Every finding on record at Lane House, The

Based on interview and record review, the facility failed to ensure a cognitively intact resident with new onset altered mental status and vomiting was monitored and treated timely resulting in the resident having a delay in treatment and death for 1 of 3 residents reviewed for quality of care (Resident B). The immediate jeopardy began on [DATE] at 10:46 a.m. when a cognitively intact resident had new onset symptoms of coughing, coffee ground emesis, complaints of feeling drunk, and staggering while ambulating. The physician ordered a Complete Blood Count (CBC) that was not obtained. The record lacked documentation of the resident's condition on [DATE]. On [DATE] the resident had altered mental status, dizziness, abdominal pain, and his pulse was 128. The physician ordered a STAT (immediately) chest x-ray, a STAT abdominal x-ray, and STAT CBC with differential for cough, nausea, vomiting, abdominal pain, altered mental status, weakness, and dizziness. The STAT CBC was not obtained prior to the resident's death. On [DATE] at 6:03 p.m. the resident continued vomiting yellow liquid emesis, continued with altered mental status, and had a temperature of 99.1 degrees Fahrenheit (F). The physician ordered Zofran 4 milligrams (mg). The x-ray results, dated [DATE] at 4:35 p.m., indicated a colonic ileus (blockage) and small right pleural effusion (accumulation of excess fluid between lung and chest wall). The physician was notified and ordered stool softeners and MiraLAX. On [DATE] at 9:55 am, the DON documented that the CNA went into the resident's room at 4:48 am and found the resident had bile like emesis. The resident became unresponsive, CPR was initiated, and the resident died at the facility. The resident's family indicated they thought the resident had been sent to the hospital. The record lacked documentation of assessments, follow-up vital signs, or nursing interventions on [DATE], [DATE], [DATE], or [DATE]. The Executive Director (ED), and Regional [NAME] President (RVP) were notified of the immediate jeopardy at [DATE] at 11:28 a.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Findings include:A confidential concern during the survey process indicated Resident B had a sudden change in his health status, and the physician ordered the resident to go to the hospital. Despite the resident continuing to get worse, the Executive Director (ED) and Director of Nursing (DON) refused to allow the resident to go, and the resident subsequently died. Resident B's clinical record was reviewed on [DATE] at 2:33 p.m. Diagnoses on Resident B's profile included prostate cancer, lung cancer, insulin dependent diabetes mellitus (DM), gastro-esophageal reflux disease (GERD), and chronic obstructive pulmonary disease (COPD). A care plan, dated [DATE], indicated Resident B was at risk for rehospitalization due to current health status, COPD, repeated falls, age-related physical debility and delirium. Interventions included discuss with the resident/family his history of hospitalization, complete labs as ordered, and staff would provide timely communication to the physician regarding any change in the resident's condition. An Indiana Physician Orders For Scope Of Treatment (POST), dated [DATE], included if the resident had no pulse and was not breathing, then attempt CPR. If the resident had a pulse and was breathing or had a pulse and was not breathing, then attempt limited additional interventions: stabilization of medical condition. In addition to care described in Comfort Measures and use of medication treatment for stabilization, the following was allowed IV fluids (hydration) and cardiac monitor as indicated to stabilize medical condition, may use basic airway management techniques and non-invasive positive-airway pressure, do not intubate, transfer to hospital if indicated to manage medical needs and comfort, and avoid intensive care if possible. The resident approved the use of antibiotics consistent with his treatment goals. The resident allowed defined trial period of artificial nutrition by tube. A physician's order, dated [DATE], ordered ondansetron (Zofran) (a medication to treat nausea and vomiting) 8 milligrams (mg), 1 tablet by mouth every 8 hours as needed for nausea and vomiting. The active physician's order was not documented as administered on [DATE], [DATE], [DATE], or [DATE]. A physician's order, dated on [DATE], ordered Meclizine HCI (antihistamine and anticholinergic medication used to treat vertigo and prevent nausea, vomiting, and dizziness) 12.5 mg, 1 tablet by mouth three times daily as needed. The active physician's order was not documented as administered on [DATE], [DATE], [DATE], or [DATE]. A quarterly Minimum Data Set (MDS) assessment, completed on [DATE], assessed Resident B as being cognitively intact. He was independent with eating, bed mobility, transfers, ambulation, did not use mobility devices, required substantial/maximum assistance with toileting hygiene, and had no recent falls since his admission. The resident had no skin breakdown. The resident routinely ate 75 - 100% of his meals and had gained a significant amount of weight (5% or more in the last month or 10% or more in the last 6 months). Review of Resident B's clinical record, dated [DATE] - 31, 2025, lacked documentation of resident complainants related to dizziness, confusion, signs of altered mental status, abdominal pain, constipation, or gastrointestinal distress to include nausea or vomiting. A nursing progress note, dated [DATE] at 10:46 a.m., indicated Resident B started coughing and had a small amount of coffee ground emesis. The resident complained of feeling drunk and staggering when he ambulated. A nursing progress note, dated [DATE] at 1:44 p.m., indicated Resident B's physician ordered a complete blood count (CBC) lab for gastrointestinal (GI) upset and vertigo, and he ordered medication changes to include discontinue diclofenac an anti-inflammatory pain reliever and to start protonix (medication to treat and heal stomach acid) 40 milligrams (mg) daily for gastrointestinal (GI) upset. The resident's record lacked documentation the CBC was obtained. Vital Signs, dated [DATE] at 2:37 a.m., indicated the resident's blood pressure (BP) was 100/65, pulse (P) was 98 beats per minute, respirations (R) was 14, and temperature (T) 96.3 degrees Fahrenheit (F). The record lacked documentation of the resident's condition on [DATE]. A nursing progress note, dated [DATE] at 8:06 a.m., indicated Resident B continued to have nausea and vomiting, and was having confusion, dizziness, complained of abdominal pain, and his pulse was 128 beats per minute. The physician ordered a STAT (immediately) chest x-ray, STAT abdominal x-ray, and a STAT CBC. The resident's record lacked documentation the STAT CBC obtained prior to the resident's death. Vital Signs, dated [DATE] at 8:06 a.m., indicated BP was 132/82, P was 128, R was 20, T was 98.9 degrees F. The clinical record lacked documentation of a Change in Resident Condition assessment or Stop and Watch Early Warning tool had been completed per the facility protocol. A contracted laboratory request daily log, dated [DATE] at 8:00 a.m., indicated an order for Resident B was input into the electronic system for a CBC. The DON indicated the order lacked documentation to specify it was a STAT order. A mobile x-ray report, date of service [DATE], included:a. Results for the abdomen X-ray for unspecified nausea and vomiting and altered mental status indicated mild to moderate colonic stool burden contributing at least in part to a mild ascending and transverse colonic ileus [implies a temporary, functional interruption of bowel motility or paralytic ileus where the intestinal muscles become temporarily paralyzed and stop moving].b. Results for the chest X-ray for cough, nausea and vomiting, and altered mental status indicated the resident had a small pleural effusion (buildup of excess fluid in the pleural place between the lungs and chest wall). A nursing progress note, dated [DATE] at 6:03 p.m., indicated Resident B continued to have yellow liquid emesis, his confusion remained, and he had a temperature of 99.1 degrees F. A nursing progress note, dated [DATE] at 6:44 p.m., indicated the physician gave new orders to include sennosides-docusate sodium (a combination laxative/stool softener) 8.6-50 mg twice daily for constipation, Miralax powder (a bulk laxative) twice daily, and doxycycline (antibiotic) 200 mg twice daily for 10 days for pleural effusion. Vital Signs, dated [DATE] at 8:03 p.m., indicated temperature of 99.1 degrees F. A nursing progress note by the Director of Nursing (DON), dated [DATE] at 9:55 a.m., indicated Certified Nursing Aides (CNAs) went into Resident B's room around 4:48 a.m. Licensed Practical Nurse (LPN) 5 went into the room to check on the resident as he had not been feeling well. The resident had vomited bile-like emesis into the trash can and on the left side of the bed. Resident B went unresponsive while the nurse was in room, with no pulse and no respirations. The code status was verified by a second nurse and Cardiopulmonary Resuscitation (CPR) was started immediately at 4:50 a.m. Two rounds of CPR were completed by staff, and EMS arrived around 4:56 a.m. and took over. EMS stopped CPR at 5:20 a.m. The resident had expired. The daughter, ED, DON and Regional Director of Clinical Services (RDCS) were notified. At 6:20 a.m., the Coroner was in possession of the body as no funeral arrangements had been made. The clinical record lacked documentation Resident B had been assessed by a nurse after 7:10 p.m. on [DATE] when a new order for Zofran 4 mg was administered. The clinical record, dated [DATE], [DATE], or [DATE], lacked documentation Resident B had been administered Zofran 8 mg or Meclizine 12.5 mg. The clinical record lacked documentation Resident B's emergency contact had been contacted by facility nursing personnel when he had a change in condition on [DATE], with updates on his condition and treatment orders, or that the resident or resident representative were consulted on a preference to be transferred to the hospital for evaluation and treatment. Confidential interviews were conducted during the survey: a. The employee indicated, they had been told the resident was ill but was surprised when he died. They did not know details but had been informed he had generally not felt well and had some vomiting. There was an unidentified staff member who had been upset when the resident was not sent to the hospital for evaluation, and they'd been told upper management would not allow him to go. When a resident became ill, nurses had critical system pathways for guidance on managing the resident in the facility. The corporate nursing consultant then had to be called for approval before any resident could be sent to the hospital for evaluation and treatment. The employee indicated corporate staff had the ability to stop any physician's order they did not feel necessary to include orders for sending a resident to the hospital for evaluation or an antibiotic. b. The employee indicated on [DATE] the resident started vomiting thick, stringy, coffee ground looking black stuff, that days later turned into just throwing up bile. The attending physician had been notified and gave orders on [DATE] and [DATE]. They could not remember if the physician had given orders to send the resident to the emergency room (ER) for evaluation, but often he would instruct nurses to defer to resident or family wishes. The DON had been made aware and kept appraised of the resident's new and deteriorating symptoms. The DON gave instruction to wait for physician's orders before sending the resident to the hospital. They indicated they were not sure if the resident had specifically been told he was being sent out to the hospital. On [DATE] at 8:00 a.m., STAT labs had been ordered for Resident B that were supposed to be completed within 8 hours, but a lab technician did not present to the facility to draw the labs until [DATE] around 9:00 a.m. after Resident B had died.c. The employee indicated they had not worked directly with Resident B recently while he was ill. But symptoms to include vomiting that started with coffee ground emesis and persisted for several days with altered mental status and dizziness with inability to safely ambulate would warrant being seen in the ER for more advanced assessment, testing, and treatment. To their knowledge, the resident's record did not have documentation to indicate if he or the resident representative had been consulted on Resident B's wishes for treatment. STAT labs meant urgent and were supposed to be completed as soon as possible. During an interview on [DATE] at 9:58 a.m., Resident B's daughter indicated although she lived out of state, she had been Resident B's emergency contact. She and the resident texted each other often and had kept in contact right up until the day before he died. A few days before the resident passed, he told her he could not walk anymore, was in a wheelchair (WC), and vomiting black stuff. Resident B was confused enough that he could not answer basic questions such as his age. The daughter called an unidentified nurse at the facility, and when she asked if a urinary analysis had been completed to check for an infection as she knew this had caused him to be confused in the past, the nurse replied she was not sure what good it would do to as he was already on an antibiotic for a finger infection and he had not felt well for a few days. The daughter indicated she understood Resident B had no Power of Attorney, but she was his emergency contact and felt like she should have been notified of his condition once he became confused. The daughter indicated, in her opinion, the nurse did not relay a sense of urgency when describing the resident's current state of decline but instead repeated several times that he had an upcoming oncology follow-up appointment scheduled. On [DATE], Resident B had texted her 3 times and stated he was being sent to the hospital. She had reminded him to take his cell phone and charger so she could keep in contact. The daughter indicated, in her opinion, her father's sudden change in mental status and sudden health decline with coffee ground emesis and vomiting that lasted multiple days should have warranted at least a hospital visit for assessment. She continued to have questions that included why he was not sent to the hospital, and why the facility staff had not been more concerned. Screen shots of text message correspondence between Resident B and his daughter, dated and timestamped included,On Friday [DATE] at 10:34 a.m.:Resident: I got to be in a wheelchair for awhile.Daughter: Why? On Friday [DATE] at 11:51 a.m.:Daughter: I talked to your nurse she said you go back to cancer doctor soon. You need to tell them or have them write something about you vomiting black s--- .that would be your cancer. And I requested a urine sample. But she said you just got off antibiotics for infection in your fingers and you were sick.Resident: I;m sorry freaking okDaughter: Dad don't be sorry I just want you to be ok.Resident: noDaughter: no whatResident: ok I don't sDaughter: your not making sense dad. Maybe you need to take a nap On Friday [DATE] at 3:26 p.m.:Resident: ok nite. I hope. I too. A two hour On Saturday [DATE] at 6:41 a.m.:Resident: Nurse said I'm not going anywhere she taking me h hospitalDaughter: So your going to hospitalResident: yesDaughter: goodResident: coohwDaughter: WhatResident: Ganmherehome hereDaughter: your not making any senseResident: Please come hereDaughter: Dad I can't its alright. They will figure out what is going on. Why are they sending you to hospitalResident: shakeypDaughter: I guarantee you have a UTIResident: he will get itDaughter: Make sure you take your phone and charger. They will find out what is going on with you and why your puking black stuffResident: okDaughter: Are they sending you by ambulanceResident: Yy. YesDaughter: Ok let me know when you get thereResident: okayDaughter: I love you. Am I still on your paperwork.Resident: love you. On Saturday [DATE] at 10:12 a.m.:Daughter: R you at the hospitalResident: am. Sed g the time lijj. HuuDaughter: whatResident: did as ask from no On Saturday [DATE] at 2:16 p.m.:Daughter: what are you doing During an interview on [DATE] at 12:42 p.m., Resident B's daughter indicated she had not received a response to her last text on [DATE] at 2:16 p.m. and thought her father might be sleeping. The daughter indicated she assumed Resident B had been sent to the hospital and waited for a hospital follow report that never came. Instead, she got a call that he had died the next morning. During an interview on [DATE] at 3:30 p.m., the DON indicated a STAT CBC with differential (a comprehensive blood test to help diagnose infections, anemia, inflammation, leukemia, and monitor overall health) ordered on [DATE] at 8:15 a.m., was not completed before Resident B died on [DATE] at approx. 4:48 a.m. She was unsure why the labs had not been completed. The resident's clinical record lacked documentation the laboratory had been called by nursing staff regarding the STAT lab when they had not shown up on [DATE]. During an interview on [DATE] at 10:37 a.m., Licensed Practical Nurse (LPN) 6 indicated all medical records and correspondence with a physician's office were scanned into a resident's electronic medical record, the facility did not retain hard paper charts or files of resident documents. A nurse could contact a physician's office by phone call, but faxed documents were all scanned. LPN 6 indicated she had looked for faxed correspondence regarding Resident B to his primary physician, and there were no further documents available that could not already be seen in the residents electronic clinical record. During an interview on [DATE] at 10:50 a.m., a representative for the primary care physician indicated routine non-urgent correspondence between the nursing facility and physician usually happened via fax, and a copy of the fax was kept in the resident's medical file at the physician's office. Urgent matters or a resident change in condition correspondence usually happened by phone. The last documentation for Resident B was dated [DATE] when the resident was seen by the physician at the nursing facility. During an interview on [DATE] at 11:34 a.m., LPN 5 indicated he had worked the night shifts of [DATE], [DATE], [DATE] and cared for Resident B on those nights. On [DATE], LPN 5 was given report that Resident B had an episode of emesis after dinner and was having some confusion. He did not witness Resident B having confusion, and to him the resident seemed to be himself. On [DATE] around 6:30 p.m., within the first 30 minutes of the shift starting, Resident B reported throwing up, and the nurse observed yellowish bile stomach content partially in the trash can and on the bed. The primary care physician was notified and gave an order for Zofran 4 mg, which LPN administered. LPN 5 indicated, on [DATE] at approximately 4:30 a.m., he had gone into Resident B's rooms to check on him before his shift ended and could hear a CNA speaking with the resident. By the time the nurse cleared the curtain as he entered the room, Resident B went unconscious with no pulse or respirations. LPN 5 indicated he initiated CPR, had one of the CNA's call 911, and another CNA get the crash cart. The ambulance arrived at the facility quickly and EMT's took over CPR. The EMTs applied a [NAME] machine (an automated, portable device that delivers chest compressions for patients in cardiac arrest), administered 3 rounds of epinephrine (used to stimulate the heart and help restore a heartbeat), intravenous (IV) fluids, and intraosseous access (IO - where the EMT drills into the chin bone to deliver fluids) was obtained. Resident B was coded for 30 minutes without ever getting a response. Resident B's daughter was notified, and when it was determined funeral arrangements had not been made previously, the coroner was called to take the body. LPN 5 indicated it was his routine to document resident information towards the end of his shift. He had checked on Resident B during the night but had not yet documented in the clinical record when the resident passed away around 4:35 a.m. During an interview on [DATE] at 2:18 p.m., a representative for the primary care physician indicated there was no fax documentation from the nursing facility in Resident B's medical file from [DATE], [DATE], [DATE], or [DATE]. The primary care physician indicated to her, he had been informed when Resident B died but thought someone told him the resident passed at the hospital. Reviewed Resident B's clinic record with the ED and DON on [DATE] at 4:05 p.m. The clinical record lacked documentation for abdominal assessments, nursing interventions for nausea and vomiting, consistent monitoring of vital signs, neurological assessments related to the sudden altered mental status, documentation of the emergency contact being notified of the resident's change in condition, there was no documentation to indicate Resident B had been asked for his preference of going to the ER, and a STAT CBC was not completed. The DON indicated she had been aware of Resident B's change in condition, she knew he was having emesis, but it was small amounts and she had not observed him to be confused as he answered basic questions appropriately. The primary care physician had not given orders and therefore Resident B was not sent to the ER. The DON indicated she had no further information to provide. If assessments and documentation were not found in Resident B's electronic medical record, it had not been done. The ED indicated staff were supposed to document resident conditions and care in the clinical record, otherwise they could not prove care and interventions had been provided. On [DATE] at 3:02pm the DON provided a Gastrointestinal (GI) Symptoms Care Path, dated 2011. The pathway indicated, for new or worsening GI symptoms or signs (i.e. nausea and/or vomiting), take vital signs to include temperature, blood pressure, respirations, oxygen saturations, and a finger stick glucose if diabetic. If vital sign criteria was met (i.e. temperature of 100.5 degrees F or above, apical pulse over 100 or below 50, respiratory rate over 28/min or below 10/min, blood pressure below 91 or above 200 systolic, oxygen saturations below 90%, or finger stick glucose below 70 or above 300, then notify the MD/NP/PA. Evaluate Symptoms