the DON indicated she was aware of the lack of documentation of interventions by the nursing staff. During an interview on 7/12/23 at 9:00 a.m., laboratory technician 8 indicated when she entered the resident's room to draw his blood the resident had vomit on his clothing. The HOB was up 30 to 45 degrees. She did not observe HOB up at all times signage posted in the resident's room. She did not lower the resident's HOB. She turned on the resident's call light and the nursing staff came in. She informed them the resident had vomited. She was able to draw the labs and was in the resident's room for 4 minutes and then she left. While she was in the room, she did not see anyone lower the head of his bed and nursing staff was in the room. During an interview on 7/12/23 at 9:25 a.m., CNA 7 indicated she observed Laboratory Technician 8 enter the resident's room at approximately 1:00 a.m., to draw the resident's labs. After she was in there for a couple of minutes Laboratory Technician 8 turned on the resident's call light. When CNA 7 entered the resident's room she observed the HOB had been lowered. She did not observe Laboratory Technician 8 lower the HOB. CNA 7 indicated she had checked and repositioned the resident at 12:30 a.m., while doing her resident rounds. She specifically adjusted the resident's HOB and she was sure the HOB was up at a 30 to 45 degree. During an interview on 7/12/23 at 12:09 p.m., CNA 13 indicated she observed Laboratory Technician 8 lower the resident's HOB. She was sure the HOB up in the upright position because she and another CNA had made rounds at 12:30 a.m., and the resident was checked and repositioned then. The laboratory technician had turned the resident's call light on and indicated the resident had vomit on his gown. The CNAs elevated the HOB up to 30 degrees and provided patient care. During an observation on 7/12/23 at 10:41 a.m., RN 4 gathered her supplies for the resident g-tube feeding. She explained to the resident and proceeded to draw the privacy curtains. She washed her hands and donned gloves. She exposed the G-tube and checked for residual by aspirating stomach contents. the resident had 0 residual. She flushed the g-tube with 120 cc water, Resource 2.0 then flushed with 120 cc water after feeding. the resident tolerated the procedure well. She indicated she would document the residual results on the MAR. If the residual was greater than 60 cc she would hold the feeding and notify the NP. The Policy and Procedure titled Enteral Therapy, dated 1/16, provided on 7/11/23 at 2:30 p.m., by the DON included, but was not limited to, .The following orders should be obtained when enteral therapy is being implemented or changed: Type, size of the tube and route (PEG,GT, Nasogastric, J-tube) Site Care Type of formula Method of administration (gravity, bolus, pump) Flow rate or cycle schedule Amount and frequency of water flushes including medication administration flushes Gastric residual checked frequency with intervention Place verification frequency .Placement of the enteral therapy tube (Gastric tube, PEG tube, Nasogastric tube, etc.) is to be assessed by the licensed nurse no less than once every shift and before any substance is administered through the tube. Gastric residual will be assessed per physician's order with appropriate interventions taken . 3.1-44(2)

Based on interview and record review, the facility failed to ensure a resident (Resident B) was informed of a physician's order restricting her ability to leave the facility for 1 of 3 residents reviewed for resident rights. Findings include: The clinical record for Resident B was reviewed on 1/11/23 at 12:42 p.m. The diagnoses included, but were not limited to, aphasia and left sided hemiparesis. The BIMS (Brief Interview of Mental Status) assessment, dated 9/17/22, indicated the resident's cognition was intact. The physician's order, dated 9/27/22, indicated the resident was not to go LOA (leave of absence) until further notice. The clinical record lacked documentation of any notification or discussion of the order with the resident. During an interview on 1/11/23 at 1:45 p.m., Resident B indicated she was not informed by any of the staff that the physician had written the order. On 1/12/23 at 11:28 a.m., the Executive Director provided a current copy of the document titled Resident Rights dated 8/98. It included, but was not limited to, Policy .Facility must ensure that the resident can exercise his or her rights without interference .Facility must ensure that information is provided to each resident in a form and manner the resident can .understand This Federal tag relates to Complaint IN00391717 3.1-3(a)

Based on record review and interview, the facility failed to ensure timely revision of the care plan to reflect the resident's noncompliance for 1 of 37 residents reviewed for care plans. (Resident 30) Findings include: The clinical record for Resident 30 was reviewed on 8/12 /22 at 12:56 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 3/9/22, indicated the resident was moderately cognitively intact. He required one physical staff's assistance. The resident was not steady with walking, moving from seated to standing, transferring, moving on and off the toilet, and walking. The clinical record lacked documentation of any revision to the care plan with the interventions for noncompliance. The nurse's note, dated 3/5/22 at 11:53 a.m., indicated the resident had an unwitnessed fall in his bedroom. The resident indicated he got up and lost his balance. The IDT (Interdisciplinary Team) follow-up note, dated 3/7/22 at 10:48 a.m., indicated the root cause of the incident indicated the resident was attempting to transfer into his wheelchair. The nurse's note, dated 3/27/22 at 6:24 a.m., indicated the resident fell in his room. He indicated he walked over to get his wheelchair and was holding onto the wheelchair handles. He was trying to walk with it and fell backwards because the chair tipped with him. The IDT follow-up note, dated 3/28/22 at 6:16 a.m., indicated the resident fell in his room while attempting to walk to with his wheelchair unassisted. The resident was found on the floor beside his wheelchair. The immediate intervention included vital signs, full assessment, neurological checks and the resident was assisted to his wheelchair. He had a skin tear to his right forearm measuring 3.0 cm (centimeters) by 0.5 cm. A treatment was applied to his skin tear to the right forearm. He had no complaints of pain. The interventions in place, at the time of the fall, included assisting the resident to his wheelchair, after the assessment was completed. The root cause of the fall was, the resident attempted to ambulate unassisted. Interventions were put in place to address the root cause of the fall. The nurse's note, dated 4/12/22 at 11:30 a.m., indicated the nurse heard the resident yelling for help from the hallway. The nurse entered the resident's room to observe him resting on his knees, in front of his dresser wearing a t-shirt only. He stated that he was attempting to get some clothes out of the dresser and that he lost his balance and fell to his knees on the floor. The room was observed to be dimly lit with a quiet environment, and free of clutter. The call light was not sounding at the time of the fall. An incontinence brief was sitting on the floor in front of the resident and the brief was wet and soiled. His wheelchair was observed to be next to the bed and his urinal was knocked over and spilled onto the floor next to the bedside. The resident was barefoot at the time of fall. He was assisted by two staff members to a standing position and then to a sitting position. A head to toe assessment was performed. The resident was alert and oriented to person, place, time, and situation with periods of intermittent confusion present, per his baseline. His speech was clear and he was able to make his needs known. He denied pain or discomfort. The resident denied hitting his head during the fall. He was encouraged to utilize his call light for assistance, as needed, and to use his wheelchair for ambulation about the room. The nurse's note, dated 4/12/22 at 9:30 p.m., indicated the nurse was called to the resident's room by the CNA (Certified Nursing Aide). She entered the room and observed the resident lying supine on the floor, lying next to the empty bed in the room. The room was dimly lit and free of clutter. The resident was fully dressed, wearing well fitting shoes, pants and his incontinence brief was partially pulled down. The resident's pants were soiled and his urinal was at his side and spilled onto the floor at the resident's feet. His wheelchair was off to the side and behind the resident. He was alert and oriented to person, place, time, and situation. His speech was clear and he was able to make his needs known. The resident indicated he just got up and was being stupid. He complained of pain to his posterior head. Three lacerations to his posterior head were present, with a moderate amount of bleeding. A towel was used to hold pressure to the back of his head. The resident was not moved from the floor, due to hitting his head during an unwitnessed fall. The NP (Nurse Practioner) was notified via phone of the unwitnessed fall. A new order was received to send the resident to the hospital emergency room for evaluation and treatment. The IDT note, dated 4/15/22 at 11:19 a.m., indicated the resident had a skin injury. He had 2 abrasions to the right side of his head and a bruise to his right upper arm. The interventions included sending the resident to the hospital for evaluation and treatment. The root cause of the fall, was the resident was attempting to use his urinal. New interventions included applying an antibiotic ointment to the areas and neurological checks. The nurse's note, dated 4/16/22 at 6:29 p.m., indicated the resident fell during dinner at 5:30 p.m. He was in his room and began yelling for help. The nurse came from the dining area and she found the resident laying on his left side with his knees curled to his chest. The nurse got another staff member's attention to assist the resident back up to his wheelchair. No visible injuries were observed. He denied pain and indicated he was just in shock from the fall. Neurological checks were restarted. The IDT note, dated 4/15/22, indicated the resident attempted to get paper towels out of the dispenser, unassisted. Immediate interventions indicated the resident was to have paper towels placed within reach, on the back of the sink. The nurse's note, dated 4/19/22 at 4:02 a.m., indicated the resident continued to stand up without assistance from his wheelchair. He was non-compliant with using the call light or asking for help. Frequent reminders were given to utilize the call light and to ask for assistance. The nurse's note, dated 4/27/22 at 1:06 a.m., indicated the resident was getting out of bed to use the restroom. He only had one wheel on his wheelchair locked, so the chair slid out from under him. He was sitting on the floor next to his bed when he was found. He had no complaints of pain. He had a 3 cm scratch on the underside of his left upper extremity. The interventions included, placing red tape on the call light to help remind the resident to call for help before getting up. The resident was educated on how to lock both wheels. Red tape was previously placed on the wheel locks. Staff would place a cushioned mat at the side of his bed, to soften and help prevent injuries, from future falls. The bed was in the lowest position. The nurse's note, dated 4/28/22 at 12:37 a.m., indicated the resident had been consistently getting out of bed and coming to the nurse's station asking, What do I do now? The resident would lay in the bed for about 5 minutes and then get back up and come back to the nurse's station and repeat the same question. He had anxiety asked about getting his medications all of the way up until the administration time for his medications. The resident would start asking about when he would receive his medications again. The resident could not relax enough to fall asleep. During an interview on 8/24/22 at 9:43 a.m., the DON (Director of Nursing) indicated the resident was picked up for therapy on Monday. His cognition had improved greatly. When he was admitted to the facility, he could not comprehend what he was being told and what his body could not do. They had put up signs, educated the resident, provided non-skid footwear, added nonskid strips, added bright colored tape to his call light and wheelchair, his clothes were moved from the closet and put on a shelf, so he could reach them. He was non-compliant with asking for help and transferring. He insisted on self transferring himself and he should have had a care plan for noncompliance. The Comprehensive Care Plan Policy, dated January 2010 and revised on October 2019, was provided on 8/24/22 at 2:30 p.m., by the Executive Director, and included, but was not limited to, . Care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition, resident preferences or family input . 3.1-35 (a)(e)