and Signs for immediate notification. Consider contacting the MD/NP/PA for orders for further evaluation and management (i.e. abdominal x-ray or ultrasound, blood work including a CBC, and digoxin blood level if relevant for nausea and vomiting). Manage in the facility included vital signs and abdominal exam findings every 4 - 8 hours, monitor intake and output (and number of episodes for vomiting and diarrhea), initiate medications for nausea, vomiting, diarrhea, constipation as appropriate, consider IV subcutaneous fluids if needed for hydration, and update advance care plan and directives if appropriate. Monitor response for vital signs criteria met, worsening condition and/or immediate notification met. If yes, notify the MD/NP/PA. On [DATE] at 3:46 p.m. the DON provided a Symptoms of Acute Mental Status (AMS) Change Care Path, dated 2011. The pathway indicated, for new or worsening AMS symptoms or signs of increased confusion (i.e. disorientation, changes in speech), decreased level of consciousness (sleepy, lethargic) inability to perform usual activities (due to mental status change), take vital signs to include temperature, blood pressure, respirations, oxygen saturations, and finger stick glucose if diabetic. If vital sign criteria was met (i.e. temperature of 100.5 F or above, apical pulse over 100 or below 50, respiratory rate over 28/min or below 10/min, blood pressure below 91 or above 200 systolic, oxygen saturations below 90%, or finger stick glucose below 70 or above 300), then notify the MD/NP/PA. Evaluate Symptoms and Signs for immediate notification. Consider contacting the MD/NP/PA for orders for further evaluation and management (i.e. portable chest x-ray, urinalysis and culture and sensitivity (C & S), blood work including a CBC). Manage in the facility included vital signs every 4 - 8 hours, consider IV or subcutaneous fluids if needed for hydration, non-pharmacological interventions for delirium, and update advance care plan and directives if appropriate. Monitor response for vital signs criteria met, worsening condition and/or immediate notification met. If yes, notify the MD/NP/PA. Resident B's record lacked documentation, dated [DATE], [DATE], or [DATE], to reflect services were provided per the Gastrointestinal (GI) Symptoms pathway and Symptoms of Acute Mental Status (AMS) Change Care pathway guidance, related to Resident B's change in condition. Missing documentation included vital signs (BP, P, R, T) and abdominal exam findings (tenderness and distention) every 4-8 hours, completion of STAT labs, and the presence or absence of bowel sounds after an x-ray result of an ileus. The record also lacked neuro checks were completed after new onset of altered mental status. A Witness Statement provided after the survey entry, dated [DATE] at 1:50 p.m., LPN 7 indicated, Daughter had called the facility either the 29th or 30th of December and I spoke to her. She had talked to resident on the phone, and he told her he had been having dizzy spells. She did say that he does not like to complain and that she wanted to assure we knew, since he told her that. During a phone interview on [DATE] at 2:25 p.m. the primary care physician indicated on 1/1 at 10:46 a.m., he had received a text message from a nurse at the nursing facility stating Resident B was having dark coffee ground emesis, dizziness, and nausea. After being told the resident had a history of lung cancer, a chest x-ray was ordered. The chest x-ray results revealed nothing alarming and with no further reports of bleeding, he assumed everything was fine. The abdominal x-ray showed constipation, and he ordered laxatives. On [DATE] at about 6:30 p.m., the physician was notified via text message that Resident B was having nausea, and he gave an order for Zofran 4 mg. The physician indicated he was not given information to indicate Resident B continued to experience vomiting for multiple days. The physician had no further contact with the facility until [DATE] at 7:50 a.m., when he was notified that Resident B had died from a sudden cardiac arrest. The physician indicated with current knowledge that the resident continued to vomit for multiple days, Resident B most likely had gastric issues versus complications from his lung cancer, and he could speculate without proof the resident might have had a GI bleed. The physician indicated he had not given orders for Resident B to be sent to the hospital with the information he was given, but had always told the nurses, if a resident or resident's family member wanted an ER evaluation, he would never say no. During an interview on [DATE] at 3:37 p.m., the DON indicated during the residents' record audits they had found some other residents that had change of conditions that were missed since [DATE] and they had corrected the concerns. There were probably around 10 errors found. The audits did not find additional stat labs issues. Her and her staff had been trained on different types of change of condition, and the process of handling and documenting related to the change of condition. She and her staff were unaware of some things that would be considered a change of condition. On [DATE] at 3:05 p.m., the Administration provided a Laboratory Services policy, reviewed on [DATE]. The policy indicated, The facility must provide or obtain laboratory services to meet the needs of the residents. The facility is responsible for the quality and timeliness of the services. The policy did not define STAT or the expectation for timeline of the blood draw. On [DATE] at 9:14 p.m., the Regional [NAME] President provided a Nursing Documentation policy, revised [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, The facility will ensure nursing documentation is consistent with professional standards of practice .Staff must document a resident's medical and non-medical status when any positive or negative condition change occurs .The medical record must reflect the resident's condition and the care and services provided across all disciplines .The medical record must contain and accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition .Critical Notes .Resident assessments should include vital signs and system reviews .Progress notes- nursing notes will reflect any significant nursing observations of the resident . On [DATE] at 9:42 p.m., the Regional [NAME] President provided a Changes in Resident's Condition or Status policy, revised [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status.A facility must 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.[B] A significant change in the resident's physical, mental, or psychosocial status [this is, a deterioration in health.2. The facility will utilize the following INTERACT tools per policy: Stop and Watch Early Warning Tool, SBAR [situation, background, assessment, recommendation. On [DATE] at 9:42 p.m., the Regional [NAME] President provided a Nursing Documentation policy, revised [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, The medical record must reflect the resident's condition and the care and services provided.The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goal, objectives and/or intentions. The Immediate Jeopardy was removed on [DATE] when the facility implemented a systemic plan that included assessments, audits, and care plans were updated. Staff were in-serviced on resident assessment, change in condition, physician and resident representative notification, laboratory policy and procedures. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This citation relates to Intake 2718798. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to immediately notify the resident's family, and/or emergency contact when a cognitively intact resident developed new onset altered mental status, vomiting, and physical decline for 1 of 3 residents reviewed for family notification (Residents B). Findings include:A confidential concern during the survey process indicated Resident B had a sudden change in his health status, and the physician ordered the resident to go to the hospital. Despite the resident continuing to get worse, the Executive Director (ED) and Director of Nursing (DON) refused to allow the resident to go. Resident B's clinical record was reviewed on [DATE] at 2:33 p.m. Diagnoses on Resident B's profile included prostate cancer, lung cancer, insulin dependent diabetes mellitus (DM) and gastro-esophageal reflux disease (GERD). A quarterly MDS (Minimum Data Set) assessment completed on [DATE], assessed Resident B as being cognitively intact. He was independent with eating, bed mobility, transfers, ambulation, and did not use mobility devices. The resident routinely ate 75 - 100% of his meals and had gained a significant amount of weight (5% or more in the last month or 10% or more in the last 6 months). A nursing progress note, dated [DATE] at 10:46 a.m., indicated Resident B started coughing and had a small amount of coffee ground emesis. The resident complained of feeling drunk and staggering when he ambulated. A nursing progress note, dated [DATE] at 1:44 p.m., indicated Resident B's physician ordered a complete blood count (CBC) lab for gastrointestinal upset and vertigo, and he ordered medication changes to include discontinue diclofenac (an anti-inflammatory pain reliever) and to start protonix (medication that heals and treats excess stomach acid) 40 milligram (mg) daily for gastrointestinal (GI) upset. The note lacked documentation the family was notified. A nursing progress note, dated [DATE] at 8:06 a.m., indicated Resident B continued to have nausea and vomiting, and was having confusion, dizziness, complainant of abdominal pain, and his pulse was 128 beats per minute. The physician ordered a STAT (immediately) chest x-ray, STAT abdominal x-ray, and a STAT CBC. The STAT CBC was not obtained prior to the resident's death. The note lacked documentation the family was notified. A nursing progress note, dated [DATE] at 6:03 p.m., indicated Resident B continued to have yellow liquid emesis, his confusion remained, and he now had a temperature of 99.1 Fahrenheit (F). The note lacked documentation the family was notified. A nursing progress note, dated [DATE] at 6:44 p.m., indicated the physician gave new orders to include sennosides-docusate sodium (a combination laxative/stool softener) 8.6-50 mg twice daily for constipation, Miralax powder (a bulk laxative) twice daily, and doxycycline (antibiotic) 200 mg twice daily for 10 days for pleural effusion. The note lacked documentation the family was notified. A nursing progress note by the Director of Nursing (DON), dated [DATE] at 9:55 a.m., indicated Certified Nursing Assistants (CNAs) went into Resident B's room around 4:48 a.m. Licensed Practical Nurse (LPN) 5 went into the room to check on the resident as he had not been feeling well. The resident had vomited bile-like emesis into the trash can and on the left side of the bed. Resident B went unresponsive while the nurse was in room, with no pulse and no respirations. The code status was verified by a second nurse and Cardiopulmonary Resuscitation (CPR) was started immediately at 4:50 a.m. Two (2) rounds of CPR were completed by staff, and EMS arrived around 4:56 a.m. and took over. EMS stopped CPR at 5:20 a.m. The resident had expired. The daughter, ED, DON, and Regional Director of Clinical Services (RDCS) were notified. At 6:20 a.m., the Coroner was in possession of the body as no funeral arrangements had been made. The clinical record lacked documentation Resident B's emergency contact had been contacted by facility nursing personnel when he had a change in condition on [DATE], with updates on his condition and treatment orders, or that the resident or resident representative were consulted on their preference to be transferred to the hospital for evaluation and treatment. Confidential interviews were conducted during the survey: a. The employee indicated they had been told the resident was ill but was surprised when he died. They did not know details but had been informed he had generally not felt well and had some vomiting. There was an unidentified staff member who had been upset when the resident was not sent to the hospital for evaluation, and they'd been told upper management would not allow him to go. b. The employee indicated on [DATE] the resident started vomiting thick, stringy, coffee ground looking black stuff, that days later turned into just throwing up bile. The attending physician had been notified and gave orders on [DATE] and [DATE]. They could not remember if the physician had given orders to send the resident to the emergency room (ER) for evaluation, but often he would instruct nurses to defer to resident or family wishes. The DON had been made aware and kept apprised of the resident's new and deteriorating symptoms and gave instruction to wait for physician's orders before sending the resident to the hospital. They indicated were not sure if the resident had specifically been told he was being sent out to the hospital. c. The employee indicated they had not worked directly with Resident B recently while he was ill. But symptoms to include vomiting that started with coffee ground emesis and persisted for several days with altered mental status and dizziness with inability to safely ambulate would warrant being seen in the ER for more advanced assessment, testing and treatment. To their knowledge, the resident's record did not have documentation to indicate if he or the resident representative had been consulted on Resident B's wishes for treatment. During an interview on [DATE] at 9:58 a.m., Resident B's daughter indicated although she lived out of state, she had been Resident B's emergency contact. She and the resident texted each other often and had kept in contact right up until the day before he died. A few days before the resident passed, he told her he could not walk anymore, was in a wheelchair (WC), and vomiting black stuff. Resident B was confused enough that he could not answer basic questions such as his age. The daughter called an unidentified nurse at the facility, and when she asked if a urinary analysis had been completed to check for an infection as she knew this had caused him to be confused in the past, the nurse replied she was not sure what good it would do to as he was already on an antibiotic for a finger infection and he had not felt well for a few days. The daughter indicated, she understood Resident B had no Power of Attorney, but she was his emergency contact and felt like she should have been notified of his condition once he became confused. The daughter indicated in her opinion, the nurse did not relay a sense of urgency when describing the resident's current state of decline but instead repeated several times that he had an upcoming oncology follow-up appointment scheduled. On [DATE], Resident B had texted her 3 times and stated he was being sent to the hospital. She had reminded him to take his cell phone and charger so she could keep in contact. The daughter indicated, in her opinion, her father's sudden change in mental status and sudden health decline with coffee ground emesis and vomiting that lasted multiple days should have warranted at least a hospital visit for assessment. She continued to have questions that included why he was not sent to the hospital, and why the facility staff had not been more concerned. During an interview on [DATE] at 12:42 p.m., Resident B's daughter indicated she had not received a response to her last text on [DATE] at 2:16 p.m. and thought her father might be sleeping. The daughter indicated she assumed Resident B had been sent to the hospital and waited for a hospital follow report that never came. Instead, she got a call that he had died the next morning. During an interview on [DATE] at 11:34 a.m., LPN 5 indicated he had worked the night shifts of [DATE], [DATE], [DATE] and cared for Resident B on those nights. On [DATE], LPN 5 was given report that Resident B had an episode of emesis after dinner and was having some confusion. He did not witness Resident B having confusion, and to him the resident seemed to be himself. On [DATE] around 6:30 p.m., within the first 30 minutes of the shift starting, Resident B reported throwing up, and the nurse observed yellowish bile stomach content partially in the trash can and on the bed. The primary care physician was notified and gave an order for Zofran 4 mg, which LPN administered. LPN 5 indicated, on [DATE] at approximately 4:30 a.m., he had gone into Resident B's rooms to check on him before his shift ended and could hear a CNA speaking with the resident. By the time the nurse cleared the curtain as he entered the room, Resident B went unconscious with no pulse or respirations. LPN 5 indicated he initiated CPR, had one of the CNA's call 911, and another CNA get the crash cart. The ambulance arrived at the facility quickly and EMT's took over CPR. Resident B was coded for 30 minutes without ever getting a response. Resident B's daughter was notified, and when it was determined funeral arrangements had not been made previously, the coroner was called to take the body. Review of Resident B's clinic record with the ED and DON on [DATE] at 4:05 p.m. The clinical record lacked documentation of the emergency contact being notified of the resident's change in condition, there was no documentation to indicate Resident B had been asked for his preference of going to the ER. The DON indicated she had no further information to provide. If documentation was not found in Resident B's electronic medical record, it had not been done. On [DATE] at 9:42 p.m., the Regional [NAME] President provided a Changes in Resident's Condition or Status policy, revised [DATE], and indicated the policy was the one currently being used by the facility. The policy indicated, .This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status.A facility must 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.[B] A significant change in the resident's physical, mental, or psychosocial status [this is, a deterioration in health.2. The facility will utilize the following INTERACT tools per policy: Stop and Watch Early Warning Tool, SBAR [situation, background, assessment, recommendation. Cross reference F684. This citation relates to Intake 2718798. 3.1-5(a)(2)3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure staff ordered, obtained, and tracked STAT (immediately) laboratory orders for 1 of 3 residents reviewed for completion of laboratory orders (Resident B). Findings include: A confidential concern during the survey process indicated Resident B had a sudden change in his health status, and the physician ordered the resident to go to the hospital. Despite the resident continuing to get worse, the Executive Director (ED) and Director of Nursing (DON) refused to allow the resident to go, and the resident subsequently died. Resident B's clinical record was reviewed on [DATE] at 2:33 p.m. Diagnoses on Resident B's profile included prostate cancer, lung cancer, insulin dependent diabetes mellitus (DM) and gastro-esophageal reflux disease (GERD). A nursing progress note, dated [DATE] at 10:46 a.m., indicated Resident B started coughing and had a small amount of coffee ground emesis. The resident complained of feeling drunk and staggering when he ambulated. A nursing progress note, dated [DATE] at 1:44 p.m., indicted Resident B's physician ordered a complete blood count (CBC) lab for gastrointestinal upset and vertigo. The CBC was not obtained. A nursing progress note, dated [DATE] at 8:06 a.m., indicated Resident B continued to have nausea and vomiting, and was having confusion, dizziness, complainant of abdominal pain, and his pulse was 128 beats per minute. The physician ordered a STAT (immediately) chest x-ray, STAT abdominal x-ray, and a STAT CBC. The STAT CBC was not obtained prior to the resident's death. A contracted laboratory request daily log, dated [DATE] at 8:00 a.m., indicated an order for Resident B was input into the electronic system for CBC. The DON indicated the order lacked documentation to specify it was a STAT order. Confidential interviews were conducted during the survey: a. The employee indicated they had been told the resident was ill but was surprised when he died. They did not know details but had been informed he had generally not felt well and had some vomiting. When a resident became ill, nurses had critical system pathways for guidance on managing the resident in the facility. b. The employee indicated on [DATE] the resident started vomiting thick, stringy, coffee ground looking black stuff, that days later turned into just throwing up bile. The attending physician had been notified and gave orders on [DATE] and [DATE]. On [DATE] at 8:00 a.m., STAT labs had been ordered for Resident B. that were supposed to be completed within 8 hours, but a lab technician did not present to the facility to draw the labs until [DATE] around 9:00 a.m. after Resident B had died.c. The employee indicated they had not worked directly with Resident B recently while he was ill. STAT labs meant urgent and were supposed to be completed as soon as possible. During an interview on [DATE] at 3:30 p.m., the DON indicated a STAT CBC with differential (a comprehensive blood test to help diagnose infections, anemia, inflammation, leukemia, and monitor overall health) ordered on [DATE] at 8:15 a.m., was not completed before Resident B died on [DATE] at approx. 4:48 a.m. She was unsure why the labs had not been completed. The resident's clinical record lacked documentation the laboratory had been called by nursing staff regarding the STAT lab when they had not shown up on [DATE]. Review of Resident B's clinic record with the ED and DON on [DATE] at 4:05 p.m. The clinical record lacked documentation a STAT CBC was completed. The DON indicated she had been aware of Resident B's change in condition, she knew he was having emesis, but it was small amounts and she had not observed him to be confused as he answered basic questions appropriately. The DON indicated she had no further information to provide. On [DATE] at 3:05pm the Administration provided a Laboratory Services policy, reviewed on [DATE]. The policy indicated, .The facility must provide or obtain laboratory services to meet the needs of the residents. The facility is responsible for the quality and timeliness of the services. The policy did not define STAT or the expectation for timeline of the blood draw. Cross reference F684. This citation relates to Intake 2718798. 3.1-49(f)(1)

Based on record review and interview, the facility failed to accurately complete an elopement risk assessment for a vulnerable resident who was found outside the facility, on the grass after falling out of his wheelchair, without the knowledge of staff for 1 of 3 residents reviewed for neglect (Resident C). The deficient practice was corrected by 9/8/25 prior to the start of the survey and was therefore past noncompliance. Findings include:A nursing progress note, dated 9/7/25 at 3:35 p.m., indicated that emergency medical services (EMS) were at the facility. A resident had gotten outside without being seen and had fallen from his wheelchair. EMS had arrived to the facility at 3:32 p.m. and indicated they had gotten a call around 3:28 p.m. that a person was crawling in the grass on the side of the facility. Nursing staff reported last seeing Resident C around 3:00 p.m. A different resident had indicated she saw a visitor coming or going who had left the door open for Resident C to go outside. The resident had no injuries from the elopement/fall. The physician, Director of Nursing, Administrator and family were notified. The resident's care plan was updated, and he was placed on 1:1 supervision of staff until further notice. A Wander Guard [ankle bracelet that would set off an alarm if exiting the facility] was placed on Resident C. The clinical record review for Resident C was completed on 9/9/25 at 10:12 a.m. Diagnoses included alcohol-induced amnestic disorder, metabolic encephalopathy, and major depressive disorder. The resident had admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated 8/22/25, indicated the resident had severe cognitive impairment, used a wheelchair for mobility and required assistance for toileting, bathing, and transferring. The resident was able to wheel himself short distances without staff assistance. An Elopement Risk Evaluation, dated 7/2/25, included an answer of no to the following questions: Is the resident cognitively impaired with poor decision-making skills ?; Does the resident ambulate independently with or without the use of an assistive device (including a wheelchair)?; Does the resident have a history of Substance Use Disorder? A health care plan, dated 6/22/25, indicated the resident had pulled the facility fire alarm intentionally related to wanting to go home. Interventions included, to anticipate and meet the resident's needs, and to help minimize potential for the resident's disruptive behaviors by offering tasks which divert his attention such as reminiscing, snacks, or magazines.The resident's clinical record lacked a care plan for elopement. A document titled, [Resident C} Elopement Timeline, was provided by the Administrator on 9/9/25 at 10:40 a.m. The timeline indicated the resident was last seen by a staff member on 9/7/25 at 3:15 p.m. around the nurses' station. The Emergency Medical Service run report indicated a unit was dispatched on 9/7/25 at 3:30 p.m. They arrived to the facility at 3:32 p.m. They observed Resident C outside the facility sitting upright next to his wheelchair. A bystander, who had been driving by, observed a male laying in the grass outside the facility next to his wheelchair. The resident indicated he had made his way outside and was on his way home. The resident had indicated he was let out of the facility by an unknown person prior to slipping out of his wheelchair to the ground. The resident was assisted to his wheelchair by the rescue crew and refused any further care or evaluation and complained of no pain. The resident was wheeled back into the facility and care was transferred back to the facility staff. During an interview on 9/9/25 at 2:23 p.m., the Director of Nursing (DON) indicated Resident C had metabolic encephalopathy and struggled to form new memories. He continually asked about his car and when it would be returned from the shop so he could go home. She had not known him to attempt to exit the facility in the past. The July assessment for risk of elopement was not accurate because he had a cognitive deficit and a history of substance abuse, and was able to move around independently in his wheelchair. She, however, felt he was not an elopement risk. Resident C had not been observed pushing on doors to exit the facility. A current facility policy, reviewed 11/19/24, titled, Area of Focus: Elopement, provided by the DON on 9/9/25 at 2:53 p.m., included the following: What Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so How Upon completion of the other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional unsafe wandering and/or elopement risk indicators and revise the resident's care plan as indicated. The deficient practice was corrected by 9/8/25 prior to the start of the survey and was therefore past noncompliance. The facility implemented a systemic plan that included re-assessment of residents in regard to elopement, staff education, visitor education, signs regarding not allowing residents to exit the building, and ongoing monitoring. This citation relates to Intake 2611338. 3.1-45(a)(2)

A. Based on observation, interview, and record review, the facility failed to ensure the low temperature dish machine (a commercial dishwashing machine that relies on chemical sanitizers, rather than high temperatures, to sanitize dishes, typically operating at temperatures between 120 Fahrenheit [F] and 140 F) wash and rinse temperatures met minimum standards and the March 2025 logs for the dish machine temperatures were completed for 1 of 2 kitchen observations. This had the potential to affect all residents who consumed food or liquids from the kitchen. B. Based on observation, interview, and record review, the facility failed to ensure the March 2025 logs for the sanitizer solution bucket (a container filled with a sanitizer solution [like bleach or a similar chemical] used to reduce germs on surfaces, often wiping cloths or equipment, to safe levels), freezer, refrigerator, and dinner meal food temperatures were completed for 1 of 2 kitchen observations. This had the potential to affect all residents who consumed food or liquids from the kitchen. C. Based on observation, interview, and record review, the facility failed to ensure the scoop to the ice container used for the resident's lunch drinks, was maintained in a sanitary manner for 1 of 2 dining observations. Findings include: A. During the initial kitchen tour, on 4/1/25 at 9:51 a.m., the facility's low temperature dish machine wash temperatures measured at 115 F and the rinse temperature was measured at 118 F. Observation of the March 2025 dish machine temperature logs lacked documentation of the temperatures being monitored after 3/17/25. During an interview, on 4/1/25 at 11:41 a.m., the Dietary Manager indicated he had re-checked the temperatures on their low temp machine and it had never got above 118 F. At the same time, he indicated he had new dietary staff, and they were still being trained. He felt that this was the reason the temperature logs had not been completed. On 4/1/25 at 12:20 p.m., the Dietary Manager provided a document, dated 4/1/25, titled, Low Temp Dishwasher Temperature, and indicated it was the policy currently being used by the facility. The policy indicated, Low-temperature dishwashers operate with wash and rinse cycles between 120 F and 140 F B. During the initial kitchen tour, on 4/1/25 at 9:51 a.m., the temperature logs for the kitchen were reviewed, and indicated the following: a. The March 2025 sanitizing bucket daily log lacked documentation of the sanitizer measurements, after 3/18/25. b. The March 2025 refrigerator and freezer temperature logs (logs documenting the temperatures to ensure foods stored were maintained at a safe temperature) lacked documentation that the temperatures had been monitored after 3/19/25. c. The March 2025 Food Temperature logs (logs that measured the holding temperatures of foods to be served for each meal) lacked documentation that the temperatures of the dinner meals had been monitored 3/18/25, and that the breakfast and lunch meals had been monitored on 3/29/25, 3/30/25, and 3/31/25. During an interview, on 4/1/25 at 11:41 a.m., the Dietary Manager (DM) indicated he had new dietary staff, and they were still being trained. He felt that this was the reason the temperature logs had not been completed. On 4/1/25 at 11:40 a.m., the Dietary Manager provided a document, with a revision date of 6/28/24, titled, Food Temperature Control, and indicated it was the policy currently being used by the facility. The policy indicated, .Guidelines: 1. Food temperatures are checked at the completion of the cooking process and before being placed in the serving line On 4/1/25 at 12:00 p.m., the Dietary Manager provided an undated document titled, Closing List for PM Cook, and indicated it was the policy currently being used by the facility. The policy indicated, .All logs are filled out C. On 4/1/25 at 11:48 a.m., an observation of the lunch meal in the main dining room was initiated. On 4/1/25 at 12:02 p.m., Registered Nurse (RN) 15 was observed to open the lid to the ice cooler, pick up the ice scoop, fill ice into a resident's glass, and placed the ice scoop back into the cooler directly on top of the ice, and close the lid. During an interview, on 4/1/25 at 12:32 p.m., the Dietary Manager indicated the ice scoop should be maintained in a container outside of the ice chest and should never be placed into the ice when used. On 4/1/25 at 1:48 p.m., the Dietary Manager provided a document, with a revision date of 6/3/24, titled, Ice Chests, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .5. Ice scoops used should be .kept on an uncovered stainless steel, impervious plastic, or fiberglass tray on top of the chest or in a mounted holder when not in use 3.1-21(a)(3)

Based on observations, interview, and record review the facility failed to ensure a sanitary environment was maintained for residents during meal service for 2 of 2 random observations. This had the potential to affect all residents on the [NAME] Hall consuming food during the use of cleaning supplies. Findings include: On 4/01/25 at 12:10 p.m., during observation of the noon meal service on the [NAME] Hall, observed Employees 8 and 3 cleaning rooms and mopping floors while drinks and food trays were being passed to residents. On 4/01/25 at 12:30 p.m., observed Employee 3 cleaning handrails outside of the residents rooms while residents were eating. On 4/01/25 at 12:18 p.m., during interview with Housekeeping Supervisor she indicated she had instructed the staff to remove carts when meals were being served. She indicated the housekeepers were not permitted to clean residents rooms or hall area when meals were being served. On 4/1/2025 at 1:48 p.m., the Administrator provided a document, titled, Housekeeping Services, dated 6/29/21, and indicated it was the policy currently being used by the facility. The policy indicated, .Routine Cleaning .18. Resident rooms should not be cleaned during meal services. 19. Cleaning carts should be removed from resident halls while meal trays are being passed 3.1-19(e)