Based on observation, record review, and interview, the facility failed to ensure interventions were appropriately implemented to prevent the development of pressure ulcers for 2 of 3 residents reviewed for pressure ulcers. (Residents 29 and 31) Findings include: 1. During an observation on 8/22/22 at 10:37 a.m., Resident 29 was resting abed. He did not have any heel boots in place. Both of his heels were lying directly on the mattress. His pressure relief boots were laying inside of a wash basin on his night stand next to the bed. RN 3 provided wound care for the resident. There was no treatment in place to the top of his right foot. The right foot had a very small scabbed area, which RN 3 measured at 1 cm (centimeter) in length (L) by 0.25 cm in width (W). The area to the left shin was healed. He had a blackened area to the left heel, which was closed, measuring 2 cm in L by 1 cm in W. RN 3 covered both of the resident's feet back up with a sheet. She indicated she was done with the resident's care. She exited the room and did not make any attempts to replace the resident's pressure relief boots. During an observation on 8/22/22 at 11:29 a.m., Resident 29 remained abed, with both heels resting directly on his mattress. His pressure relief boots remained inside the wash basin on the night stand. The clinical record for Resident 29 was reviewed on 8/19/22 at 8:49 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 10/16/20 and last revised on 8/16/22, indicated the resident was at risk for further skin break down due to decreased mobility, extensive assistance with bed mobility, turning and positioning, frail skin, incontinence of bowel and bladder, advanced age, [CONDITION(S)], decreased sensory perception, and pressure injuries. The goal for the resident was to have no further skin breakdown through the next review. The interventions included, but were not limited to, specialized splint at all times, remove every two hours to assess skin (dated 4/1/22), elevate heels while in bed using heels off pillow (dated 4/13/21), and staff to assist resident every two hours and as needed with bed mobility (dated 4/13/21). The wound management report, dated 6/4/21, indicated the resident had an unstageable pressure wound to the left heel, which was present on admission/readmission. The wound measured 4 cm in L by 3 cm in W, with no depth. There was moderate seropurulent drainage and the wound was 100% eschar tissue. On 6/17/21 the wound was improving and able to be staged at a stage 3 measuring 1.7 cm in L by 3 cm in W with a depth of 0.2 cm. On 10/3/21 the wound was indicated as healed by the DON. The boots and skin prep were continued as preventative measures. The nurse's note, dated 10/20/21, indicated the resident had a 1 cm fluid filled blister to the back of the left leg. The pillow was covered with a soft blanket. The area was cleaned and a new order for [MEDICATION(S)] and daily dressing until healed, were put into place. The wound healed on 1/12/22. The wound observation, dated 1/20/22, indicated a new unstageable pressure ulcer to the resident's left heel was identified. The wound measured 4 cm in L by 3.5 cm in W. A treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDT note, dated 1/20/22 at 11:17 a.m., indicated the root cause of the wound to the left heel was pressure, and a new intervention to apply z flow boots and a heel pillow was put into place. On 3/11/22 the wound was reclassified as a stage 3 pressure ulcer, measuring 0.8 cm in L by 0.4 cm in W, with a depth of 0.2 cm. The wound was documented as healed on 7/22/22. The IDT note, dated 3/23/22, indicated the resident was evaluated by occupational therapy for a plan to treat positioning in his wheelchair and bed and core strengthening. The resident received bed mobility secondary to a stage 3 to his left heel and needing the heel off loaded with possible specialized splint. The IDT note, dated 4/1/22, indicated the resident continued with occupational therapy and a specialized splint was ordered for his left foot. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The splint may be removed for bathing. The IDT note, dated 7/22/22, indicated the resident had a SDTI (Sustained Deep Tissue Injury) to the left posterior leg from friction, from the boot. A treatment to cleanse the wound with wound cleanser, paint with [MEDICATION(S)] and periwound with skin prep and cover, was put into place. The wound observation, dated 8/11/22, indicated the resident had a new stage 2 pressure ulcer to the left ankle. The wound measured 1.4 cm in L by 1 cm in W, with no depth, it was 100% granulation tissue and described as a ruptured blister. The wound observation, dated 8/11/22, indicated a new stage 2 pressure ulcer to the left top of the foot was identified. The wound measured 1.5 cm in L by 1.5 cm in W and was described as a ruptured fluid filled blister. The wound observation, dated 8/12/22, indicated a new unstageable pressure ulcer to the left heel was identified. The wound measured 1.4 cm in L by 1.2 cm in W. It was described as a closed or resurfaced deep tissue injury, which was dark purple or rusty colored. The wound observation, dated 8/15/22 indicated a new stage 2 pressure ulcer to the left calf was identified. The wound measured 3.2 cm in L by 1.7 cm in W. During an interview on 8/19/22 at 8:19 a.m., Resident 29 indicated he had a sore that couldn't get healed to his left heel which he thought had been there since he got to the facility. During an interview on 8/23/22 at 1:33 p.m., the Director of Nursing (DON) indicated the resident was supposed to have heel boots in place. She was aware the boots had not been in place, because she had been the one to put them back on him. 2. During an observation on 8/22/22 at 11:29 a.m., Resident 31 was in her recliner in her room with the back of her legs and her heels resting directly on the recliner foot rest. During an observation on 8/22/22 at 1:54 p.m., RN 3 provided wound care to Resident 31. The resident had a bordered gauze in place to her right lower extremity. The dressing was dated 8/19/22 and was saturated through the dressing with green drainage. The dressing was removed and an open area was observed. RN 3 measured the wound and indicated it measured 1.5 cm in L, by 2.75 cm in W. There was a discoloration surrounding the wound which measured 6 cm in L by 5 cm in W. The perimeter of the area was indented in the shape of the bordered gauze and was non-blanchable. RN 3 applied Santyl and then an Unna Boot treatment to the resident's leg before securing the dressing with coban. The resident also had a hardened callus to the left heel which was peeling away from the surface. There was a light purple area of discoloration beneath the callus, which RN 3 indicated was boggy to the touch. RN 3 asked the resident to roll over. A foam dressing was observed to the resident's coccyx area. The dressing was dated 8/17/22. RN 3 removed the dressing. There was a reddened area to the coccyx, appearing as a crack in the skin, measuring 1.5 in L and 0.2 in W. The periwound was reddened and was non blanching. The nurse applied a bordered foam dressing, and indicated it was supposed to be changed daily. She thought it had not been changed since 8/17/22 according to the date on the dressing. During an observation on 8/22/22 at 1:05 p.m., Resident 31 was in her recliner. Her legs were resting directly on her recliner foot rest. Her heels were not lifted or off loaded. During an observation on 8/23/22 at 11:30 a.m., Resident 31 was in her recliner in her room. Her heels and calves were not elevated or offloaded and there was no foam padding to the metal bar on her table. During an observation on 8/23/22 at 1:15 p.m., Resident 31 was in her recliner in her room. Her heels and calves were not elevated or offloaded and there was no foam padding to the metal bar on her table. The clinical record for Resident 31 was reviewed on 8/23/22 at 9:09 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 7/27/22 and last revised 8/22/22, indicated the resident had impaired skin integrity due to being admitted with an ulcer to the right calf and had a new injury to the coccyx and stage 2 to the left heel. The resident had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions, dated 7/27/22, included, but were not limited to, turn and reposition every 2 hours, treatment as ordered. On 8/8/22 a new intervention of pressure reducing roho cushion to the chair was added. On 8/22/22 a new intervention of foam padding to the lower bed or over bed table for added padding when the resident used the bar as a foot rest, was added. The care plan lacked documentation of any interventions to offload the resident's heels or lower extremities while abed or in her recliner. The Admission observation, dated 7/26/22, indicated the resident had an ulcer to her right calf measuring 4.5 cm in L by 3 cm in W. No other ulcers were indicated on the admission assessment. The Admission Braden Scale, dated 7/26/22, indicated the resident scored 15 points which was at risk for developing pressure ulcers. The treatment order, dated 7/26/22 thru 8/10/22, indicated to cleanse the wound to the resident's right lower calf, apply Santyl to the wound bed and a wet to dry dressing once daily. The treatment was not documented as completed on 7/28/22. The Wound Observation, dated 7/27/22, indicated the resident was admitted with a stage 4 pressure ulcer to the right calf, which measured 4.5 cm in L by 3 cm in W with no measurable depth. The wound was 60% granulation tissue and the edges were macerated or soft. The Wound Observation, dated 8/8/22, indicated the resident had developed a new stage 2 pressure ulcer to the coccyx, measuring 3 cm in L by 0.2 cm in W, with no measurable depth. The wound was 75% granulation tissue with macerated or soft edges. The IDT Initial Wound Review note, dated 8/8/22 at 11:43 a.m., indicated the resident had a new ulcer to the coccyx. The root cause of the injury was identified as friction from her recliner chair. The interventions included a roho cushion to the chair and barrier cream. The current treatment order was to apply barrier cream to the coccyx. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Observation, dated 8/11/22, indicated the resident had developed a new stage 2 pressure ulcer to the left heel, which was closed or resurfaced, with calloused or firm wound edges. The wound measured 0.7 cm in L by 0.3 cm in W. The IDT Initial Wound Review note, dated 8/11/22 at 1:12 p.m., indicated the resident had a new ulcer to the left heel. The root cause of the wound was pressure from her feet being on the floor while she was in her recliner. The new intervention was to skin prep the area and the resident to off load her heels with sitting recliner back. The current treatment order was for skin prep twice daily. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan lacked documentation of any interventions to off-load the resident's heels or lower extremities. During an interview on 8/22/22 at 2:00 p.m., RN 3 indicated the resident was supposed to have an Unna Boot treatment in place. She had been the one to put the gauze dressing in place on 8/19/22, and she did it because that was the type of dressing that was on the resident when she went to change it. She didn't know why she didn't put it on as it was ordered. On the resident's coccyx the treatment was to put zinc cream on it a couple times a day, but they were putting a dressing on it because it felt better for the resident, though she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She had not seen the area to the resident's heel before and was not aware she had it. She had never skin prepped the resident's heels. During an interview on 8/22/22 at 2:23 p.m., the DON indicated there was no reason why the resident shouldn't have had her Unna Boot treatment in place. She expected treatment orders to be done every day and to be done as ordered. During an interview on 8/23/22 at 1:33 p.m., the DON indicated the resident should have a foam pad in place to the bar of her bedside table. They had not put an intervention in place to off load her legs. There should be something they could put in place. Initially she indicated a pillow might not be appropriate because the resident may try to get up and then trip over it, but then indicated it could be appropriate because the resident was alert and oriented enough to be educated to move the pillow. The Dressing Change Clean Technique (Incision or Wound) policy, provided on 8/23/22 at 10:00 a.m., last revised on 6/21, included but was not limited to, . Procedure steps . 1. Verify Resident and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Skin Management Program policy, provided on 8/23/22 at 10:00 a.m., by the DON, included but was not limited to, It is the policy . to ensure that each resident receives care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing . 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure a resident received pain medication as ordered by the physician for 1 of 2 residents reviewed for pain management. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 8/23/22 at 11:04 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 10/16/20 and last revised on 8/23/22, indicated the resident was at risk for pain related to a history of pelvic fracture, [CONDITION(S)] of hands and lower legs, acute general pain, arthritis, and wounds. The goal for the resident was for his pain to be managed through the next review. The interventions included, but were not limited to, medications will be administered as ordered or requested (dated 3/13/22), The need for pain assessments to be done quarterly, yearly, and with any significant change and as needed (dated 4/13/21), the staff would monitor for signs and symptoms of non-verbal pain (dated 4/13/21), and the staff would report to the physician if the resident had new or worsening pain (dated 4/13/21). The Nurse Practitioner's (NP) note, dated 2/4/21 at 12:27 p.m., indicated the resident was seen for bilateral hand pain and left foot pain. He was taking [MEDICATION(S)] 300 mg (milligrams) three times daily and Tylenol 1000 mg, three times daily. The resident indicated the Tylenol did not help his foot. He had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . A new prescription with a quantity of 30 pills was sent to the pharmacy. The Controlled Drug Use Record indicated during the month of February 2022, the resident had not receive any doses of his [MEDICATION(S)]-APAP 5/325 mg until four day after the order was received on 2/8/22. The NP's note, dated 2/8/22 at 12:32 p.m., indicated the resident was seen for a follow-up to his left foot pain. He was unable to indicate if the [MEDICATION(S)]-APAP was helping. The NP checked the record and the resident had not received any of the medication since the order was written. A new order was written to change the resident's [MEDICATION(S)]-APAP order to 5/325 mg every 8 hours to scheduled. The Controlled Drug Use Record indicated the resident only received his [MEDICATION(S)]-APAP 5/325 mg tablets on 2/8/22 at 7:00 p.m., 2/9/22 at 8:00 a.m., 2/10/22 at 8:00 a.m., 2/11/22 at 11:00 a.m., 2/12/22 at 8:00 a.m., 2/13/22 at 8:00 a.m., 2/14/22 at 8:00 a.m., and 2/17/22 at 5:00 a.m. and 9:00 p.m. The NP's note, dated 2/17/22 at 9:05 a.m., indicated the resident was evaluated as a follow-up to his left foot pain. The resident indicated his left foot was still hurting. He was again unable to tell if the [MEDICATION(S)]-APAP was helping. The NP checked the records and the resident had not been given his scheduled medication since 2/14/22. The nurse was asked to confirm the order was changed. The prescription had been updated the week prior. The resident also complained of neck pain. The assessment and plan indicated to give the medication as directed. The nurse's note, dated 2/21/22 at 7:51 a.m., indicated to change the resident's [MEDICATION(S)]-APAP back to as needed, related to the resident being drowsy. During an interview on 8/23/22 at 11:21 a.m., the DON (Director of Nursing) indicated she was not aware of the order not being administered as ordered. If the NP didn't do the telephone order or did not fill out a written order, and the NP just put the information in her note she wouldn't have known about the order. During an interview on 8/24/22 at 8:15 a.m., the DON indicated the NP ordered the pain medication for the resident, as needed on 2/4/22, but he did not receive it from the pharmacy until 2/8/22. The NP saw him again on 2/8/22 and made it routine. She documented in her note, the prescription was updated, however the NP had updated the pharmacy and not the facility, so the staff continued to give it as needed. On 2/14/22 the NP updated the medication to three times daily and that was when they observed the order. It was updated, and then the resident became lethargic. He should have gone up to twice daily, three times daily was too much. They were going to have to get with the doctor and the NP and make sure they wrote the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She had talked to the NP before, because she was sending all of the orders to the ADNS, and then she would write all the orders. Then she was giving the orders to the nurses and then texting management what orders she was giving. They reviewed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . They had no way of knowing. They should have read the note from the NP to see there was an order in there. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to monitor food products for expiration dates. This had the potential to affect 31 of the 33 residents residing in the facility. Findings include: During an observation on [DATE] at 9:08 a.m., the following concerns were observed, in the reach-in refrigerator, in the facility's kitchen: -There were two containers of half and half creamer in the refrigerator, with expiration dates of [DATE]. -There were four outdated containers of vanilla yogurt. Two of the containers had an expiration date of [DATE], one container with an expiration date of [DATE], and one container with an expiration date of [DATE]. During an observation on [DATE] at 8:13 a.m., the following concerns were observed, in the reach in- refrigerator, in the facility's kitchen: -There were two containers of half and half creamer in the refrigerator, with expiration dates of [DATE]. -There were four outdated containers of vanilla yogurt. Two of the containers had an expiration date of [DATE], one container with an expiration date of [DATE], and one container with an expiration date of [DATE]. -The container of yogurt with an expiration date of [DATE], had an open date which indicated it had been opened for use on [DATE] after the expiration date. The container was three-quarters used as indicated by the Dietary Manager. During an interview on [DATE] at 8:24 a.m., the Dietary Manager indicated the morning cook had a check list that was to be done daily by 9:00 a.m. She herself then went and made rounds on the food dates. She usually checked on Wednesdays and did a full round of food items, but had been out for eleven days. The foods should have been rotated and expired foods tossed out. They should have seen the dates and gotten rid of them already. During an interview on [DATE] at 9:01 a.m., the Dietary Manager indicated upon reviewing her checklists, staff were not having to sign off on checking the food dates. When they implemented the new corporate check off list, it did not include to check for expiration dates. The Food Storage policy, provided on [DATE] at 9:00 a.m., last revised on ,d+[DATE], included, but was not limited to, . 7. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of food . 11. Refrigerated, ready-to-eat, potentially hazardous food purchased from approved vendors shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded. The opened food can be held no more than 7 days and the date marked may not exceed the manufacturer's use-by-date . 3.,d+[DATE](i)(3)