Based on observation, record review, and interview, the facility failed to ensure falls were documented, interventions implemented, and a call light was within the resident's reach for 1 of 2 residents reviewed for falls (Resident 29). Findings include: During an observation, on 4/1/25 at 11:05 a.m., Resident 29 was in his recliner with no call light within his reach. The call light was observed at the end of his bed. At the same time, the resident indicated he used the call light to request assistance when needed, and it was over there on the bed somewhere. When queried how he used the call light when it was on the bed, the resident indicated, I don't. The resident requested to lay back down in bed. During an interview, on 4/1/25 at 12:07 p.m., Resident 29's daughter indicated he had fallen a lot since being at the facility. He fell often at home too. The resident used the call light to ask for help and knew how to use it, but he sometimes got up without assistance. The resident had fallen earlier in the day on 4/1/25. Resident 29's record was reviewed on 4/3/25 at 2:15 p.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, generalized muscle weakness, subsequent encounter for a fracture of the unspecified carpal (bones in wrist) bone of the right wrist, and history of falling. A Progress Note, dated 1/3/25, indicated the resident's roommate turned on the call light and reported the resident rolled out of bed. The resident was lying beside the bed and indicated he was sleeping. The bed was in the lowest position with a mat placed at bedside. An Interdisciplinary Team (IDT) note, dated 1/6/25, indicated the resident had an unwitnessed fall on 1/3/25. The bed was placed in the lowest position. The resident had another unwitnessed fall on 1/4/25 at 4:25 p.m. when he was found on the floor mat next to his bed. The resident had no injuries and was assisted back to bed by staff. New interventions included floor mat next to bed and bed in the lowest position. The IDT Note lacked documentation of new interventions placed after the fall on 1/4/25, as the low bed and mat next to the bed were initiated after the resident's fall on 1/3/25. Progress Notes lacked documentation of the fall on 1/4/25, at the time it occurred, including a post-fall assessment or new interventions put into place. A Progress Note, dated 1/9/25 at 4:35 a.m., indicated the resident fell from a raised bed onto the floor while the Certified Nurse Aide (CNA) provided care to the resident at 4:10 a.m. The note lacked documentation an intervention was initiated immediately to prevent further falls. An IDT Note, dated 1/9/25 at 10:13 a.m., indicated the resident had a witnessed fall at 4:10 a.m. The resident rolled out of his raised bed while the CNA provided care, and landed on his right side. There were two skin tears to the resident's right elbow. A new intervention of two staff to assist with resident care was initiated. An admission Minimum Data Set (MDS) Assessment, dated 1/13/25, indicated the resident had a severe cognitive impairment, required substantial/maximal assistance with transfers, and one fall since the resident's admission. An IDT Note, dated 1/17/25 at 9:22 a.m., indicated the IDT reviewed the resident's fall from 1/16/25 at 9:20 a.m. The resident was found lying beside his bed on the floor mattress with no injuries. The new intervention was to monitor the resident for restlessness and assist the resident into his wheelchair as needed. The Progress Notes lacked documentation of the fall on 1/16/25, at the time it occurred, including a post-fall assessment or new interventions put into place. A Progress Note, dated 3/28/25, indicated another resident reported Resident 29 was sitting on the floor. The staff went to the resident and found he had gotten himself up from the floor and was sitting on the other bed in his room. The resident was assessed and denied pain. The note lacked documentation of an intervention implemented immediately to prevent further falls. A Progress Note, dated 3/29/25 at 11:21 a.m., indicated the resident complained of right wrist pain. The resident's daughter requested evaluation in the emergency room (ER) for x-ray. The resident's daughter reported the resident had a history of a wrist fracture, but she was unable to remember which wrist he previously fractured. The resident was transported to the ER via ambulance. A Progress Note, dated 3/29/25 at 2:17 p.m., indicated the resident returned to the facility. The resident's daughter reported he was to wear the splint for four weeks, and there was no orthopedic treatment recommended. The resident was moved to a room closer to the nurse's station for increased observation. An x-ray report, dated 3/29/25, indicated evidence of a chronic healing fracture to the left wrist. An x-ray report, dated 3/29/25, indicated a fragment along the dorsum (back or upper side) of the right wrist which was concerning for a possible triquetral (bone on inner side of wrist) fracture. An IDT Note, dated 3/31/25, indicated the IDT reviewed the resident's unwitnessed fall on 3/28/25. The resident was placed on 15-minute checks and moved closer to the nurse's station. A Progress Note, dated 4/1/25 at 9:45 a.m., indicated the resident was found on the floor next to his closet, and his recliner was tipped over on its side. The resident was assisted to his wheelchair. The note lacked documentation of an assessment of the resident after the fall or an intervention implemented immediately to prevent further falls. On 4/4/25 at 11:20 a.m., the Director of Nursing (DON) provided the following Risk Management documents. At the same time, the DON indicated the falls should have been documented in the Progress Notes and Risk Management. The Risk Management was an internal incident report and included information about the falls and interventions. The Risk Management documents were visible to nurses and management. a. An unwitnessed fall occurred on 1/3/25. The resident's roommate reported the resident was on the floor. The resident had rolled out of bed and indicated he was sleeping. The resident was assessed, and no injuries were noted. Interventions to prevent further falls were bed in lowest position and mat placed at bedside. b. An unwitnessed fall occurred on 1/4/25. The CNA found the resident sitting on the floor. There were no injuries noted, and the resident was unable to say what happened. The Risk Management document lacked documentation of an intervention put in place to prevent further falls. c. An unwitnessed fall occurred on 1/16/25. The resident was found lying on the mat next to his bed on his left side. An assessment was completed. The Risk Management document lacked documentation of an intervention put in place to prevent further falls. d. An unwitnessed fall occurred on 4/1/25. The resident was found lying on his right side next to his recliner. The recliner was flipped over next to the resident. The resident told his daughter he was trying to get into his chair. No injuries were noted, and the resident was assisted into his wheelchair. The immediate intervention was to ensure staff provides frequent checks for resident when in recliner. A care plan, target dated 4/21/25, indicated the resident was at risk for falls. The resident rolled out of bed, on 1/3/25, with no injuries, was found sitting on the floor at bedside, on 1/4/25, with no injuries, rolled out of bed while being assisted by staff with incontinence care, on 1/9/25, was found lying on the floor mat, on 1/16/25, and was observed by another resident sitting on the floor and then got himself up, on 3/28/25. Interventions included monitor for restlessness and get resident up into wheelchair as needed, initiated on 1/17/25, bed in lowest position, initiated on 1/6/25, floor mat at bedside, initiated on 1/6/25, two staff assistance with activities of daily living (ADLs), initiated on 1/9/25, anticipate and meet the resident's needs, initiated on 3/29/25, assist with ADLs as needed, initiated on 1/3/25, call light within reach, initiated on 1/3/25, complete fall risk assessment, initiated on 1/3/25, and resident monitored for safety every 15 minutes, initiated on 3/29/25. During an interview, on 4/4/25 at 10:41 a.m., the DON indicated falls were documented in the Progress Notes and Risk Management documents. Risk Management documents were internal incident reports and were visible to nurses and management. An intervention should have been initiated at the time of each fall. The IDT reviewed falls and ensured care plans were updated. Staff was notified of fall interventions verbally and education was provided as needed. During an interview, on 4/4/25 at 11:20 a.m., the DON indicated she reviewed the resident's record and was unable to find Progress Notes for the falls on 1/4/25 and 1/16/25. During an interview, on 4/4/25 at 11:30 a.m., CNA 13 she was taking care of Resident 29. The resident had fallen a few days ago, but she had not worked in about a week. She should have been notified of any required fall interventions for the resident when she received report. She was not sure what intervention was put in place for the resident's last fall, and she was not aware of any interventions specific to the resident's recliner. The resident's call light should have been kept within his reach, and he was able to use the call light. During an interview, on 4/4/25 at 11:55 a.m., the DON indicated the resident's wrist fracture may have been old, but they were unable to tell for sure. The resident's daughter reported he previously fractured his wrist, but she was unable to remember which wrist. On 4/4/25 at 1:06 p.m., the DON provided a document titled, Fall Management, last revised 3/11/25, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls .Procedure .4. The interdisciplinary team will review and revise the care plan, if indicated .upon a fall event and as needed thereafter .6. The interventions to reduce the risk of falls should be individualized based on the resident risk factors and fall history 3.1-45(a)(2)

Based on record review and interview, the facility failed to address a significant weight discrepancy for 2 of 4 residents reviewed for nutrition and the facility failed to obtain daily weights for 1 of 4 residents reviewed for weights (Residents 27, 17, and 21). Findings include: 1. Resident 27's record was reviewed on 4/2/25 at 1:45 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic combined systolic (congestive) and diastolic (congestive) heart failure (a long-term condition where the heart's ability to pump blood effectively impairs both systole [contraction] and diastole [relaxation], leading to fluid buildup and other symptoms) and cardiomegaly (an enlarged heart). A quarterly Minimum Data Set (MDS) assessment, dated 2/26/25, indicated the resident had severe cognitive impairment and indicated the resident had weight loss in the last 6 months and was not on a weight loss regimen. A care plan, dated 1/14/25, indicated the resident had unplanned/unexpected weight gain related to 5% weight gain in 30 days. Interventions included but were not limited to, daily weight, observe and report to medical doctor as needed situations leading to increased food consumption, reasons for weight gain, and significant weight changes. A physician order, dated 2/20/25, indicated to obtain a daily weight in the morning before breakfast every day and report a 3-pound weight gain/day or a 5-pound weight gain/week to medical doctor. A physician order, dated 2/26/25, indicated the resident was to have a regular diet, mechanically altered texture (foods that have been modified to be softer and easier to chew), and nectar/mildly (used for people with swallowing difficulties to reduce the risk of choking) consistency. Review of the resident's weights indicated she weighed 174 pounds on the most recent MDS assessment dated [DATE]. Subsequent weights included, but were not limited to the following: a. On 2/28/25 at 2:33 p.m., the resident was weighed in her wheelchair. Her weight was 180.9 pounds. b. On 3/4/25 at 6:08 p.m., the resident was weighed in her wheelchair. Her weight was 185.9 pounds. c. On 3/5/25 at 12:25 p.m., the resident was weighed in her wheelchair. Her weight was 179.3 pounds. d. On 3/9/25 at 11:23 a.m., the resident was weighed in her wheelchair. Her weight was 186.5 pounds. e. On 3/10/25 at 12:37 p.m., the resident was weighed in her wheelchair. Her weight was 191.6 pounds. f. On 3/12/25 at 1:38 p.m., the resident was weighed in her wheelchair. Her weight was 182.3 pounds. h. On 3/15/25 at 5:51 p.m., the resident was weighed in her wheelchair. Her weight was 190.1 pounds. i. On 3/17/25 at 9:23 a.m., the resident was weighed in her wheelchair. Her weight was 181.2 pounds. j. On 3/18/25 at 9:57 a.m., the resident was weighed in her wheelchair. Her weight was 187.7 pounds. k. On 4/2/25 at 6:21 p.m., the resident was weighed in her wheelchair. Her weight was 187.2 pounds. l. On 4/3/25 at 2:45 p.m., the resident was weighed in her wheelchair. Her weight was 199.2 pounds. The record lacked documentation that the significant weight discrepancies in the resident's weights had been addressed by the facility and the record lacked documentation of the weights being conducted before breakfast daily as ordered by the physician. During an interview, on 4/2/25 at 1:56 p.m., Registered Dietitian (RD) was not concerned about Resident 27's weight but she had been gaining weight recently, she further indicated she usually eats well, and she had edema at times. The RD had questioned rather staff was weighing the resident accurately. During an interview, on 4/4/25 at 1:32 p.m., the Director of Nursing (DON) indicated the facility had noticed some inconsistency with some of the residents' weights back in the fall of 2024 and they felt the scale could have been off and needed recalibrated, but it had not been looked at yet. She indicated there was a systemic issue that the facility needed to work on, and staff should have notified the medical doctor as ordered for weight discrepancies. She was aware Resident 27 was a congestive heart failure resident, and her weights should be monitored more closely. 34525 2. Resident 17's record was reviewed on 4/4/25 at 10:26 a.m. The profile indicated the resident's diagnoses included, but were not limited to, mild protein calorie malnutrition ( a condition caused by a deficiency in both protein and calories, leading to poor growth, muscle weakness, and potential neurological complications), dysphasia (swallowing difficulties), and gastrostomy tube (feeding tube-a flexible, hollow tube inserted through the abdominal wall and into the stomach which provides a direct route for administering nutrition and medications into the stomach). An annual Minimum Data Set (MDS) assessment, dated 2/11/25, indicated the resident had no cognitive deficit, had a documented weight loss of 5% in the last month or 10% in past 6 months, and had a feeding tube. A care plan, dated 5/19/23, indicated the resident had the potential for nutritional problems related to protein calorie malnutrition and dysphasia, and being NPO (nothing by mouth) with a feeding tube. A care plan, dated 7/15/24, indicated the resident required a tube feeding related to diagnoses of dysphasia and history of malignant neoplasm of lip, oral cavity, and pharynx (a cancerous growth in the tissues lining the mouth, lips, and upper throat). A care plan, dated 3/17/25, indicated the resident would refuse his tube feeding if not offered at scheduled times. A physician's order, dated 4/26/24, indicated to weigh the resident weekly on the day shift, every Tuesday, related to his tube feeding. Review of the residents' weights indicated the resident weighed 213.8 lbs. (pounds) on 9/3/24 and dropped to 177.4 lbs. on 1/7/25. This indicated a weight loss of 17.03% in 90 days. A quarterly Registered Dietician (RD) assessment, dated 1/3/25, indicated the resident's weight on 12/24/24 had been 177.6 lbs., which indicated a significant weight loss of 22 lbs. or an 11% weight loss in 1 month or 32 lbs. or an 15.3 % weight loss in 6 months. The RD questioned the accuracy of weight obtained on 12/24/24, (177.6) as inconsistent with the previous month's weights which indicated an upward trend of his weights of 194.2 lbs. to 199.8 lbs. The RD recommended that weights and tolerance to tube feeding continue to be monitored and requested a new weight be obtained. During an interview, on 4/2/25 at 11:17 a.m., the RD indicated she believed the facility had some issues with their scales in the fall and the beginning of the year. She had recommended additional bolus feedings, at that time, but the resident refused because he did not accept the weight that had been indicated by the scales. She also had failed to see any evidence of the resident being malnourished or having any significant weight loss. During an interview, on 4/4/25 at 11:24 a.m., the Director of Nursing (DON) indicated the resident had always been weighed in his wheelchair. He had been care planned for refusal to accept his feedings at times and had failed multiple swallow studies. When she was the Assistant Director of Nursing (ADON), she had recognized many inconsistencies with the facility's scale and had asked to get the scale looked at, but the previous administration never acted on her request. During the period when she had been made aware of the resident's weight loss, she met with him and did not notice any signs that he had any significant weight loss (i.e., clothes fitting more loosely or his watch being loose on his wrist). At the same time, she indicated the expectation would be that when the RD documented a need for a re-weight, it should be done as soon as possible to make sure that the weight loss was an actual loss or a malfunction of the scale. On 4/4/25 at 1:08 p.m., the DON provided a document, with a revision date of 8/19/24, titled, Weight Measurement, and indicated it was the policy currently being used by the facility. The policy indicated, .Critical Notes .3. Notify the nurse if the weight obtained is significantly different from the prior weight (greater or equal to 3 lbs. for a weekly weight; greater or equal to 5 lbs. for a monthly weight). Reweigh as needed. 4. The unit manager/designee should review and verify the weights on the day they are obtained to ensure there is no unexplained significant variance from the prior weight by utilizing the weight reports in PCC (Point Click Care-the electronic medical record) 38847 3. Resident 21's record was reviewed on 4/3/25 at 11:16 a.m. Diagnoses on the resident's profile included, but were not limited to, chronic systolic congestive heart failure (CHF) (a condition in which the heart does not pump blood effectively). An admission Minimum Data Set (MDS) assessment, dated 2/18/25, indicated the resident was cognitively intact. A Physician's Order, dated 3/17/25, indicated daily weight in the morning before breakfast related to CHF. A weight gain of three pounds in a day or five pounds in a week should have been reported to the physician. A Medication Administration Record (MAR), dated March 2025, lacked documentation a daily weight was obtained on 3/20/25, 3/21/25, 3/22/25, 3/25/25, 3/27/25, and 3/28/25. A MAR, dated April 2025, lacked documentation a daily weight was obtained on 4/1/25. The weights vital signs section of the electronic record lacked documentation daily weights were obtained on 3/20/25, 3/21/25, 3/22/25, 3/25/25, 3/27/25, 3/28/25, and 4/1/25. Progress Notes, dated March and April 2025, lacked documentation the resident refused daily weights. During an interview, on 4/3/25 at 2:52 p.m., the Director of Nursing (DON) indicated the daily weights were ordered because of the resident's CHF diagnosis, but he was not symptomatic. She reviewed the resident's chart but was unable to find additional weights, refusals, or reasons why the daily weights were not obtained. Daily weights should have been completed everyday, and if they were not completed for some reason, the reason should have been documented on the MAR. On 4/3/25 at 2:52 p.m., the DON provided a document titled, [NAME] Advisor-Diseases and Conditions: Heart failure, long-term care, dated 2025, and indicated it was the facility's policy related to caring for residents with CHF. The policy indicated, .Monitoring: Daily or weekly weight 3.1-46(a)(1)

Based on observations, interviews, and record review, the facility failed to ensure proper storage of respiratory equipment for 1 of 2 residents reviewed for respiratory care (Resident 14). Findings include: 1a. On 4/1/25 at 11:21 a.m., Resident 14's unbagged nebulizer (turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing were observed laying on top the nebulizer machine. The resident was sitting in her wheelchair next to her bed. 1b. On 4/1/25 at 2:38 p.m., Resident 14 was sitting up in her wheelchair watching T.V. and her unbagged nebulizer mouthpiece and tubing were observed laying on top of the nebulizer machine on her bedside table. 1c. On 4/2/25 at 9:50 a.m., Resident 14 was resting in bed and her nebulizer mouthpiece and tubing was observed sitting on top of her nebulizer machine in a clear plastic trash bag. The trash bag was not labeled with the resident's name or date. 1d. On 4/3/25 at 10:28 a.m., Resident 14's unbagged nebulizer mouthpiece and tubing were observed to be sitting on top of her nebulizer machine. The resident indicated that she knew the mouthpiece and tubing should be bagged when not in use, but she doesn't have good dexterity of her fingers to put it in the bag herself. Resident 14's record was reviewed on 4/3/25 at 10:34 a.m. The profile indicated the resident diagnosis included, but were not limited to, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing related problems). An admission Minimum Data Set (MDS) assessment, dated 3/14/25, indicated the resident was cognitively intact and received oxygen therapy. A care plan, dated 3/7/25, indicated the resident had altered respiratory status/ difficulty breathing related to anxiety (intense, excessive, and persistent worry and fear about every situation), COPD, and asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). Interventions included, but were not limited to, administer medications/puffers as ordered. A physician's order, dated 3/7/25, indicated albuterol sulfate solution (a medication that can help people with lung problems, like asthma or obstructive pulmonary disease, breathe easier) 2.5 milligrams (mg)/3 milliliters (ml) inhale 3ml orally via nebulizer every 6 hours for shortness of breath. During an interview on 4/3/25 at 1:45 p.m., Licensed Practical Nurse (LPN) 10 indicated the nebulizer mouthpiece and medication chamber was to be rinsed out after use and once dried it should be placed in a bag with the resident's name and date on it. The nebulizer mouthpiece and tubing should not be left out unbagged when not in use. During an interview on 4/3/25 at 2:12 p.m., Director of Nursing (DON) indicated the nebulizer mouthpiece, and tubing should be bagged when not in use. On 4/3/25 at 2:52 p.m., the DON provided a document with a revised date of 10/11/24, titled, Oxygen Administration (Safety, Storage, Maintenance), and indicated it was the currently policy currently being used by the facility. The policy indicated, .3. Storage oxygen and respiratory supplies in bag labeled with resident's name when not in use 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure behaviors were documented to support the declination of a medication gradual dose reduction (GDR) for 1 of 5 residents reviewed for unnecessary medications (Resident 36). Findings include: Resident 36's record was reviewed on 4/2/25 at 10:55 a.m. Diagnoses on the resident's profile included, but were not limited to, major depressive disorder single episode and unspecified mild anxiety disorder. Progress Notes, dated December 2024, lacked documentation of behaviors, including restlessness. A physician's order, dated 12/31/24, indicated administer Ativan (antianxiety medication) 0.25 milligrams (mg) via gastrostomy tube (g-tube) twice daily for anxiety. A physician's order, dated 12/31/24, indicated administer sertraline (antidepressant medication) 25 mg via g-tube once daily for depression. Progress Notes, dated January 2025, lacked documentation of behaviors, including restlessness. A Medication Administration Record (MAR), dated February 2025, indicated monitor and document behaviors of yelling out and disturbing others every shift related to unspecified anxiety disorder. The documentation included interventions and their efficacy. The resident had one episode of behaviors on 2/2/25, day shift. The MAR lacked documentation of other behaviors during February 2025. A quarterly Minimum Data Set (MDS) assessment, dated 2/21/25, indicated the resident had a severe cognitive impairment and received antidepressant and antianxiety medications during the look-back period. Progress Notes, dated February 2025, lacked documentation of behaviors, including restlessness. A MAR, dated March 2025 indicated monitor and document behaviors of yelling out and disturbing others every shift related to unspecified anxiety disorder. The documentation included interventions and their efficacy. The resident had one episode of behaviors on 3/8/25, day shift. The MAR lacked documentation of other behaviors during March 2025. Progress Notes, dated March 2025, indicated the resident yelled out several times throughout the night shift on 3/24/25. The Progress Notes lacked documentation of other behaviors during March 2025. A Psychiatry Progress Note, dated 3/20/25, indicated, Per staff, [Resident 36] has remained psychiatrically stable at baseline with no new concerns or behaviors since last visit. Seen in her room, alert and calm. Is mostly nonverbal but indicated her mood has been okay. Does endorse some anxiety. Denies changes with sleep or appetite The note lacked documentation of persistent restlessness. A Pharmacy Consultation Report, dated 3/24/25, indicated the resident had received sertraline 25 mg daily for the management of major depressive disorder since 9/27/24. The pharmacist recommended an initial GDR attempt of a trial off of the sertraline. The Nurse Practitioner (NP) declined the GDR and documented, will increase at next visit d/t [due to] persistent restlessness and then GDR Ativan. The NP signed the form on 4/1/25. A Pharmacy Consultation Report, dated 3/24/25, indicated the resident had received Ativan 0.25 mg twice daily for anxiety since 9/7/24. The pharmacist recommended a GDR to lorazepam 0.25 mg once daily. The NP declined the GDR and documented, more alert and restless. Will likely increase Zoloft [sertraline] and then GDR Ativan. The NP signed the form on 4/1/25. A care plan, target dated 5/15/25, indicated the resident exhibited behaviors of yelling out and disturbing others and had the potential to be verbally aggressive towards staff related to poor impulse control. Interventions included, but were not limited to, observe and document behaviors and attempted interventions each shift and analyze key times, places, circumstances, triggers, and what de-escalates behaviors and document. A MAR, dated April 2025 indicated monitor and document behaviors of yelling out and disturbing others every shift related to unspecified anxiety disorder. The documentation included interventions and their efficacy. The MAR lacked documentation of any behaviors. Progress Notes, dated April 2025, lacked documentation of behaviors, including restlessness. During an interview, on 4/3/25 at 10:26 a.m., the Director of Nursing (DON) indicated she reviewed the resident's medical record and was unable to find additional documentation the resident had behaviors. Behaviors and the interventions attempted should have been documented by the nursing staff. During an interview, on 4/3/25 at 10:36 a.m., the Social Services Director (SSD) indicated behaviors and interventions attempted were documented on the MAR. There was no additional documentation of Resident 36's behaviors. On 4/3/25 at 10:45 a.m., the DON provided a document titled, Psychotropic Medication Use, dated 2025, and indicated it was the policy currently being used by the facility. The policy indicated, .10. If physician/prescriber orders a psychotropic medication in the absence of a diagnosis, facility should ensure that the ordering physician/prescriber reviews the medication plan and considers a gradual dose reduction .of psychotropic medications for the purpose of finding the lowest effective dose unless a GDR is clinically contraindicated. 10.1 physician/prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. 11. Facility staff should monitor the resident's behavior pursuant to facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication .Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to ensure keys to the medication room were kept in an area only accessible to nursing staff, food was not kept in the medication room, multi-use medication containers were dated when opened, and insulin was disposed of once it was past the use by date for 1 of 1 medication rooms reviewed and 1 of 2 medication carts reviewed (Residents 33 and 12). Findings include: 1. During an observation, on 4/7/25 at 10:19 a.m., the Director of Nursing (DON) removed keys from an unsecured drawer at the nurse's station and unlocked the medication room. The nurse's station was not locked or secured and was accessible to staff and visitors. The keys obtained from the unsecured drawer unlocked the narcotic and refrigerated emergency drug kits (EDKs) in the medication room. A container of peanut butter bars was observed on the counter in the medication room. A medication bottle contained three vials of Aplisol (tuberculosis testing solution) and was stored in the refrigerator. One of the vials of Aplisol was opened. There was no opened date on the Aplisol vial or the medication bottle. At the same time, the DON indicated the nurses were not supposed to have food at the nurse's station so it was in the medication room. 2. During an observation, on 4/7/25 at 10:24 a.m., Registered Nurse (RN) 14 opened the wing medication cart. A Humalog (fast-acting insulin) pen for Resident 33 had an opened date of 2/21/25 and a pharmacy filled date of 2/19/25. A stock bottle of Prosource Plus Liquid Protein was opened and undated. A bottle of Milk of Magnesia (MOM) for Resident 12 was opened and undated. At the same time, RN 14 indicated she thought insulin could be used for 30 days after it was opened, and the liquid protein and MOM should have been dated when opened. 2a. Resident 33's record was reviewed on 4/7/25 at 10:40 a.m. Diagnoses on the resident's profile included, but were not limited to, type two diabetes mellitus (a chronic condition where the body either does not produce enough insulin, or the body's cells do not respond normally to insulin, leading to high blood sugar levels). A Physician's Order, dated 8/26/22, indicated Humalog Kwikpen 100 units (u)/milliliters (ml), inject per sliding scale before meals. 2b. Resident 12's record was reviewed on 4/7/25 at 10:44 a.m. A Physician's Order, dated 1/10/25, indicated MOM 30 ml by mouth daily as needed for constipation. During an interview, on 4/7/25 at 10:34 a.m., the Assistant Director of Nursing (ADON) indicated insulin should have been discarded 28 days past the opened date. The Aplisol, liquid protein, and MOM should have been dated when they were opened. During an interview, on 4/7/25 at 10:59 a.m., the Nurse Consultant indicated the medication room keys should not have been stored where they were accessible to anyone other than nursing staff. At the same time, the DON indicated they kept the medication and EDK keys in the drawer at the nurse's station. On 4/7/25 at 10:53 a.m., the DON provided a document titled, Storage Recommendations for Injectable Diabetes Medications, dated 2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Humalog .Opened .Room Temperature .28 days On 4/7/25 at 10:53 a.m., the DON provided a document titled, .Storage and Expiration Dating of Medications, Biologicals, dated January 2022, and indicated it was the policy currently being used by the facility. The policy indicated, .This Policy .sets forth the procedures relating to the storage and expiration dates of medications .PROCEDURE: 1. Facility should ensure that only authorized Facility staff, as defined by Facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with Applicable law .3.6 Facility should ensure that food is not stored in the .general storage areas where medications and biologicals are stored .5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container .when the medication has a shortened expiration date once opened .5.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial 3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure accurate staffing sheets were posted daily for 3 of 5 days during the recertification survey. Findings include: During an observation, on 4/01/25 at 12:19 p.m., the staffing sheet posted on the wall outside of the nurses' station was dated correctly, but the posting lacked documentation of the total number of the facility census and the name of the facility. During an observation, on 4/2/25 at 9:27 a.m., the staffing sheet posted on the wall outside of the nurses' station, was dated on the top half of the sheet for 4/2/25 and the bottom half for 4/3/25, but the posting lacked documentation of the total number of the facility census and the name of the facility. During an interview, on 4/2/25 at 9:30 a.m., the Director of Nursing (DON) indicated she was not aware the staffing sheet posted was not completed accurately. She indicated the scheduler was responsible for making sure the posting was completed accurately. The DON indicated she would post the staffing sheet in the morning if the scheduler wasn't there. On 4/2/25 at 1:14 p.m., the DON provided a document with a revised of 6/12/24, titled, Staffing, and indicated it was the policy currently being used by the facility. The policy indicated, .3. The daily posting must include: a. Facility name b. Current date .d. Resident census

Based on record review, observation, and interview, the facility failed to ensure a dependent resident had adequate supervision, a safe environment, and was provided care to remain free from injuries of unknown origin for 1 of 3 residents reviewed for accidents (Resident B). Finding includes: On 7/26/24 at 10:45 a.m., a review of an Indiana Department of Health (IDOH) Reportable Incident document, dated 7/6/24 at 6:01 a.m., indicated Resident B was found with bruising to bilateral face and swelling to the nose. She also had a skin tear noted to her left forearm. The type of injury that was noted on the document indicated bruising of unknown etiology. A head-to-toe assessment was completed, and the resident was sent to the emergency room for evaluation and an investigation was initiated. On 7/26/24 at 11:05 a.m., Resident B was observed sitting in a wheelchair outside of her room across from the nurses' station. No bruising was noted to her face at this time, but she did have a foam dressing on her left hand. The resident was unable to communicate about why she had a dressing on her hand. The resident's room was noted to have an end table (with a drawer) next to the bed and was approximately an inch and half away from the mattress. On the other side of the bed was a standard high back chair. There were no side rails noted on the bed. Resident B's record was reviewed on 7/26/24 at 11:15 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS) assessment, dated 6/29/24, indicated the resident was severely cognitively impaired and required assistance from staff for bed mobility, transfers, and toilet use. A care plan, dated 7/7/24, indicated the resident had a skin tear/potential for skin tear of the left forearm and bilateral facial bruising related to unknown injury. Interventions included, but were not limited to, inform staff of causative factors and measures to prevent skin tears and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. A nurse's note, dated 7/6/24 at 6:06 a.m., indicated Licensed Practical Nurse (LPN) 7 noticed Resident B had multiple bruised areas to her face, her nose appeared swollen, and she had a left hand that was bruised, swollen, and contained a 5 centimeter (cm) skin tear. An emergency room note, dated 7/6/24, indicated they were unsure of etiology of the facial purpura (a rash of purple spots due to small blood vessels leaking blood into the joints, intestines, or organs) /petechiae (small red or purple spot that appear on skin which is caused by hemorrhage of capillaries). This could be from patient scratching at her face or some type of trauma. A Care Management note, dated 7/8/24 at 10:02 a.m., indicated Resident B was found to have bilateral facial bruising on 7/6/24 in the morning with a swollen nose and a skin tear to her left hand. There was no reported fall or injury. The resident was sent to the emergency room and returned with no abnormal lab values or fractures noted. Interviews with staff continued currently. An event note, dated 7/8/24 at 7:05 p.m., indicated Resident B had purple spots on bilateral cheeks and 3 cm bruise on left side of jaw and some splotches to left neck. A follow up note, dated 7/11/24, indicated an investigation had been completed and there were no indications or validation of any type of abuse. Staff interviews did not indicate a fall of any kind. Resident B was a two-person transfer requiring extensive assistance with all transfers. Resident was scheduled to have a follow up appointment with a dermatologist on 7/15/24. A skin integrity note, dated 7/11/24, indicated Resident B had petechiae to bilateral cheeks. These areas appeared to be purple and red in color. She had bruises to her left jaw and neck area and 2 small yellowing bruises to chest area. A dermatology progress note, dated 7/15/24, indicated Resident B had purpura to bilateral cheeks and hands. The purpura was consistent with a traumatic injury. Concurrent laceration on the left dorsal hand spoke to traumatic injury. The note was signed by nurse practitioner of the dermatology office. During an interview, on 7/26/24 at 12:04 p.m., the Assistant Director of Nursing (ADON) indicated the facility did a thorough investigation into Resident B's injuries and was unable to determine the cause. The facility interviewed staff taking care of the resident leading up to the morning of July 6th. She indicated their investigation gave them no answers to what had happened. A signed statement, dated 7/6/24, LPN 11 indicated she was asked by a Certified Nurse's Aide (CNA) to enter Resident B's room at around 5:30 a.m. LPN 11 indicated the resident was lying on her left side and her left side had been noted to have appeared purple and had a 5 cm split on the top of her hand. The LPN then noticed multiple bruises on both hands and face. She noted all the bruises were deep purple in color. At 6:00 a.m., she notified the charge nurse. A signed statement, dated 7/6/24 at 2:14 p.m., indicated CNA 12 laid Resident B down for bed around 8 p.m. the night of July 5th, and she did not see any marks on her skin when she went to bed. During an interview, on 7/26/24 at 2:35 p.m., the Director of Nursing (DON) indicated they had their theories on what happened to Resident B but were not able to prove anything. They were unable to determine the cause of her injuries. The DON indicated the resident was not combative with care and was cognitively impaired. She was not aware of any staff having previous disciplinary actions against them. During an interview, on 7/29/24 at 9:45 a.m., CNA 8 indicated she arrived to work on the morning of July 6th and saw Resident B's bruising. She indicated the night shift was unaware of what happened. CNA 8 indicated the facility did an in-service on reporting accidents and abuse and how long they have to report it to management. During a phone interview, on 7/29/24 at 10:29 a.m., LPN 7 indicated she was working the morning that the injuries to Resident B were noted. Resident B was sitting up in the hallway in her wheelchair across from the nurse's station when she arrived at 6:00 a.m. She questioned the night shift CNA about what happened and was told the resident was found that way. LPN 7 indicated she thought the resident had gotten her head caught between the mattress and her bedside table, but she was unable to prove that was what happened. LPN 7 indicated the resident had bruising to bilateral sides of her face and it was swollen, she also had a skin tear to her left hand. The LPN indicated the bruising eventually moved down jaw and neck. During an interview, on 7/29/24 at 1:15 p.m., CNA 17 indicated she was not working the day that Resident B's bruising was noted but she did work on the following Monday. She indicated the resident was pretty bruised up and something had to have happened to her, but no one came forward with anything. During an interview, on 7/29/24 at 1:30 p.m., DON indicated there had been no allegations against staff regarding abuse or being rough with residents. During an interview, on 7/29/24 at 1:37 p.m., Social Service Director (SSD) indicated Resident B had no behaviors, was not combative with care, and didn't thrash around in her bed. She further indicated something had happened to Resident B, but they were unable to determine the cause. SSD indicated she had some theories as to what may have happened but was unable to prove them. The SSD interviewed 11 residents, and no one had complaints about staff being rough during care. On 7/29/24 at 11:09 a.m., the DON provided a document with a revised date of 9/24/23, titled, Incident and Reportable Event Management, and indicated it was the policy currently being used by the facility. The policy indicated, .The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents This citation relates to Complaint IN00438305. 3.1-45(a)