Based on record review and interview, the facility failed to ensure residents were free of misappropriation for 4 of 5 residents reviewed for misappropriation of property. (Residents B, C, D, and E.) Findings Include: 1. The clinical record for Resident B was reviewed on 5/11/22 at 10:47 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change in status MDS (Minimum Data Set) assessment, dated 12/20/21, indicated the resident was severely cognitively impaired, received a scheduled pain medication regimen and non-medication interventions for pain. The care plan, dated 6/1/21 and last revised on 12/30/21, indicated the resident had pain related to complaints of pain to her bilateral knees, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included, but were not limited to, medications per physician order, notify family as needed, and treatment per physician order. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 1/5/22 at 9:59 a.m., indicated the resident was calling out several times and unable to get comfortable in the bed. She requested 7 times to be repositioned by 8:00 a.m. The CNA (Certified Nurse Aide) and nurse repositioned her but she was still unable to get comfortable. When asked if she was experiencing pain, the resident did not respond. She had watery eyes, facial grimacing, calling out and moaning during repositioning several times throughout the morning. The NP (Nurse Practitioner) was notified. The resident previously had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] had been ineffective at managing her pain at the time and her [MEDICATION(S)] patches 25 mcg and 12 mcg to be placed simultaneously and changed every 3 days were restarted related to chronic pain. The POA and resident were notified. The nurse's note, dated 1/6/22 at 8:41 a.m., indicated new orders were given to discontinue [MEDICATION(S)] solution every hour as needed for pain and start [MEDICATION(S)] every 2 hours as needed for pain. The Nurse Practitioner's note, dated 1/6/22 at 2:45 p.m., indicated the resident was evaluated for pain. She was restarted on her [MEDICATION(S)] 12 mcg and 25 mcg patches the day prior. [MEDICATION(S)] 5 mg order was changed from every 4 hours to every 2 hours as needed. Both orders were sent on 1/5/22. The resident was fidgety during assessment and stated that she was in pain. The Review of the MAR (Medication Administration Record) for January, indicated the resident received both the 12 mcg and the 25 mcg patches on 1/8/22, and were due to be administered again on 1/11/22. The nurse's note, dated 1/9/22 at 12:15 a.m. indicated the resident [MEDICATION(S)] patch was in place and she had no signs or symptoms of pain. The review of the incident file, provided on 5/11/22 at 9:51 a.m., included a timeline, which indicated on 1/10/22, RN 4 reported Resident B's [MEDICATION(S)] patch was not present. Further investigation showed another resident was also missing their [MEDICATION(S)] patch. On 1/10/22, a new order for both 12 mcg and 25 mcg [MEDICATION(S)] patches was implemented and new patches were applied on both 1/10/22 and 1/13/22 at 9:00 a.m., according to the MAR. The nurse's note, dated 1/10/22 at 11:46 a.m., indicated the resident denied any pain, the writer questioned her three separate times and she said she had no pain and was trying to sleep. On 1/13/22, a new order for both 12 mcg and 25 mcg [MEDICATION(S)] patches was implemented and new patches were again applied, according to the MAR. The incident file timeline, indicated on 1/13/22 a new patch had been placed on Resident B at 10:30 a.m. and was found to be missing at approximately 11:15 a.m. Another resident's patch was checked and found to also be missing. The nurse's note, dated 1/14/22 at 10:42 a.m., indicated a pain assessment was completed at this time and the resident denied pain. Upon asking staff if they noticed any pain with turning and repositioning the resident they replied yes and told them her 'butt' hurt. The resident was turned onto her side with pillows used for positioning which relieved the pain. The incident report timeline indicated on 1/14/22, a nurse working as a CNA noticed Resident B's [MEDICATION(S)] patch was missing and informed the SSD, who informed the resident's nurse. The nurse indicated when replacing patches that morning the patches being replaced were not present. The nurse's note, dated 1/14/22 at 6:45 p.m., indicated a new order was given to hold [MEDICATION(S)] patches through Monday. Family was notified. The nurse's note, dated 1/17/22 at 2:25 p.m., indicated a new order to resume the patches was given. 2. The clinical record for Resident C was reviewed on 5/11/22 at 11:22 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment, dated 12/8/21, indicated the resident was severely cognitively impaired, was not on a pain medication regimen, could not answer a pain assessment, and did not display any indicators of pain. The care plan, dated 12/8/22 and last revised on 5/2/22, indicated the resident was at risk for pain related to [CONDITION(S)], constipation, [CONDITION(S)], GERD, contractures, abnormal posture, and pressure areas. Interventions included, but were not limited to, administer medications as ordered, assist with positioning to comfort, document effectiveness of as needed medications, notify physician if pain is unrelieved or worsening, observe for adverse side effects of pain medication, observe for nonverbal signs of pain, and offer non pharmacological interventions. The nurse's note, dated 1/7/22 at 2:28 p.m., indicated the resident recently had [MEDICATION(S)] added to her medication regimen for pain control. Her only signs of pain observed was when she was up in her chair. She moaned and verbalized noises during those times. She was up for meals and laid back down in between. The nurse's note, dated 1/10/22 at 1:51 p.m., indicated upon assessing the resident that morning her [MEDICATION(S)] patch was not in place. She was non-verbal but had no distress visualized, however her heart rate was elevated at 114 beats per minute. A new patch was placed. The nurse's note, dated 1/16/22 at 10:48 a.m., indicated the resident pain patch was changed, her old one was removed and a new one was placed to the right scapula. The nurse's note, dated 1/17/22 at 3:28 a.m. indicated the resident's [MEDICATION(S)] patch was in place to her right shoulder and had no signs or symptoms of pain. The incident report timeline indicated Resident C's [MEDICATION(S)] patches were found to be missing on 1/10/22 after finding another resident's patch missing, on 1/13/22 upon return from a wound care clinic appointment, and again on 1/17/22. On 1/17/22 Housekeeper 6 and an RN provided care to the resident at 10:00 a.m. The patch had been verified as in place prior to and during the care. Another nurse observed the housekeeper in the room [ROOM NUMBER] to 20 minutes later. The ED (Executive Director) then observed the housekeeper exit the facility. The ADON (Assistant Director of Nursing) checked Resident C for patch placement and found the patch to be missing, with the area to the right shoulder where the patch was located observed to be red. The nurse's note, dated 1/18/22 at 1:51 p.m. indicated the resident had no signs or symptoms of distress related to the recent reportable incident. The nurse's note, dated 1/18/22 at 4:50 p.m., indicated the resident was experiencing signs of non-verbal pain. The resident was moaning and having constant repetitive crying out vocalization and grimacing while up in her chair and when turned in bed. She was refusing to eat or drink and it was obvious the resident was in a great amount of pain. It was disrupting the residents in the dining room and visitors as well as her room mate, the NP and ADON were notified with new orders to add a one time dose of an additional [MEDICATION(S)] 12 mcg/hr patch to equal 24 mcg until the 25 mcg patch arrived. The NP's note, dated 1/25/22 at 11:07 a.m. indicated the resident was evaluated for continued pain. She was started on [MEDICATION(S)] 12 mcg on 1/4/22 and was increased to 25 mcg on 1/18/22. Staff reported her moaning while she was up in her chair this day and the day prior. The patient was moaning in between bites of food. Orders were given to increase her [MEDICATION(S)] patch to 37.5 mcg/hr every 3 days. During an interview, on 5/11/22 at 11:59 a.m., RN 4 indicated she had been the one to initially find the patches were missing on Resident B, and then upon checking the other residents found Resident C was also missing her patch. She reported the patches as missing to her ADON and they tried to figure out why they weren't in place. Both Resident B and C were cognitively impaired and wouldn't have been able to tell if heir patches were missing or who took them. Another resident who was not missing her patch would have been able to tell. The patches came up missing she believed about three different times. The 10th was the first time, then she believed they were missing again the following Thursday and Friday. She was there the day they figured out who was taking them. Housekeeper 5 was also a PCA (Personal Care Assistant) and was helping on the floor with another nurse who was working as a CNA and she, RN 4, was the nurse that day. The other nurse and Housekeeper 5 were doing resident care. They had checked the placement of everyone's patches the morning they came on, and checked with the off going nurse. The other nurse working as the CNA verified it as well. Everyone had seen Resident C's patches on her that morning, the ADON, herself, and the other nurse. Two staff went in together to provide care together because the patch missing was such an issue. When they went in a room they always took two staff. When the nurse and Housekeeper 5 went in the room, and came back out she was at the nurses cart a couple of rooms down and saw Housekeeper 5 go back in the room alone. The ED went in behind her and found the patch was missing. They narrowed it down to the only person going in the room alone was Housekeeper 5. During an interview, on 5/11/22 at 1:58 p.m., the ADON indicated RN 4 was working the floor nurse on 1/10/22, they had given Resident B a bed bath and went in to do her patch check. RN 4 wanted to know if she had taken it off. She informed the ED who also verified there were not patches. A couple days went by where nothing else happened. A couple days later the CNA's then noticed the patches weren't in place again. They would be there at the end of one shift and then be gone. The last one with Resident C, RN 6 and herself had verified placement that morning. She then went in and did care for Resident C, with Housekeeper 5 who is a PCA. They did incontinent care and she had visualized and verified the patches were in place. RN 6 left the room and Housekeeper 5 was left to clean up the linens. The ED watched Housekeeper 5 walk in the room, leave, and then walk outside. She came and got the ADON and together they checked the resident and found her patch was missing and the skin was still red from where, she presumed, the patch had been removed. 3. The clinical record for Resident D was reviewed on 5/11/22 at 12:15 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS assessment, dated 2/14/22, indicated the resident was severely cognitively impaired. She required extensive assistance for all her ADL's (activities of daily living). The care plan, dated 2/9/22, indicated the resident was at risk for pain related to a history of right hip fracture with surgical repair. The interventions included, but were not limited to, administer medications as ordered, assist with positioning for comfort, document effectiveness of prn (as needed) medication, notify the physician if pain was unrelieved or worsening, observe for adverse side effects of pain medication, observe for nonverbal signs of pain, and offer nonpharmacological interventions. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain management flowsheet indicated the resident had not complained of pain and was not assessed for pain since 1/15/22. The PRN [MEDICATION(S)] on the medication record indicated the resident's last dose of [MEDICATION(S)] was on 1/15/22 at 9:00 p.m. The pharmacy Controlled Drug Use record indicated the [MEDICATION(S)] was signed out as administered to the resident on 12/18/21 at 9:00 a.m., 12/23/21 at 8:00 p.m., 12/24/21 at 7:00 p.m., 12/25/21 at 1:00 a.m., 12/26/21 at 8:00 p.m., 12/27/21 at 4:00 a.m., 12/29/21 at 7:00 p.m., 12/30/21 at 3:00 a.m. and 7:00 p.m., 12/31/21 at 4:00 a.m. and 7:00 p.m., 1/1/22 at 4:00 a.m., 1/2/22 at 7:00 p.m., 1/3/22 at 4:00 a.m., 1/5/22 at 7:00 p.m., 1/6/22 at 4:00 a.m. and 7:00 p.m., 1/7/22 at 4:00 a.m. and 7:00 p.m., 1/8/22 at 4:00 a.m., 1/9/22 at 7:00 p.m., 1/10/22 at 5:00 a.m., 1/12/22 at 7:00 p.m., 1/13/22 at 5:00 a.m. and 7:00 p.m., 1/14/22 at 5:00 a.m., 1/15/22 at 7:00 p.m., 1/16/22 at 7 p.m., and 1/17/22 at 5:00 am., by LPN (Licensed Practical Nurse) 7. The incident investigation report, dated 1/17/22, it was observed that PRN medication [MEDICATION(S)] was being administered to the resident. Further review of narcotic sheets revealed the same pattern on another resident. Further investigation through laboratory work and resident interview revealed the resident was not receiving the medication. A review of the hospital laboratory report dated 1/18/22 indicated the resident was negative for [MEDICATION(S)], THC, [MEDICATION(S)], barbiturates, and [MEDICATION(S)], phencyclidine, cocaine, opiates, amphetamines, benzodiazepines, antidepressants, and barbiturate. During an interview, on 5/11/22 at 1:30 p.m., the DON indicated the nurse on duty did not document a pain assessment on Resident D. She indicated the nurse stated she gave the resident a pain pill at 5:00 a.m. The labs were drawn at 6:45 a.m. for [MEDICATION(S)] and the results came back negative. During an audit on the narcotics for the fentyl patches a pattern was observed by the ADON and an investigation was started. 4. The clinical record for Resident E was reviewed on 5/11/22 at 1:15 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 4/6/22, indicated the resident was cognitively intact. He required supervision for all for his ADL's. The care plan, dated 2/9/22, indicated the resident was at risk for pain related to peripherical vascular disease, right AKA (above the knee amputation), and pressure ulcer to the coccyx. Interventions included, but were not limited to, administer medications as ordered, assist with positioning for comfort, document effectiveness of PRN medication, notify the physician if pain was unrelieved or worsening, observe for adverse side effects of pain medication, observe for nonverbal signs of pain, and offer nonpharmacological interventions. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The pharmacy Controlled Drug Use record indicated the [MEDICATION(S)] was signed out as administered to the resident on 1/5/22 at 8:00 p.m., 1/6/22 at 12:00 a.m., 4:00 a.m., and 8:00 p.m., 1/7/22 at 12:00 a.m. and 4:00 a.m., 1/12/22 at 7:00 p.m., 1/13/22 at 8:00 p.m., 1/16/22 at 8:00 p.m., and 1/17/22 at 3:00 a.m. by LPN 7. The incident investigation report, dated 1/17/22, indicated while conducting a routine narcotic count audit it was noted that PRN medication [MEDICATION(S)] was being administered to the resident. Further review of narcotic sheets revealed the same pattern on another resident. Further investigation through laboratory work and resident interview revealed these residents were not receiving their medication. The incident timeline, indicated on 1/17/22 the physician requested a urinalysis on Resident E to determine if medication was in his system. Results of the laboratory screen revealed the resident was negative for this medication in his system. Staff interviewed Resident E was interviewed for the use of [MEDICATION(S)]. He was alert and oriented. The resident stated he had not asked for any pain medication for over 2 weeks and requested the medication be discontinues. During an interview, on 5/11/22 at 11:59 a.m., the ADON indicated during the whole process with the fentyl patches missing, they found the incident with LPN 7. They found the resident's having multiple PRN medication administrations that no one else was signing out. LPN 7 was the only one documenting as administering the narcotics. There was no pain assessment, no related documentation. The was no documentation the residents ever complained of pain. Resident E hadn't asked for any in weeks since he came back to the facility. RN 4 spoke with him and came to report it to the ADON. They drug tested Resident D, because she never made any indication that she was in pain. The ADON spoke to the nurse practitioner, asked for a drug screen, they collected it, checked it, and all of it came back negative. There was nothing in the Resident's system, and she'd had one according to the sign out sheet at 5:00 a.m. that morning. It would have stayed in her system at least 4 hours. The ADON had gotten there at 6:15 a.m., and as soon as LPN 7 left at 6:45 a.m. She collected the urine. The resident should have had at least some trace of the medication in her system from the night before and that morning. The Abuse Prohibition, Reporting, and Investigation policy, issued 9/2001, provided on 5/11/22 at 9:00 a.m., by the Executive Director, included, but was not limited to, . 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 . Misappropriation of Resident Funds or Property - Deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's property or money without the resident's consent . This Federal tag related to Complaint IN 969. The deficient practice was corrected, on 1/18/22, prior to the start of the survey and was therefore Past Noncompliance. The facility had completed staff education, medication review, medication audits, resident pain monitoring, and verification of staff education and misappropriation. This Federal tag relates to Complaint IN 969. 3.1-28(a)

Based on interview and record review, the facility failed to ensure a resident's (Resident B) representative was notified, in a timely manner, of an incident that occurred during a transfer for 1 of 3 residents reviewed for family notification. Findings include: The clinical record for Resident B was reviewed on 12/14/21 at 1:42 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident B's Power of Attorney (POA) for healthcare, dated 2/22/21, indicated there were two (2) family members co-assigned for the resident. The nurse's note, dated 12/2/21 at 10:12 a.m., indicated staff reported to LPN (Licensed Practical Nurse) 2 that, during a transfer, the resident had hit her leg on the bed rail. The leg was assessed for injury with no bruising or swelling observed. Resident B told LPN 2 that the left side of her body always hurt due to a previous stroke. The nurse practitioner was notified the resident hit her leg during a transfer and the resident's pain with no new orders provided. The clinical record lacked documentation of any family member notification of the incident that occurred during the transfer. During an interview on 12/14/21 at 5:12 p.m., LPN (Licensed Practical Nurse) 2 indicated she did not notify the family due to the resident did not have a healthcare POA, only a financial POA and the resident was her own responsible party. On 12/14/21 at 5:38 p.m , the Director of Nursing provided a current copy of the document titled Resident Change of Condition dated 9/2021. It included, but was not limited to, Policy .It is the policy of this facility that all changes in resident condition will be communicated to the .family/responsible party .Procedure .Non-Urgent Medical Change . This Federal tag relates to Complaints IN 809 and IN 842. 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure interventions were implemented to prevent the development and worsening of pressure ulcers, which resulted in the development of a stage II pressure ulcer, and a state III pressure ulcer which worsened to a stage IV for 1 of 4 residents reviewed for pressure ulcers. (Resident 130) Findings include: During an observation of wound care for Resident 130, on 6/16/21 at 1:00 p.m., RN 11 assisted LPN (Licensed Practical Nurse) 13, with wound care. She removed the ABD (Abdominal) pad, which was dated 6/16/21 from the left buttock. The area from hip to hip and coccyx to scrotum was reddened. The LPN indicated she felt the redness was [MEDICATION(S)]. The wound measured at 5.5 cm deep tunneling. 5.0 cm (centimeters) long x 4.5 cm wide x 3 cm deep. The LPN indicated the resident had been in and out of the hospital several times. His wound had almost healed when he went into the hospital this last time. It was worse now, but the color was good. The clinical record for Resident 130, was reviewed on 6/17/21 at 9:05 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, initiated 4/3/20 and revised 3/15/21, indicated the resident was at risk for further skin breakdown due to decreased mobility, history of pressure ulcers, decreased sensation related to [CONDITION(S)] and contraction, sitting in his chair/bed for long periods of time due to non ambulatory status. He needed extensive to total assist with activities of daily living. The aggravating factors for skin integrity issues included the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, on 4/3/20 and revised on 8/24/20, notify MD (medical doctor) of any changes in my skin. On 4/3/20 Skin condition will be observed at least twice a week by the CNA (Certified Nursing Aide) during showers and weekly by the charge nurse. The care plan, dated 6/16/21, indicated the resident had impaired skin integrity related to abrasion to the left posterior thigh and scrotum. The interventions included, but were not limited to, Assess wound weekly documenting measurements and description. Notify MD of worsening or no change in wound or for signs of infection. The care plan, dated 6/16/21 indicated the resident had impaired skin integrity related to an abrasion to the left posterior thigh. Interventions included, but was not limited to, on 6/16/2021 assess wound weekly documenting measurements and description. A nurse's note, dated 1/8/21 at 3:01 p.m., indicated the resident was sent to hospital per order. All wounds in Wound Tracc were closed at this time and they would reassess his skin when he readmitted . A nurse's note, dated 1/19/21 at 8:00 p.m., indicated the resident readmitted back to the facility with bilateral red buttocks. The Nursing admission assessment, dated 1/20/21, indicated the resident did not have any pressure injuries, or skin impairments to the buttocks. The Nurse Weekly Skin Assessment, dated 1/24/21 indicated no areas of skin impairment. The clinical record lacked documentation of any nursing skin assessments or shower sheets with skin impairment observations between 1/24/21 and 2/5/21. The Nurse Weekly Skin Assessment, dated 2/6/21, indicated See Wound Tracc. The Wound Tracc assessment, dated 2/8/21, indicated the resident had a new Stage II pressure injury to the right buttock, measuring 4 cm (centimeters) in length, by 2 cm in width by 0.2 cm in depth, with sanguineous drainage, [CONDITION(S)], and irregular edges, the MD and family were notified. A treatment order, dated 2/8/21, indicated to cleanse area to the right lower buttock with normal saline, pat dry. Apply skin prep to peri wound, apply [MEDICATION(S)] to wound bed and cover with dry dressing/bordered gauze. Change every 48 hours and prn soiled/dislodgement. every day shift every other day for the Stage II wound. The clinical record lacked documentation of any weekly skin assessments from 2/6/21 to 2/14/21. The shower skin observation, dated 2/12/21 indicated no new areas identified, however the buttocks on the skin tool was circled. The Nurse Weekly Skin Assessment, dated 2/14/21 and 2/20/21, did not identify any current or new pressure injuries. On 2/16/21 the Wound Tracc indicated a Stage III Pressure Ulcer to the left buttock was assessed and measured: 8.5 cm x 3.5 cm x 0.1 cm., with sanguineous drainage, [CONDITION(S)], and irregular edges with 30% granulation, 70% slough, yellow drainage, intact periwound, and irregular edges, which was not present on admission. The wound was observed on 2/8/21. The MD (Medical Doctor) and family were notified of the pressure ulcer discovery. A treatment order, dated 2/16/21, indicated to cleanse area on left lower buttock with wound cleanser, pat dry. Cover with border gauze daily every day shift for stage 2. The Wound Tracc document, dated 2/16/21, indicated the resident had a stage III pressure ulcer to the left buttock, measuring 8.5 cm in length by 3.5 cm in width by 0.1 cm in depth with 30% granulation, 70% slough, yellow drainage, intact periwound, and irregular edges, which was not present on admission. The family and physician were notified. A treatment order, dated 3/4/21, indicated to discontinue the current treatment to the buttocks and scrotum. New order to apply Dakin's 1/2 strength to right gluteal fold/scrotum after cleansing with wound cleanser & patting dry-cover with border gauze every day. A treatment order, dated 3/4/21, indicated to apply [MEDICATION(S)] to scrotum and buttocks two times daily after cleansing with wound cleanser and patting dry. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Tracc, dated 3/9/21, indicated the resident was admitted to the hospital on 3/7/21 due to blood in the suprapubic catheter. The Wound Tracc, dated 3/10/21, indicated the wound measured 6.5 cm x 5.0 cm x 1.2 cm upon readmission to the facility. A treatment order, dated 3/25/21, indicated to discontinue Dakin's treatment to left buttocks. Cleanse the wound with wound cleanser, pat dry. Apply [MEDICATION(S)] to wound base and pack with normal saline gauze, cover with a dry dressing. Change daily and as needed soiled or dislodgement. The Wound Tracc, dated 3/30/21, indicated the stage II to the right buttock had healed. A treatment order, dated 4/3/21, indicated to apply Dakin's 1/8 strength to left buttocks 2 times daily. Cleanse the wound with wound cleanser, pat dry, pack the wound with Dakin's soaked gauze, Wet to Dry dressing and cover with border gauze 2 times daily. Discontinue the [MEDICATION(S)]. A treatment order, dated 4/3/21, indicated to obtain a wound culture of the left coccyx wound. The Culture Report, dated 4/4/21, indicated the resident had beta hemolutis streptococcus group g heavy growth, [MEDICATION(S)] and [MEDICATION(S)] are drugs of choice, did not recommend a sensitivity testing. Result 2, mixed skin flora including multiple gram negative rods, heavy growth. Anaerobic culture- no growth times 72 hours. A treatment order, dated 4/5/21, indicated to discontinue the treatment to the left buttock. Start [MEDICATION(S)], pack with normal saline and cover with a dry dressing. The Wound Tracc, dated 4/7/21, indicated the wound measured 3.0 cm x 4.5 cm x 2.0 cm. The resident admitted to the hospital on 4/9/21 and returned to facility on 4/16/21. Debridement occurred at the hospital and a wound vac was placed. The nurse's note, dated 4/7/21 at 1:06 p.m., indicated IDT (Inter-disciplinary Team) to contact the surgeon for wound consult. A nurse's note, dated 4/9/21, indicated the culture report had been received and the MD was notified with no new orders. The wound care MD was unable to see the resident until the following Friday. A new appointment was scheduled for 4/14/21 at 10:00 a.m., and transportation was arranged. A nurse's note, dated 4/9/21, indicated the resident was sent to the hospital due to a sudden change in condition at the facility. He had a wound infection and a urinary tract infection and had received 2 doses of his prescribed antibiotic [MEDICATION(S)]. The hospital admission notes, dated 4/10/21, indicated the admission was due to worsening confusion, UTI (urinary tract infection), and enlarging decubitus ulcer stage IV on his left buttock. The resident received debridement of the pressure ulcer, by a general surgeon, during his hospitalization . The clinical records lacked documents of wound assessments between 4/16/21 and 4/21/21 after the resident's return from the hospital on 4/16/21. A nurse's note, dated 4/16/21 at 5:55 p.m., indicated the resident arrived via EMS to the facility. The wound vac was in place to the left buttock. A treatment order, dated 4/21/21, indicated to change the wound vac dressing every 3 days. May change wound vac dressing as needed for soilage or dislodgement. Apply barrier cream (pharmacy compound) to buttocks every shift. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated 5/23/21, indicated the pressure ulcer had worsened to 5 cm deep. The wound vac was not in place and a wet to dry dressing had been applied instead. A nurse's note, dated 5/24/21, indicated the wound vac was not on due to all of the supplies were not available. A wet to dry dressing was applied to the left buttock pressure ulcer. The clinical record lacked documentation of any notification to the physician of the wound vac not being applied per order. A nurse's note, dated 5/27/21, indicated the resident missed his 4/14/21 wound appointment an issue with EMS (Emergency Medical Service) being unable to transport. The resident had a Letter of Medical Necessity for Non-Emergency Stretcher Transportation, dated 5/13/21, and must be transported by EMS. The EMS were unable to transport the resident due to an emergency run. The facility had to reschedule the appointment and they had no other options. Before the next appointment, the resident was sent out to the hospital. The Wound Tracc, dated 6/1/21, indicated the wound to the left buttock, measured 12.0 cm x 4.0 cm x 4.0 cm. An IDT weekly wound monitoring note, dated 6/2/21 at 2:52 p.m., indicated the resident had a stage 4 full thickness wound to the coccyx with a wound vac present. He was followed by wound care and had an appointment scheduled on 6/3/21. A nurse's noted, dated 6/2/21 at 3:30 p.m., indicated a change in condition of mental status. The resident's doctor was notified and a new order to send the patient to a local hospital for evaluation and treatment as necessary. A nurse's note, dated 6/2/21 at 4:15 p.m., indicated the resident was transferred to a local hospital. At 7:04 p.m., a report was called to a local hospital emergency room for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A recent lab specimen was sent to another local hospital and no results had resulted at this time. A treatment order, dated 6/6/21, indicated a clarification for sacral/coccyx wound treatment: Cleanse area with NS (Normal Saline), pat dry. Apply 1/4 strength Dakin's soaked kerlix or rolled gauze gently packed to tunneled/undermining areas and wound bed. Cover with ABD BID (twice daily) and as needed. A treatment order, dated 6/6/21, indicated to check treatment to coccyx/sacral area for dislodgement/soilage every shift BID. A nurse's note, dated 6/8/21 at 3:34 p.m., indicated the resident returned to the facility. His coccyx wound continued with MRSA (methicillin-resistant staphylococcus aureus) in wound. The wet to dry dressing was performed. A nurse's note, dated 6/9/21 at 7:42 p.m., indicated the resident's IV [MEDICATION(S)] was infusing as ordered without any s/s of infection or infiltration at Midline site in LUE. A treatment order, dated 6/10/21, indicated to apply Dakin's quarter strength of D. 125% solution apply soaked gauze in 4 x 4 to right gluteal/buttock open area BID and as need until healed. A treatment order, dated 6/10/21, indicated to apply a mixture of AD ointment, [MEDICATION(S)] and [MEDICATION(S)] TID and peri area as needed for incontinence. May apply ABD pad as needed. A nurse's note, dated 6/10/21 at 11:37 a.m., indicated the family and doctor were notified of the resident's return to the facility. A nurse's note, dated 6/10/21 at 3:00 p.m., indicated new orders for treatments to peri-area, and the open areas. A nurse's note, dated 6/10/21 at 6:20 p.m., indicated the [MEDICATION(S)] was started as ordered. Patient and family were notified of new orders and reasoning. The nurse's note, dated 6/14/21 at 1:51 p.m., indicated the resident's wound bed was bright red with no redness noted to surrounding area. The nurse's note, dated 6/14/21 at 2:21 p.m., indicated on 6/8/21 at 4:43 p.m., a head to toe assessment of the stage IV wound measured 6 cm x 3 cm Exudate with moderate, foul smelling odor. Moderate. The undermining measurement was 0.3 cm at 12 o'clock. The tunneling measurement 0.3 cm at 9 o'clock. 100% granulation tissue was covered by red, friable granulation tissue. Rolled under/thickened edges. Skin surrounding the wound: Assess within 4 cm of wound edge:[CONDITION(S)] (redness)/blanchable; white or grey pallor. The wound vac was not present. The wound was declining. A treatment order, dated 6/15/21, indicated to discontinue order to apply mixture of AD ointment [MEDICATION(S)] and [MEDICATION(S)] to post peri area and excoriated areas on peri area, coccyx and thighs. Apply [MEDICATION(S)] oxide ointment to the excoriated areas on peri area, coccyx and thighs two times daily and as needed until healed. Flush PICC (peripherally inserted central catheter) line with 5 cc (cubic centmeters) NS every 8 hours. A treatment order, dated 6/16/21, indicated to discontinue the order to apply a mixture of A & D (vitamins a and d) ointment, [MEDICATION(S)] and [MEDICATION(S)] three times daily (TID) and peri area as needed for incontinence. May apply ABD pad as needed. Apply [MEDICATION(S)] oxide ointment 20% to excoriated area on peri area, coccyx and thighs TID and as needed. A treatment order, dated 6/16/21, indicated to cleanse the open area to the left ischium/upper thigh with NS. Apply [MEDICATION(S)] and cover with border gauze BID and as needed for 14 days. Check placement every shift for soilage/dislodgement. The clinical records lacked documentation of the physician being notified of the wound vac falling off of the wound or discontinuation of the wound vac. During an interview, on 6/17/21 at 10:13 a.m., CNA (Certified Nursing Aide) 12 indicated she did skin checks during showers. During an interview, on 6/17/21 at 9:45 a.m., the DON (Director of Nursing) indicated it was standard for the CNAs to turn and reposition the residents, so they do not document the task. Skin inspections are conducted weekly and if an issues was found the NP would be notified. During an interview, on 6/17/21 at 2:30 p.m., the DON indicated the order for the wound vac was discontinued in May. She could not indicate what the discontinuation date was. During an interview on 6/17/21 at 2:40 p.m., the DON there was an issue, the supplies were in her office, and staff had called her, and she told them to put a wet to dry dressing on it and notify the doctor and they would get the supplies out the next day. She indicated she knew it was not documented. They had supplies, they just might not have been available at that time. That was her error. She didn't know they were stored there. Notification to the physician should have been documented in the progress notes or in the events. During an interview, on 6/17/21 at 4:08 p.m., Medical Doctor 8 indicated the facility they didn't communicate to her when the wound vac was falling off and wasn't working. She didn't feel this caused the pressure ulcer to worsen. The resident has had multiple hospitalization s and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He has had hydronephrosis and an abscess of the kidney, causing infection in the abdomen. This has led to the development of the infection of his hip. His heavy smoking didn't help with wound healing either. During an interview, on 5/81/21 at 1:57 p.m., RN 11 indicated the resident had to be transported by EMS. He had a Medical Necessity Form filled out and no other method of transportation could be used. He was made an appointment the following week, but was sent to the hospital before he could sent to it. He was seen by wound care at the hospital. During an interview, on 6/18/21 at 2:48 p.m., the DON indicated she could not find the TAR (Treatment Administration Record) for April for the wound treatments. Someone came in and scanned them into the new program and those must have been lost. During an interview, on 6/18/21 at 3:25 p.m., the DON indicated the nursing staff needed education on skin assessments because they weren't being conducted like they should have been. The review on 6/18/21 at 9:44 a.m., of the Wound Assessment policy, last revised on October 2011, included, but was not limited to, .At a minimum, measure pressure ulcers on a weekly basis. Measure the length, width, and depth of the wound and record each in centimeters . The review on 6/18/21 at 9:44 a.m., of the Changes in Resident Status-Notification policy, revised on December 2018, included, but was not limited to, The facility will immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is .A need to alter treatment significantly, such as a need to discontinue an existing form of treatment due to adverse consequences, or to start a new form or treatment to deal with a problem . 3.1-40(a)(1)

Based on interview and record review, the facility failed to follow a resident/representative's wishes (Advance Directives) to resuscitate (Full Code) for 1 of 3 residents reviewed for advance directives. (Resident B) This deficient practice resulted in a resident not receiving life saving measures when respirations ceased and had the potential to affect 7 of 7 residents with a full code status. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:40 a.m. when staff failed to initiate Cardiopulmonary Resuscitation (CPR) on a resident (Resident B) with an active full code status. The Executive Director, Director of Nursing, and Nurse Consultant were notified of the Immediate Jeopardy on [DATE] at 4:50 p.m. The Immediate Jeopardy that began on [DATE] at 5:40 a.m. was removed on [DATE] at 1:00 p.m. when the facility completed staff education/inservices on the identification of full code residents and nurses response on [MEDICAL CONDITION] in relation to full code status and facility policy. The correction date was prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record for Resident B was reviewed on [DATE] at 10:44 a.m. [DIAGNOSES REDACTED]. The document titled Code Status Determination and signed by the resident's physician and representative on [DATE] included, but was not limited to, the following: Cardiopulmonary resuscitation (hereafter CPR) is a procedure that is done in an attempt to revive someone whose heart & respiration has stopped .The potential benefit would be restoration of heart & lung function .You have the right to decide if you want this procedure done should your heart & respirations stop. If you choose FULL CODE every measure to restore heart & respiratory function will be done .It is my desire that I be given: (box with a check mark} FULL CODE - CPR (Cardiopulmonary Resuscitation) . The physician order, dated [DATE] at 6:55 p.m., indicated the resident was to be a full code with chemical resuscitation only. The advance directive care plan included, but was not limited to, the following; I DESIRE TO BE A FULL CODE STATUS WITH CHEMICAL RESUSITATION (sic) .MY DESIRES WILL BE HONORED THROUGH NEXT REVIEW .MY DESIRES WILL BE HONORED BY NURSING .SHOULD I GO INTO A CARDIAC/RESPIRATORY ARREST, STAFF WILL INITIATE CPR AND CALL 911, EMS (EMERGENCY MEDICAL SERVICES) CAN DO CHEMICAL RESUSITATION (sic) . The nurse's note, dated [DATE] at 5:40 a.m., indicated the resident was found by the CNA (Certified Nursing Assistant) when she went to dress him and his pupils were dilated and non-reactive to light with no apical heart rate and no respirations. The nurse's note, dated [DATE] at 7:06 a.m., indicated when the resident was discovered his skin was cool to touch and his extremities were stiff. During an interview on [DATE] at 1:08 p.m., CNA 5, who found the resident on [DATE], indicated she had last seen the resident at 3:30 a.m. and had heard Resident B talking to his roommate until about 4:30 a.m. Some where between 5:20 a.m. and 5:40 a.m., she entered the resident's room to get him up and he was lying in bed with his eyes and mouth open. She felt his face, which was cool to touch and his body was warm from his neck down. She went and got LPN (Licensed Practical Nurse) 6, and he checked the resident's eyes, pulse, and listened to see if his heart was beating. He touched different areas of his face and then went back to the nurse's station. During an interview on [DATE] at 1:35 p.m., LPN 6 indicated he assessed Resident B, found no pulse or respirations, pupils flat, his extremities were somewhat stiff, and that he did not initiate CPR because the resident was deceased . During an interview on [DATE] at 3:20 p.m., the Director of Nursing indicated if a resident is non-responsive with no pulse, CPR should be initiated, 911 called, and the nurses are not allowed to make the decision whether or not to initiate CPR if the resident is a full code. On [DATE] at 10:25 a.m., the Administrator provided a current copy of the document titled Full Code Directives, dated ,[DATE]. It included, but was not limited to, the following: Policy: It is the policy of this facility that CPR (cardio-pulmonary resuscitation) will be performed on all residents who have indicated that they wish to receive CPR. CPR will be initiated as soon as the nurse has assessed that the resident does not have respirations or a pulse .6. The nurse will initiate CPR immediately when he/she observes a resident who has been designated as a full code without respirations and pulse EVEN IF THE NURSE BELIEVES THAT CPR WOULD NOT BE SUCCESSFUL BASED ON HIS/HER ASSESSMENT OF THE RESIDENT'S CONDITION .7. 911 will be called by another staff member as directed by the nurse .9. CPR will be continued until a physician stops the procedure until an EMT (emergency medical technician) or someone as qualified as or more qualified than the nurse relieves the nurse, or until the victim regains adequate circulation and respirations The past noncompliance Immediate Jeopardy that began on [DATE] at 5:40 a.m. The Immediate Jeopardy was removed and deficient practice corrected by [DATE] at 1:00 p.m. after the facility implemented a systemic plan that included the following: all staff completed education/inservices on the identification of full code residents and nurses response on [MEDICAL CONDITION] in relation to full code status and facility policy. All residents were audited for code status. This Federal tag relates to Complaint IN 006 3XXX,[DATE](4)(B)(7)

Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse when a staff member raised her voice during a conversation with a resident for 1 of 3 residents reviewed for abuse. This deficient practice had the potential to affect 33 of 33 residents residing in the facility. (Resident #B) Findings include: The clinical record for Resident #B was reviewed on 8/2/16 at 2:20 p.m., the [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated 6/21/16, indicated Resident #B had a BIMS (Brief Interview of Mental Status) score of 13, which signified intact cognition. The MDS also indicated it was very important to him/her to attend his/her favorite activities. The ISDH (Indiana State Department of Health) reportable, dated 7/7/16 at 3:45 p.m., included, but was not limited to, the following: .Residents Involved .(Resident #B's name) .Staff Involved .(Administrators name) .Brief Description of Incident .7/7/2016 during a meeting in the Administrator's office involving the resident, Administrator and DON (Director of Nursing), between approximately 3:10PM to 4PM, the resident and Administrator engaged in a heated' conversation. Both the resident and Administrator started to cry. The DON calmed the situation at which time the resident and Administrator apologized to each other. Once the resident left the Administrator's office (sic) the Director of Operations, (name of Director of Operations), was notified to the incident immediately .Immediate Action Taken .Resident has no immediate family and is considered her own responsible party. Attending physician notified of incident. The Administrator has been put on suspension, pending the results of the investigation . The nurses note, dated 7/7/16 at 8:30 p.m., included, but was not limited to, the following: .Resident involved this afternoon in a verbal incident with a staff member . The nurses note, dated 7/8/16 at 3:19 p.m., included, but was not limited to, the following: .This nurse met with resident this am (a.m.) to assess for any further issues or concerns, or s/sx (signs/symptoms) of emotional distress r/t (related to) yesterday's (sic) incident .reports .afraid .going to have to leave the facility . The typed statement from the DON, dated 7/7/16 and untimed, included, but was not limited to, the following: At approximately 3:05 PM, (Administrators name) came to the nurses station and said (sic) (DON's first name) (sic) I need you in my office now please. Upon entering Administrator's office (sic) Resident (Resident #B's name) was sitting in wheel chair. Resident made comment (sic) I guess I'll be in the pink book tomorrow.After I shut the door and sat down, (Administrator's first name) looked at (Resident #B's first name) and said (sic) We are here because you cannot behave the way you did in the dining room just now. (Slightly raised voice) (Resident #B's first name) replied (sic) so I can't voice my opinion like everyone else. (Raised voice) (Administrator's first name) and (Resident #B's first name) went back and forth multiple times, voices escalating, regarding the issues brought up at the Meet-and-Greet meeting. After the conversation started to escalate (sic) I looked at both (Resident #B's first name) and (Administrator's first name) and said (sic) stop, please calm down .(Administrator's first name) made comments such as (sic) you cannot sit in there at that meeting and tell me that I'm not fit to do this job or that I don't know what I'm doing. The conversation began to escalate again with voices raised .I looked at (Administrator's first name) and said (sic) (Administrator's first name) stop, you need to stop (sic) (Administrators first name) turned around in her desk chair and faced the opposite direction. I turned to (Resident #B's first name) to try to calm her down .I reassured (Resident #B's first name) that most of the concerns that she had brought up in the meeting in the dining room and the meeting with (Administrator's first name) in the office are not of her concern and not to get upset with something she's not involved with The typed statement for the Administrator, dated 7/7/16 and untimed, included, but was not limited to, the following: .walking back to my office, I saw (Resident #B's first name and initial of last name) .and said to (him/her), I want to talk with you in the office .I started the meeting by telling (Resident #B's first name) that (his/her) behavior at the meeting was not ok .