Based on record review and interview, the facility failed to ensure a resident's gastrostomy tube (g-tube-a tube inserted through the belly that brings nutrition directly to the stomach) was maintained in a clean and sanitary condition, for 1 of 2 residents reviewed for g-tube (Resident C). The deficient practice was corrected on 7/17/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: A complaint intake document, dated 7/12/24, indicated Resident C had been seen in the emergency room (ER) of the local hospital. During the physical assessment, live maggots (fly larvae) were found crawling around his g-tube site. Resident C's record was reviewed on 7/26/24 at 11:15 a.m. The profile indicated the resident's diagnoses included, but were not limited to, history of malignant neoplasm (a cancerous tumor) of the lip, oral cavity and pharynx (a hollow, muscular tube inside the neck that starts behind the nose and opens into the larynx [the area of the throat containing the vocal cords and used for breathing, swallowing, and talking] and esophagus), and history of g-tube placement. A quarterly Minimum Data Set (MDS) assessment, dated 6/27/24, indicated the resident had no cognitive deficit, required physical assistance of 2 with activities of daily living (ADLs-basic care tasks of everyday life), and had a g-tube. A care plan, dated 5/19/23, indicated the resident was non-compliant with care related to refusal of additional g-tube feedings. The care plan interventions lacked documentation of assessments to any dressings applied to the g-tube site. A nurse progress note, documented as a late entry, on 7/12/24 at 2:15 p.m., indicated the g-tube site had been assessed and no parasites (maggots) were noted, and a clean dry dressing was in place. Review of the record lacked documentation that any assessment had been completed. A nurse progress note, dated 7/12/24 at 4:27 p.m., indicated while cleaning the residents g-tube site, maggots were noted around the stoma (a surgical connection between an internal organ and the skin on the outside of your body). The resident was sent to the ER for evaluation. An ER report, dated 7/12/24, indicated the resident had presented to the ER for evaluation of maggots found at his g-tube site. The ER course summary indicated upon examination the resident some mild surrounding inflammation. Multiple maggots had been removed by the physician and nursing staff. The report indicated the patient appeared to have been receiving substandard care to his g-tube, at the nursing home. A nurse progress note, dated 7/13/24 at 6:05 p.m., indicated during a g-tube dressing change 2 maggots were observed on the g-tube site. A review of the resident's physician's orders lacked documentation of an order to assess the g-tube site dressing being intact and/or in place, prior to 7/15/24. The resident's Treatment Administration Record (TAR) and Medication Administration Record (MAR), from 1/1/24 to 7/15/24, lacked documentation of an order to assess the g-tube site dressing being intact and/or in place, prior to 7/15/24. A physician order, dated 7/15/24, indicated to validate the g-tube dressing was in place, dry, and intact, when resident returned from being outdoors, four times a day. A physician's order, dated 7/15/24, indicated to assess the g-tube exit site every shift. The resident's care plan was updated on 7/17/24, to indicate the resident preferred to remain outside for extended periods of time during the daytime hours in the elevated temperatures and humidity and often refused to come indoors. Interventions, dated 7/17/24, included, but were not limited to, staff will clean g-tube site and covers with drain sponge, per physician's orders. A care plan, dated 7/15/24, indicated the resident required a tube feeding. Interventions included, but were not limited to, dressing change to g-tube site every shift. On 7/29/24 at 10:30 a.m., the Director of Nursing (DON) provided documentation of the facility's investigation of the incident. At the same time, she indicated the documentation included the correction plan and events that had been put into place to ensure the situation does not occur again. The documents included, but were not limited to, the following: a. An invoice, dated 7/16/24, from a pest control service, which indicated the facility had been treated with fly bait to minimize the presence of flies in the facility. b. Hand hygiene education had been provided to the resident to ensure his hands were cleaned when he re-entered the facility after being outside. c. Statements from staff as to the lack of presence of flies in the resident's room during assessment of the g-tube site. d. Audit documentation of the facility's 2 residents' g-tube site assessments. e. Education to nursing staff on g-tube site care and observance for flies in the building. The education included skills check sign-off sheets for the g-tube assessment and care. During an interview, on 7/26/24 at 10:58 a.m., Resident C indicated he had gone to the hospital a little while back to get his G-tube looked at. It did not hurt but felt like someone was trying to pull it out. When they looked at it at the hospital, they said they found maggots around it. He acknowledged that he had seen flies in his room on multiple occasions. During an interview, on 7/29/24 at 10:01 a.m., the Administrator (ADM) indicated they had completed an investigation related to the maggots which were found on the Resident C's g-tube site. A State Reportable incident was completed and sent. They re-educated all staff on the care and assessment of g-tube sites and were auditing the two residents with g-tubes. The audits would be reviewed by the quality assurance and improvement (QAPI) committee. They also had a pest control service come in and treat the facility in hopes of decreasing the number of flies in the building. This would be an on-going service. During an interview, on 7/29/24 at 11:35 a.m., Certified Nursing Assistant (CNA) 15 indicated the resident has had a dressing on his g-tube for as long as she could remember. She was aware that they had found maggots around his g-tube. She had participated in education on g-tube care and assessment recently. On 7/29/24 at 11:09 a.m., the DON provided a document, dated 8/25/23, titled, Enteral Access Device (EAD) Site Care and Management, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .Critical Notes .2. The nurse will observe for any change .and will inspect the tube .Because .tubes exit through the abdominal wall they require careful skin care .to prevent infection .Caring for gastrostomy .Assess the tube exit site .apply a sterile gauze dressing and external stabilization .around the site .Complications associated with enteral feeding tube exit site care may include .infection This deficient practice was corrected by 7/17/24, after the facility implemented a systemic plan that included the following actions: education provided to all nursing staff on the care and proper assessment of g-tube sites, audits of the resident's with g-tubes were being conducted and results reviewed by the facility QAPI committee, obtained new physician orders for the assessment and care of the resident's g-tube sites, and updated the care plans for the resident's with g-tubes. This citation relates to Complaint IN00438706. 3.1-44(a)(2)

Based on observation, interview, and record review, the facility failed to ensure hair restraints (hair covering and nets, beard restraints, and clothing that cover body hair) were worn in the kitchen during meal service and preparation during 2 of 2 kitchen observations. Findings include: 1. On 2/13/24 at 11:49 a.m., during observation of the lunch meal service in the main dining room, an area in the kitchen was observed to be marked with tape, across the floor, which designated the area staff could not go beyond, without a hair restraint. Licensed Practical Nurse (LPN) 4 was observed entering the kitchen area, beyond the designated area, to retrieve meal trays without a hair restraint. At the same time, the Dietary Manager was observed standing in the kitchen, beyond the designated area, with uncovered facial hair. During an interview, on 2/13/24 at 12:01 p.m., the Dietary Manager indicated that both he and LPN 4 were past the designated area of the kitchen and should have been wearing hair restraints. 2. During observation of pureed food (a way to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) preparation, on 2/16/24 at 10:30 a.m., the Dietary Manager was preparing the pureed food with uncovered facial hair. At the same time, the Dietary Manager acknowledged that he should have his facial hair covered, but failed to put on any hair restraint, and completed the procedure. On 2/14/24 at 10:01 a.m., the Executive Director (ED) provided a document, with a revision date of 3/28/23, titled, Associate Conduct and Dress Code, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: The facility will ensure all foodservice associates adhere to the company's established code of conduct and dress code .Hair Restraints/Jewelry/Nail Polish-Dietary staff must wear hair restraints (e.g., hairnet .beard restraint) .Procedure: .1 .e. All facial hair including moustaches and beards should be .covered 3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident was transferred properly for 1 of 1 resident reviewed for accidents (Resident 14). Findings include: On 2/13/24 at 2:10 p.m., a local police officer was observed entering Resident 14's room with the resident's family member. During an interview, on 2/13/24 at 2:12 p.m., the Executive Director (ED) indicated there had been an allegation of abuse from a resident which indicated a staff had hit her in the right breast during care. The facility had sent in a State reportable incident form and begun an investigation. They also contacted the local police to get statements and investigate. Resident 14's record was reviewed on 2/19/24 at 9:55 a.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), unspecified dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities without a specific diagnosis), and cognitive communication deficit (difficulty with thinking and how someone uses language which may occur after a stroke, tumor, brain injury, progressive degenerative brain disorder, or other neurological damage). A quarterly Minimum Data Set (MDS) assessment (part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 11/10/23, indicated the resident had moderate cognitive deficit and had no documented behaviors. A care plan, dated 6/4/19, indicated the resident had activities of daily living (ADL-activities related to personal care) self-care performance deficit. Interventions included, but were not limited to, the resident transfers with stand by assistance (SBA-the presence of another person within arm's reach that is necessary to prevent, by physical intervention, injury while performing the ADL task in question) of 1 staff assist. A fall risk assessment, dated 1/1/24, indicated the resident was a high risk for falls. A State reportable incident form, dated 2/13/24, was observed. The form indicated the resident had alleged Certified Nursing Assistant (CNA) 8 had been rough with her. The CNA had been suspended pending the facility investigation. The resident was assessed, and no injury was noted. The facility's investigation had been initiated, A typed statement, by Licensed Practical Nurse (LPN) 4, dated 2/13/24, indicated she had often offered assistance to CNA 8, but CNA 8 would get angry when assistance was offered. CNA 8 did not use a gait belt (an assistive device which can be used to help safely transfer a person from a bed to a wheelchair, assist with sitting and standing, and help with walking around) with her transfers. A typed statement by CNA 8, dated 2/13/24, indicated on 2/12/23 at approximately 6:30 a.m., she had completed morning (am) care with the resident. At times when she assisted the resident to her wheelchair, she would place her arm under the resident's arm to guide her. The resident did not complain during care or exhibit any signs or symptoms of pain or injury during the time of the transfer. The statement lacked documentation that the CNA had used a gait belt when she transferred the resident. During an interview, on 2/19/24 at 11:01 a.m., CNA 7 indicated staff were supposed to use gait belts when transferring residents. Each resident who was assisted with transfer would have a gait belt in their room. At the same time, a gait belt was observed in a bag hanging on the back of Resident 14's door. During an interview, on 2/19/24 at 11:03 a.m., Resident 14 indicated she could not remember if CNA 8 had used the gait belt on her when she was attempting to transfer her on the date of the incident. During an interview, on 2/19/24 at 11:19 a.m., the Assistant Director of Nursing (ADON) indicated during the facility's investigation, it was determined that CNA 8 did not use a gait belt while transferring Resident 14. It was the policy of the facility that staff would use gait belts when transferring residents. At the same time, the ADON provided telephone contact information for CNA 8, and indicated the Director of Nursing (DON) had called CNA 8 and instructed her that someone would be calling her to question her about the alleged incident, and to make sure she answered her phone. Three attempts were made to contact CNA 8 by telephone on 2/19/24. The first attempt was at 11:30 a.m., with no answer and a message was left informing the CNA that a second call would be forthcoming. The second attempt was made at 11:40 a.m., with no answer. The third attempt was made at 11:50 a.m., with again no answer. During an interview, on 2/19/24 at 12:05 p.m., the DON indicated facility used the [NAME] guidelines (provides evidence-based procedure guidance at the point of care with over 1,700 procedures and skills from a wide variety of nursing specialties) for the gait belt use as the policy for the facility. If CNA 8 was reinstated to her position, the CNA would be educated on the guidelines, and pass the skills check-off, prior to returning to her regular schedule. On 2/19/24 at 12:05 p.m., the DON provided a document, with a revision date of 9/11/23, titled, Gait Belt Use, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: The facility will provide Gait Belt Use in accordance with professional standards of practice, as outlined by [NAME] .Procedure: The facility will utilize Lippincott procedures On 2/19/24 at 12:05 p.m., the DON provided a document, dated 9/15/23, titled, Skills Checklist-Gait Belt Use, and indicated it was the policy currently being used by the facility. The policy indicated, .Objective: To use a gait belt according to the standard of care .Checklist Step .Wrap gait belt around the patient's waist .Adjust the gait belt so that it fits snugly around the patient's waist .Position yourself close to the patient so that you're facing each other. Grasp both sides of the gait belt with an underhand grip. While firmly gripping the gait belt .instruct the patient on the count of three, to push off the bed or other surface .Keeping a firm grip on the gait belt, gently lower the patient onto the destination surface 3.1-45(a)(1)

Based on observation, record review, and interview, the facility failed to ensure they were free of a medication error of 5% or higher with an error rate of 6.67% for 1 of 5 residents observed for medication administration (Resident 24). Finding includes: During an observation of medication administration, on 2/15/24 at 9:30 a.m., Registered Nurse (RN) 3 proceeded into the main dining room where Resident 24 was standing. RN 3 had a medication cup with the resident's medication in it. Resident 24 was standing by a table with her walker when RN 3 set down the cup of pills on the table. The nurse obtained the resident's blood pressure and indicated to Resident 24 these were her morning pills and that she would be back in a minute because she needed to check on her blood pressure parameters due to her low blood pressure reading. RN 3 walked away from the resident and exited the dining room with 2 pills still in the medication cup minus her blood pressure medication. RN 3 did not observe the resident take her medication before she left the dining room. Resident 24's record was reviewed on 2/15/24 at 11:45 a.m. The profile indicated the resident's diagnoses, included but were not limited to, unspecified dementia (a condition characterized by progressive or persistent loss if intellectual functioning) without behavioral disturbance, essential (primary hypertension) high blood pressure that is not due to another medical condition, and unspecified atrial fibrillation (the heart's upper chambers, called the atria, beat chaotically and irregularly). A quarterly Minimum Data Set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents), dated 1/17/24, indicated the resident had moderate cognitive impairment. A physician order, dated 2/14/24, indicated Lasix (treat fluid retention) 20 mg (milligram) by mouth one time a day for edema (swelling). A physician order, dated 12/11/23, indicated Venlafaxine (antidepressant) 75 mg by mouth one time a day for depression. During an interview, on 2/15/24 at 1:18 p.m., Licensed Practical Nurse (LPN) 4 indicated the nurse must stay with a resident during medication administration and ensure the resident had taken their medication as ordered. On 2/15/24 at 11:33 a.m., the Regional Director of Clinical Services provided a document, with a revised date of 9/22/21, titled, Oral Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Stay with the patient until the patient has swallowed the drug 3.1-48(c)(1)

Based on record review, the facility failed to ensure the medical record of medication administration was accurately documented for 1 of 5 residents reviewed (Resident 31). Findings Include: On 2/15/24 at 10:52 a.m., the medical record of Resident 31was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, chronic obstruction obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems) COPD, aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension) following a cerebral infarction (a stroke which is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel), anxiety disorder (a feeling of fear, dread, and uneasiness which might cause you to sweat, feel restless and tense, and have a rapid heartbeat), malignant neoplasm of right female breast (cancerous tumor), depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks). Physician orders included but were but not limited to, Paroxetine HCl oral tablet 10 mg (milligrams) (Paroxetine HCl) give 20 mg by mouth one time a day for depression, dated 10/20/2023; Lorazepam oral tablet 0.5 mg (Lorazepam) give 1 tablet by mouth at bedtime related to anxiety disorder, dated 11/7/2023; Trazodone HCl oral tablet 50 mg (Trazodone HCl) give 25 mg by mouth at bedtime for anxiety dated 2/13/2024; Hydrocodone-Acetaminophen oral Tablet 10-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth four times a day for pain dated 3/27/2023; Gabapentin Capsule 300 mg give 1 capsule by mouth three times a day for pain - mild dated 4/27/2023; Magnesium Oxide oral tablet 400 mg (Magnesium Oxide) give 1 tablet by mouth three times a day for leg cramps dated 6/2/2023; and Acetaminophen Tablet 325 mg give 2 tablets every 4 hours as needed (PRN) for pain. A quarterly Minimum Data Set, (MDS) (a standardized assessment tool that measures health status in nursing home residents), dated 12/8/23, indicated the resident had a moderate cognitive impairment. A care plan, dated 5/15/23, included Resident expressed pain & discomfort related to arthritis and cancer. Interventions included but were not limited to, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, identify, and record previous pain history and management of pain and impact. Review of medication administration record (MAR) for December 2023 lacked documentation that the following medication were administered. Hydrocodone 1-325 mg (milligrams) on 12/7/23 at 6:00 a.m., 12/22/23 at 6:00 p.m., and 12/23/24 at 6:00 a.m. The Medication administration record for January 2024 lacked documentation that the following medication was administered. Omeprazole 40 mg 1/21/24 a.m. dose. The Medication administration record for February 2024 lacked documentation that the following medication were administered: Docusate Sodium 100 mg 2/10/24 p.m. dose, Gabapentin 300 mg 2/10/24 p.m. dose, and Magnesium oxide 400 mg 2/10/24 p.m. dose. On 2/15/2024 at 11:33 a.m., the Director of Nursing Services (DON) provided a document titled, Administration of medications, dated 2/13/23, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .The facility will ensure medications are administered safely and appropriately per physician order .B. Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration .6. Right Documentation .Make sure to write the time and any remarks on the chart correctly .Medication administration should be documented timely following the administration to the resident .Controlled substances should be signed out from the descending count sheet and documented on the MAR for each routine and PRN dose of medication administered 3.1-50(a)

Based on observation, record review, and interview, the facility failed to ensure proper handling of medication patches during the medication administration pass for 2 of 5 residents reviewed during medication administration (Residents 9 and 26). Findings include: 1. During a medication administration observation, on 2/15/24 at 9:44 a.m., RN 3 placed a Lidocaine (pain relief medicated patch) external patch onto Resident 9's right shoulder. RN 3 did not have gloves on when removing the patch from the packaging or when placing the patch onto the resident's shoulder. Resident 9's record was reviewed, on 2/15/24 at 1:20 p.m. The profile indicated the resident diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe) and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one sided weakness, but without complete paralysis). An annual minimum date set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents), dated 12/11/23, indicated the resident had moderate cognitive impairment. A physician order, dated 7/24/23, indicated Lidocaine external patch 5%, apply to right shoulder every morning for pain. 2. During a medication administration observation, on 2/15/24 at 10:35 a.m., RN 3 removed a NicoDerm (smoking sensation medication) patch from the box and used a pair of scissors to cut the patch out of the package with her bare hands. RN 3 proceeded from the medication cart to Resident 26's room with her medications. The nurse removed an old NicoDerm patch from the right side of her chest and placed the new patch on the left side of her chest. The nurse did not wear gloves when removing the old patch and placing a new patch on the resident. Resident 26's record was reviewed, on 2/15/24 at 1:29 p.m. The profile indicated the resident diagnosis included, but were not limited to, COPD and fibromyalgia (a long-term condition that involves widespread body pain and tiredness). An admission MDS assessment, dated 1/22/24, indicated the resident was cognitively intact. A physician order, dated 1/15/24, indicated NicoDerm cq transdermal patch 24-hour 21mg (milligram), apply one transdermal patch once a day for smoking cessation. During an interview, on 2/15/24 at 10:35 a.m., RN 3 indicated she should have worn gloves when removing and or placing medication patches on the residents. During an interview, on 2/15/24 at 1:18 p.m., Licensed practical nurse (LPN) 4 indicated nursing staff should always wear gloves when removing or placing medication patches on the residents. On 2/15/24 at 11:33 a.m., the Regional Director of Clinical Services provided a document, with a revised date of 9/23/21, titled, Transdermal Ointment and Patch Application, and indicated it was the policy currently being used by the facility. The policy indicated, .Put on gloves and as needed, other personal protective equipment to comply with standard precautions 3.1-18(b)(1)

Based on observation and interview the facility failed to maintain all mechanical equipment was kept in safe operating condition for 2 of 2 observations of the laundry service area. Findings Include: On 2/19/24 at 11:02 a.m., during routine observation of the laundry service area, two large fans were observed. The fan blades and the fan cage covering the blades were coated in a thick layer of grey lint. On the floor behind washers were a large amount of grey lint and debris. Lint traps in two dryers contained a moderate amount of lint on the screens. The cleaning logs indicated the lint traps were cleaned frequently. The lint on the fans and behind the washers created a risk for fire hazard. On 2/19/24 at 1:30 p.m., during an interview with the Administrator indicated the fans and floors of the laundry area must be kept clean and free of lint. On 2/19/2024 at 11:30 a.m., the Assistant Director of Nursing (ADON) provided a document titled, Laundry Services- General Policy, dated 2/12/20, and indicated it was the policy currently being used by the facility. The policy indicated, .Separating clean from Dirty in the Laundry .5. All areas should be cleaned on a regular basis 3.1-19(bb)

Based on interview and record review, the facility failed to ensure blood thinner medication (Eliquis) was administered to 1 of 3 residents reviewed the prescribed medication. This deficient practice resulted in Resident B being admitted to the hospital for treatment of [REDACTED]. Findings include: Resident B's clinical record was reviewed on 5/15/17 at 10:30 a.m. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Medication Notes on the back of the form for April 1,2,3,4,8,10, and 14 indicated the medication was not available. Twenty-six doses of the prescribed thirty-nine doses had not been given. Seven nurses had signed the doses had not been given. A physician's telephone order, dated 4/20/17, was noted of, Send to ER (emergency room ) to evaluate and treat right leg numbness and discoloration, negative pedal pulse, shortness of breath, and diaphoretic. A hospital note, dated 4/23/17, included, but was not limited to, .Diagnostic results showed cold pulseless right leg due to arterial occlusion ([MEDICAL CONDITION]). The patient was treated with IV (intravenous) [MEDICATION NAME] (blood thinner) followed by thrombectomy The Administrator was interviewed on 5/15/17 at 1:55 p.m. She indicated the Director of Nursing (DON) had authorized two different times for a three day supply of the medication to be sent. On 5/16/17 at 10:55 am., the DON was interviewed. She indicated a prior authorization form, required for insurance coverage, had been sent to the resident's physician (MD) for signature a few times and had not been returned. She indicated there was no evidence of the physician being notified of the resident missing several doses of the medication. A facility policy and procedure for unavailable medications, provided by the DON on 5/15/17 at 2:40 p.m., dated 11/10/11, documented We are having issues with mediations being unavailable and nurses' circling the medication in the MAR indicated [REDACTED]. If medication is unavailable from the EDK (emergency drug kit) a.) Circle it in the MAR b.) Notify the on-call nurse c.) Notify the physician d.) Notify the family e). Document when medication will arrive and that the on-call nurse, MD, & (and) family was notified f). Add to 24 hour report This Federal tag relates to complaint IN 915. 3.1-48(c)(2)

A. Based on record review and interview, the facility failed to ensure a C.N.A. was proficient in the use of a slide board used for transfers. This deficient practice impacted 1 of 1 resident reviewed who used a slide board for transfers and was transferred incorrectly, sustaining a fracture as a result of the deficient practice. (Resident #C, C.N.A. #1) B. Based on record review and interview, the facility failed to provide evidence that 3 of 3 newly hired C.N.A.s were visually observed and were able to demonstrate competency in all basic job skills specific to a C.N.A. after being hired. This deficient practice had the potential to impact 50 total residents of the facility. (C.N.A. #1, C.N.A. #2, and C.N.A. #3) Findings include: A.1. In an interview during the initial orientation tour on 9/7/11 at 10:05 A.M., the Staff Development Coordinator indicated Resident #C had sustained a fracture during a transfer to bed using a slide board about 6-8 weeks ago. The resident was now being transferred with a Hoyer mechanical lift. The clinical record for Resident #C was reviewed on 9/7/11 at 1:20 P.M. [DIAGNOSES REDACTED]. A "Nurse's Notes" progress note, dated 7/24/11 at 3:15 P.M., indicated that an injury occurred to Resident #C's right knee. An X-ray report, dated 7/24/11 at 6:32 P.M., indicated "Two limited views were obtained of the right knee.... Impression: Nondisplaced spiral fracture proximal tibia." An investigation was initiated on 7/24/11, and a document titled "Witness Interview Form," dated 7/24/11 at 6:45 P.M., indicated: "Name of witness: Certified Nursing Assistant #1.... The following is a statement about the facts: C.N.A. was transferring resident from his wheelchair to his bed using a transfer board (sliding board).... Resident got his right leg caught on the bed and was bent backward. C.N.A. heard a pop and Resident immediately started complaining of pain in his right knee and lower leg...." A "Witness Interview Form," dated 724/11 at 8:30 P.M., indicated: "Name of witness: (Resident #C), Title of witness: Resident.... The following is a statement about the facts: C.N.A. (#1) was moving Resident from the wheelchair to the bed using the transfer board (sliding board). Resident's right foot caught on the sheet pulling his leg bending it all the way underneath him.... Resident feels like C.N.A. is too short to move him... Resident #C feels that C.N.A. #1 is not experienced enough... C.N.A. #1 did not use a gait belt.... C.N.A. had trouble once before.... Resident gave C.N.A. another chance today but shouldn't have...." A "P.T. (Physical Therapy) Daily Progress Note," dated 7/7/10, indicated "P.T. evaluation completed. Plan of care developed and skilled treatment recommended for sliding board transfer.... Teach training to aides.... This intervention is medically necessary in order to transfer from bed to W/C (wheelchair)." A copy of the Physical Therapy "Functional Maintenance Program," dated 7/19/10, was provided by the Director of Nursing on 9/8/11 at 11:10 A.M. The program included, but was not limited to, "Transfers: Patient is to slide board transfer with assist x 1 from bed to electric wheelchair or from wheelchair to bed...." Another "P.T. Daily Progress Note," dated 7/20/10, indicated "This intervention is medically necessary in order to ensure safety and competence with all C.N.A.'s and nursing staff for performance of slide-board (sliding board) transfer.... During today's session, 2 C.N.A.s were trained in performing slide-board transfer from bed to wheelchair...." A copy of the Physical Therapy "Functional Maintenance Program," dated 12/29/10, was received from the Director of Nursing on 9/8/11 at 11:10 A.M. The program indicated "Transfers: patient is to slide board transfer to and from wheelchair and recliner with gait belt and assist of one...." On the bottom of the document, 4 staff members had signed their names for "C.N.A.'s that were trained by therapist on this FMP." None of the signatures were for C.N.A. #1. A "Plan of Treatment," dated 7/19/11, indicated "Plan of Treatment Functional Goals: The patient (Resident #C) will safely perform bed to motorized wheelchair transfers with sliding board at maximum assistance...." A Care Plan entry, dated 7/28/10, addressed a "Problem/Need" of "Resident is on nursing restorative program for transfers to help maintain current functional ability and decrease assistance with transfers. Approaches were listed as: "Staff to assist/supervise resident to use slideboard (sliding board) to transfer to and from wheelchair and recliner with gait belt to help maintain current functional ability...." This care plan was discontinued as of 9/3/2011. A Care Plan dated 8/1/11 indicated "Resident has pain associated with recent fracture of his tibia that occurred during a sliding board transfer.... Hoyer lift (mechanical lift) for all transfer, no sliding board transfers...." In an interview on 9/7/11 at 2:45 P.M., the Executive Director indicated that Resident #C had been using the sliding board for transfers for a long period of time. She indicated she was not aware of who officially trained the C.N.A.s, and did not have any documentation regarding training with the sliding board. The Executive Director indicated that C.N.A.s often train each other on skills. In an interview on 9/8/11 at 9:15 A.M., Resident #C indicated that during the incident that broke his right tibia, C.N.A. #1 did not use a gait belt to transfer him. The resident indicated that the C.N.A. had difficulties one other time transferring him, and he notified the charge nurse at that time. Resident #C indicated he now uses a Hoyer lift (mechanical lift) for transfers, and is no longer able to use the sliding board. He indicated he had used the sliding for board over [AGE] years. In an interview on 9/8/11 at 10:55 A.M., the Director of Nursing indicated the only time staff would have been trained on a sliding board was when the resident was first placed on a "functional maintenance plan" that specified the use of a sliding board. The Restorative Certified Nursing Assistants were trained, not the unit C.N.A.s. The Director of Nursing was unable to verify if C.N.A. #1 had received any training on the correct use of the slide board with a gait belt, and had no record of such training. The employee file for C.N.A. #1 was reviewed on 9/8/11 at 9:00 A.M. The C.N.A. was hired by the facility on 3/7/11. A "Termination Form," dated 7/27/11, indicated the C.N.A. was terminated on 7/24/11 because she "did not follow safety protocols while providing resident care (for Resident #C) on 7/24/11...." B.1. The employee file for C.N.A. #1 was reviewed on 9-8-2011 at 9:00 A.M. The C.N.A. was hired by the facility on 3/7/11. A "Body Mechanics/Transfer Training Demonstration Checklist" form, signed on 3/15/11 by a prior Staff Development Coordinator, indicated C.N.A. #2 had "successfully demonstrated" lifting objects, 1 and 2 person transfers in and out of bed and chair--with and without a gait belt, and mechanical lift transfers. There was no other checklist or documentation found that indicated the C.N.A. had been directly observed performing all of the other required job skills for her position, such as bed baths and showers, checking vital signs, taking weights, following hand hygiene or standard precaution infection control protocols, dressing residents, turning and repositioning, denture care, etc. 2. The employee file for C.N.A. #2 was reviewed on 9/7/11 at 11:30 A.M. The C.N.A. had recently completed C.N.A. training, received her registration, and was hired by the facility on 8/17/11. A "Checklist for New Facility Associate Orientation" form was found in the employee's file. The form was dated 8/17/11 and signed by the S.D.C. (Staff Development Coordinator). The "Checklist" listed general areas of orientation covered, such as "dress code, safety program, theft policy, job description," etc. There was no categories addressing observation of the C.N.A. performing the required job skills in order to determine proficiency in those skills. A "Body Mechanics/Transfer Training Demonstration Checklist" form, signed on 8/30/11 by the Staff Development Coordinator, indicated C.N.A. #2 had "successfully demonstrated" lifting objects, 1 and 2 person transfers in and out of bed and chair--with and without a gait belt, and mechanical lift transfers. There was no other checklist or documentation found that indicated the C.N.A. had been directly observed performing all of the other required job skills for her position, such as bed baths and showers, checking vital signs, taking weights, following hand hygiene or standard precaution infection control protocols, dressing residents, turning and repositioning, denture care, etc. 3. The employee file for C.N.A. #3 was reviewed on 9/7/11 at 11:40 A.M. The C.N.A. was hired by the facility on 8/2/11. A "Checklist for New Facility Associate Orientation" form was found in the employee's file. The form was dated 8/2/11 and signed by the S.D.C. (Staff Development Coordinator). The "Checklist" listed general areas of orientation covered, such as "dress code, safety program, theft policy, job description," etc. There was no categories addressing observation of the C.N.A. performing the required job skills in order to determine proficiency in those skills. A "Orientation Checklist--Certified Nursing Assistant (C.N.A.)" form was located in the file. The form listed categories such as "Introduction to Department Heads, Location of Fire Alarm and Pull Stations, Review of Job Description, Review of Risk Management Procedures, Review of Infection Control Technique, Review of Reports to Charge Nurse," etc. The form was initialed by the new employee as completed on 8/2/11. There was no co-signature by any other licensed staff person. A "Body Mechanics/Transfer Training Demonstration Checklist" form, signed on 8/2/11 by the Staff Development Coordinator, indicated C.N.A. #2 had "successfully demonstrated" lifting objects, 1 and 2 person transfers in and out of bed and chair--with and without a gait belt, and mechanical lift transfers. There was no other checklist or documentation found that indicated the C.N.A. had been directly observed performing all of the other required job skills for her position, such as bed baths and showers, checking vital signs, taking weights, following hand hygiene or standard precaution infection control protocols, dressing residents, turning and repositioning, denture care, etc. 4. In an interview on 9/7/11 at 11:50 A.M., the Staff Development Coordinator indicated she had been in her position since sometime in March, 2011, and had not previously had any staff training experience. She indicated there was no specific job orientation documentation. Following the initial orientation period, a newly hired C.N.A. would be assigned to a unit, with the licensed nurse on duty acting as a preceptor. The nurses who were preceptors supervised the C.N.A.s but did not specifically observe each performing all of the required skills, nor did they document any information related to observed skills that were completed successfully. This Federal tag relates to Complaint IN 158. 3.1-14(i)