(Resident #B's first name) said something about me demanding that (he/she) come to my office and I replied that I asked you to come to my office. I replied that I didn't mean for (himher) to feel like that .(DON's first name) made a facial gesture and said (sic) (Administrator's first name) that made me consider, am I getting louder with my voice .Later in the conversation (sic) (Resident #B's first name) said (he/she) had hurt feelings and was tearful .After (Resident #B's first name) left the office, I said to {DON's first name), that was not good .I then realized that my raising my voice in our meeting (sic) that this could be construed as very poor conduct or bordering on verbal abuse . The typed interview, by the Director of Operations, for Resident #B, dated 7/7/16 and untimed, included, but was not limited to, the following: .I asked the resident (Resident #B) to tell me what happened after the Group Meeting .Administrator said (sic) I want to see you in my office now. (sic) When I asked resident (Resident #B) what happened in the private meeting (sic) (he/she) said it got heated. (sic) I asked the resident (Resident #B) if (he/she) felt intimidated by the Administrator. Resident (Resident #B) responded (sic) Yes, I'm afraid she will ask me to leave . During an interview on 8/2/16 at 3:30 p.m., Resident #B indicated the Administrator tapped her finger on the hydration cart and stated, I want you in my office now. Resident #B indicated the Administrator went and got the DON. Resident #B further indicated the Administrator stated, Don't you ever talk to me like that or question my authority again! Resident #B indicated he/she enjoyed the Meet-and-Greets, but was not attending any more of them because he/she got in trouble the last time he/she went. Resident #B also indicated he/she has been trying to lay low since the incident occurred. During an interview on 8/3/16 at 9:15 a.m., Resident #C indicated, about 3 weeks ago, the Administrator became overwhelmed and ended the Meet-and-Greet. Resident #C indicated the Administrator and (Resident #B's first name) got a little loud, but that was in her (Administrator) office. Resident #C indicated the door was shut and I could still hear them in the dining room. Resident #C further indicated it seemed like they were arguing and it was getting out of hand. During an interview on 8/3/16 at 10:09 a.m., the DON indicated, on 7/7/16, the Administrator asked her to come to her office, however, she was unaware of why. The DON indicated when she got to the Administrator's office, Resident #B was entering the office and she assisted him/her due to his/her wheel chair use. The DON indicated the Administrator told Resident #B, this type of behavior will not be tolerated in this type of setting (referring to the Meet-and-Greet). The DON indicated the conversation, after about 5 or 10 minutes, got heated. The DON indicated she knew the Administrator was upset and not backing down, so she told the Administrator to stop. The DON indicated the Administrator turned away and was crying hysterically and had lost it. The DON further indicated the Administrator's voice and tone warranted being reported and her tone was probably not becoming of an Administrator. During an interview on 8/3/16 at 11:00 a.m., Resident #D indicated the Administrator got her feelings hurt at the Meet-and-Greet about 3 weeks ago and was really upset. Resident #D also stated, I don't know why she got so upset. I thought that was why we had the meetings, to talk about concerns. During an interview on 8/3/16 at 3:32 p.m., the Administrator indicated she was leading the Meet-and-Greet that occurs twice monthly. The Administrator indicated Resident #B had multiple complaints and was wanting other residents to support him/her. The Administrator indicated Resident #B was mad and she was concerned that Resident #B and Resident #C were going to get into it. The Administrator indicated she tried to end the meeting, however, Resident #B kept on and was loud, angry and accusatory. The Administrator indicated she thought Resident #B's behavior care plan was to tell him/her when his/her behavior was unacceptable so she asked Resident #B to come to her office. The Administrator indicated she went and asked the DON to come to her office. The Administrator indicated she told Resident #B his/her behavior was not ok, and the Meet-and-Greet was not the time or place for the discussion Resident #B wanted to have. The Administrator indicated the conversation went back and forth and it did not go good. The Administrator indicated she had a freak out moment and thought this isn't how this was suppose to happen. The Administrator indicated she heard the DON say stop. The Administrator indicated she was tearful, torn up and questioned herself regarding her tone of voice, at which point, she turned away and tried to analyze her emotions. The Administrator further indicated she thought she was following Resident #B's plan of care, and stated, I was wrong, I messed up. I knew immediately things could have been handled differently. On 8/3/16 at 10:35 a.m., the Administrator provided a current copy of the document titled, Resident Mistreatment, Neglect, Abuse & Misappropriation of Property, dated February, 2015. It included, but was not limited to, the following: .Standard .Residents will be free from mistreatment .abuse .verbal .Definitions .Abuse .intimidation .This presumes that instances of abuse of all residents .cause physical harm, or pain or mental anguish .Verbal Abuse .oral .or gestured language . This Federal tag relates to Complaint IN 617 3.1-27(b)

Based on interview and record review, the facility failed to ensure policy and procedures were followed in ensuring a resident was free from verbal abuse by a staff member for 1 of 3 residents reviewed for abuse. This deficient practice had the potential to affect 33 of 33 residents residing in the facility. (Resident #B) Findings include: The typed statement for the Administrator, dated 7/7/16 and untimed, included, but was not limited to, the following: .walking back to my office, I saw (Resident #B's first name and initial of last name) .and said to (him/her), I want to talk with you in the office .I started the meeting by telling (Resident #B's first name) that (hisher) behavior at the meeting was not ok .(Resident #B's first name) said something about me demanding that (he/she) come to my office and I replied that I asked you to come to my office. I replied that I didn't mean for (him/her) to feel like that .(DON's first name) made a facial gesture and said (sic) (Administrator's first name) that made me consider, am I getting louder with my voice .Later in the conversation (sic) (Resident #B's first name) said (he/she) had hurt feelings and was tearful .After (Resident #B's first name) left the office, I said to {DON's first name), that was not good .I then realized that my raising my voice in our meeting (sic) that this could be construed as very poor conduct or bordering on verbal abuse . The nurses note, dated 7/7/16 at 8:30 p.m., included, but was not limited to, the following: .Resident involved this afternoon in a verbal incident with a staff member . The clinical record for Resident #B was reviewed on 8/2/16 at 2:20 p.m., [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated 6/21/16, indicated Resident #B had a BIMS (Brief Interview of Mental Status) score of 13, which signified intact cognition. During an interview on 8/2/16 at 3:30 p.m., Resident #B indicated the Administrator tapped her finger on the hydration cart and stated, I want you in my office now. Resident #B indicated the Administrator went and got the DON. Resident #B further indicated the Administrator stated, Don't you ever talk to me like that or question my authority again! During an interview on 8/3/16 at 9:15 a.m., Resident #C indicated, about 3 weeks ago, the Administrator became overwhelmed and ended the Meet-and-Greet. Resident #C indicated the Administrator and (Resident #B's first name) got a little loud, but that was in her (Administrator) office. Resident #C indicated the door was shut and I could still hear them in the dining room. Resident #C further indicated it seemed like they were arguing and it was getting out of hand. During an interview on 8/3/16 at 10:09 a.m., the DON indicated, on 7/7/16, the Administrator asked her to come to her office, however, she was unaware of why. The DON indicated when she got to the Administrator's office, Resident #B was entering the office and she assisted (him/her) due to (his/her) wheel chair use. The DON indicated the Administrator told Resident #B, this type of behavior will not be tolerated in this type of setting (referring to the Meet-and-Greet). The DON indicated the conversation, after about 5 or 10 minutes, got heated. The DON indicated she knew the Administrator was upset and not backing down, so she told the Administrator to stop. The DON indicated the Administrator turned away and was crying hysterically and had lost it. The DON further indicated the Administrator's voice and tone warranted being reported and her tone was probably not becoming of an Administrator. During an interview on 8/3/16 at 3:32 p.m., the Administrator indicated she was leading the Meet-and-Greet that occurs twice monthly. The Administrator indicated Resident #B had multiple complaints and was wanting other residents to support (him/her). The Administrator indicated Resident #B was mad and she was concerned that Resident #B and Resident #C were going to get into it. The Administrator indicated she tried to end the meeting, however, Resident #B kept on and was loud, angry and accusatory. The Administrator indicated she thought Resident #B's behavior care plan was to tell (him/her) when (his/her) behavior was unacceptable so she asked Resident #B to come to her office. The Administrator indicated she went and asked the DON to come to her office. The Administrator indicated she told Resident #B (his/her) behavior was not ok, and the Meet-and-Greet was not the time or place for the discussion Resident #B wanted to have. The Administrator indicated the conversation went back and forth and it did not go good. The Administrator indicated she had a freak out moment and thought this isn't how this was suppose to happen. The Administrator indicated she heard the DON say stop. The Administrator indicated she was tearful, torn up and questioned herself regarding her tone of voice, at which point, she turned away and tried to analyze her emotions. The Administrator further indicated she thought she was following Resident #B's plan of care, and stated, I was wrong, I messed up. I knew immediately things could have been handled differently. On 8/3/16 at 10:35 a.m., the Administrator provided a current copy of the document titled, Resident Mistreatment, Neglect, Abuse & Misappropriation of Property, dated February, 2015. It included, but was not limited to, the following: .Standard .Residents will be free from mistreatment .abuse .verbal .Definitions .Abuse .intimidation .This presumes that instances of abuse of all residents .cause physical harm, or pain or mental anguish .Verbal Abuse .oral .or gestured language . This Federal tag relates to Complaint IN 617 3.1-28(a)