Based on observation, interview, and record review, the facility failed to ensure residents were provided with necessary care and treatment related to the lack of treatment and intervention for a resident with [MEDICAL CONDITION] which resulted in the development of more ulcers on the foot, a delay in treatment for [REDACTED]. This deficient practice affected 3 of 13 residents reviewed for the implementation of necessary care and services in a total sample of 13 residents. (Residents # 1, # 13, and # 16) Findings include: 1. The clinical record for Resident # 13 was reviewed on 2/8/11 at 11:35 A.M. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. An admission minimum data set (MDS) assessment, with an assessment reference date of 1/7/11, indicated the resident was dependent upon staff for her activities of daily living. a. During the orientation tour with the Director of Nursing on 2/7/11 at 10:35 A.M., she indicated Resident # 13 was admitted to the facility with a Stage II pressure area. She did not indicate the resident had a wound on her feet at that time. An "Initial Data Collection Tool/Nursing Service" form, dated 1/1/11, indicated the resident had a dry lesion on the foot. A nurse's note, dated 1/1/11 at 9:00 P.M., indicated, "...dry, scab like lesion sole (left) foot (without) redness. Hx (history) osteo[DIAGNOSES REDACTED] (an infection in the bone) (and) surgery (left) foot...." There was no documentation in the clinical record to indicate a care plan was developed or a treatment was put into place for the resident's foot wound at that time. A physician's progress note, dated 1/7/11, indicated, "Debrided the left wound to subq (subcutaneous tissue)-start wound care (and) decrease weight bearing..." A note from the resident's podiatrist, dated 1/7/11, indicated "...Examination of the sx (SIC) site reveals: The dressing has mild serous drainage. The wound on the bottom of the left foot measures 2 x 9 x 2 mm (millimeters). There is moderate hpk (SIC) and fibrotic tissue build up. There is blistering up the medial side. There is no purulence or fluctuance. No necrosis. The base is moist and granular. There is no [DIAGNOSES REDACTED] (redness). No focal [MEDICAL CONDITION]. There is 2+ [MEDICAL CONDITION] to both LEs (lower extremities)...Assessment: Grade I ulcer left midfoot. Larger due to loss of follow up and weight bearing...Diabetic Foot Risk Category III...Plan:...I debrided the wound to and including subQ (subcutaneous) and dressed the wound. Continue to dress daily. Orders given...." A physician's orders [REDACTED]. A nurse's note, dated 1/7/11 at 4:20 P.M., indicated, "... Noted 3+ [MEDICAL CONDITION] (swelling) to lower ext (extremity) bilat (bilateral) ... (and) unable to detect (left) pedal pulse-dressing in place to ankle-awaiting ointment of [MEDICATION NAME] to start tx (treatment) to pre-existing [MEDICAL CONDITION].Encouraged res. (resident) to elevate lower extremities for swelling, resident verbalized her understanding...." A "Non-Pressure Skin Condition Record" form, initially dated 1/1/11, indicated the resident had a dry scab lesion to the left foot. On 1/1/11, the form indicated the area measured 0.8 centimeters by 0.8 centimeters and was described as "brownish". The next assessment and measurement of the wound was 1/18/11. At that time, the area measured 1.3 centimeters by 0.9 centimeters and the depth was unknown. The area was described as a "dark brown scab". The next assessment and measurement of the wound was 1/25/11. At that time, the area measured 1.3 centimeters by 0.8 centimeters and the depth was unknown. The area was described as "brown scabbed". The next measurement of the wound was on 2/8/11. At that time, the area measured 1 centimeters by 0.5 centimeters and the depth was unknown. The area was described as "dry white scabbed light brown". Documentation was lacking to indicate there was any care plan related to care for the resident's feet in the clinical record. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. There were no initials on the above dates to indicate the [MEDICATION NAME] treatment was applied. On 1/28/11, the word "healed" was written across the area where the order was signed out. There was no additional documentation on the MAR for 1/11 to indicate the [MEDICATION NAME] treatment was applied. Review of the MAR for 2/11 indicated the word "healed" was written next to the order for [MEDICATION NAME]. There was no documentation on the MAR indicated [REDACTED]. There was no documentation in the clinical record to indicate the order for the [MEDICATION NAME] was discontinued by the physician. A "Weekly Skin Integrity Data Collection" form, initially dated 1/1/11, indicated a weekly skin assessment was completed on 1/1/11, 1/20/11, and 1/25/11. There was no documentation in the clinical record to indicate skin assessments were completed on a weekly basis. During an interview with LPN # 2 on 2/8/11 at 5:55 P.M., she indicated Resident # 13 had a wound to the left foot. She indicated the current order was to apply [MEDICATION NAME] cream to the area. She indicated the measurements of the wound were not completed during the previous week because she was pulled to work on the floor. An interview with the Executive Director on 2/9/11 at 9:15 A.M., indicated the measurements of the resident's wounds were not done weekly. She indicated the wound on the resident's foot was measured on her admitted on 1/1/11 and then not again until 1/18/11. She indicated the nursing staff had indicated the wound was healed on the MAR because it was scabbed over, but the wound nurse was still measuring the wound. She indicated she was not able to verify that the [MEDICATION NAME] treatment was applied as ordered, but the staff probably did the treatment but without initials she was not able to prove the treatment was completed. During observation of Resident # 13 with RN # 13 on 2/9/11 at 11:00 A.M., the following was observed: Upon entering the resident's room, the resident was observed sitting in her wheelchair with her feet resting on the floor. The resident had gripper socks in place. RN # 13 removed the resident's socks. At that time, RN # 13 indicated there were 5 wounds to the top of the resident's left foot. She indicated the top area on the resident's 2nd toe appeared to be an abraded area. She indicated the bottom area on the resident's 2nd toe appeared to be scabbed with some inflammation. She indicated there were 2 scabs noted to the resident's 3rd toe. She indicated there was 1 scab observed on the resident's 4th toe. There was no treatment in place to the resident's toes at that time. A wound was noted to the bottom of the resident's left foot. In an interview immediately following the observation, RN # 13 indicated she was not the wound nurse, and she was not aware of the wounds on the top of the resident's foot. She indicated she was only aware of the wound on the bottom of the resident's foot. A "Non-Pressure Skin Condition Record" form, dated 2/8/11, indicated the resident had four abrasions on the left foot which were first observed on that date. The areas were measured as follows: 2nd toe: 0.4 centimeters by 0.6 centimeters 3rd toe: 1) 0.3 centimeters by 0.2 centimeters 2) 0.4 centimeters by 0.3 centimeters 4th toe: 2 centimeters by 2 centimeters There was no documentation on the form to indicate the 5th area was identified and measured by the wound nurse on 2/8/11. At the time of the observation of the wounds on 2/9/11 at 11:00 A.M., the facility had not received treatment orders from the physician for the wounds identified on 2/8/11. During an interview with the Executive Director on 2/9/11 at 2:10 P.M., she indicated the nursing staff should look at the feet daily when doing the treatment. She indicated the MAR indicated [REDACTED]. She indicated the staff should have notified the physician that the area was healed, and the [MEDICATION NAME] treatment should not have been discontinued without an order from the physician. She indicated there should have been a weekly measurement of the wound. She indicated the wound nurse had to work the floor and was not able to measure wounds the previous week due to the weather. She indicated the staff should have made other arrangements to ensure the wounds were measured. She indicated she would expect to have treatments for the wounds identified on 2/8/11 today (2/9/11). She indicated she would assume the area that was not measured was new, and she assumed the wound nurse would have measured all of the areas if they were present during her assessment on 2/8/11. A current undated facility policy, provided by the Executive Director on 2/10/11 at 9:30 A.M., titled "[MEDICAL CONDITION] Risk Assessment" indicated, "...Residents with [MEDICAL CONDITION] (e.g., secondary to diabetes mellitus) are at risk for developing foot ulcers. Methods to help prevent the formation of foot ulcers include, but are not limited to: control of the underlying condition...footwear modifications to reduce pressure....and foot/skin care...." b. A nurse's note, dated 1/19/11 at 8:45 A.M., indicated, "...c/o (complained of) pain under bilat (bilateral) arms-yeast associated odor noted-Res. (resident) states that [MEDICATION NAME] (an anti-fungal medication) used in the past (with) positive results (and) fax prepared for MD (medical doctor)..." A "Fax Order Request/Notification Form", dated 1/19/11, indicated, "...Res c/o pain to axillary areas (with) redness noted-has yeast associated smell-May we have order for [MEDICATION NAME] powder/cream?..." A physician's orders [REDACTED]. The order was dated 1/20/11, and indicated the resident was to receive an order for [REDACTED]. A nurse's note, dated 1/20/11 at 10:05 A.M., indicated, "...cont. (continues) to have some burning under arms-waiting for orders for tx (treatment)..." A nurse's note, dated 1/20/11 at 7:40 P.M., indicated, "awaiting response for tx cream to bilateral arm pits..." A nurse's note, dated 1/21/11 at 5:00 P.M., indicated, "Resident (with) excoriation to under side of breasts (and) skin folds; sent request for [MEDICATION NAME] cream to MD..." A nurse's note, dated 1/22/11 at 11:25 A.M., indicated, "...excoriation cont. (continues) under arms..." A nurse's note, dated 1/22/11 at 7:30 P.M., indicated, "... Awaiting response for tx cream request..." A nurse's note, dated 1/23/11 at 6:50 P.M., indicated, "Excoriation to arm pits remain; awaiting tx orders..." A nurse's note, dated 1/24/11 at 5:35 P.M., indicated, "Received N.O. (new order) to apply [MEDICATION NAME] powder to axillary areas BID (twice daily) x (times) 2 wks (weeks)..." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the Executive Director on 2/9/11 at 2:00 P.M., she indicated the [MEDICATION NAME] cream was started on 1/26/11, when the facility received the medication from the pharmacy. She indicated she would have liked to have the treatment started sooner, and would have expected the nurses to follow up. 2. The clinical record for Resident # 1 was reviewed on 02/08/2011 at 9:50 a.m. [DIAGNOSES REDACTED]. A care plan for constipation, dated 11/20/2010, indicated, "...Give stool sofners (SIC) as ordered...Follow bowel protocol as needed...." An "Assessment for Bowel and Bladder Training," dated 12/22/2010 indicated the resident was incontinent of bowel and bladder and was a poor candidate for scheduling or retraining bowel and bladder elimination. The "Monthly Flow Report," dated January 2011, indicated no bowel elimination on January 7, 8, 9, 10, 11, 12, 13, 20, 21, 22,23, 24, and 25, 2011. The Physician's Recapitulation dated 01/2011 indicated, "[MEDICATION NAME] 10 MG (milligram) SUPPOSITORY INSERT 1 SUPPOSITORY RECTALLY ONCE A DAY AS NEEDED-CONSTIPATION...MILK OF MAGNESIA SUSP (suspension) GIVE 30 ML (milliliters) ORALLY ONCE A DAY AS NEEDED-CONSTIPATION...." Documentation was lacking to indicate daily interventions for constipation were implemented or that the physician was notified when the resident did not have a bowel movement for more than 4 days. During an interview on 02/11/2011 at 9:30 a.m., RN # 20 indicated a prn (as needed) medication should have been given when a resident had not had a bowel movement for 3 days. During an interview on 02/11/2011 at 9:32 a.m., LPN # 21 indicated a prn medication should have been given and the physician notified when a resident had been more than 3 days without bowel elimination. She indicated the charge nurse reviewed the bowel elimination records daily and informed the medication nurses when a prn medication was needed to aid in bowel elimination. During an interview on 02/11/2011 at 9:35 a.m., LPN # 2 indicated the protocol for bowel elimination was to give a prn medication when a resident had been more than 3 days without a bowel movement. 3. The clinical record for Resident # 16 was reviewed on 02/07/2011 at 1:20 p.m. [DIAGNOSES REDACTED]. A care plan for constipation, dated 11/20/2009 and reviewed on 1/12/2011, indicated, "...Review recent bowel elimination pattern daily...Administer laxatives/stool softeners as ordered by physician...." The "Monthly Flow Report," dated December 2010, indicated no bowel elimination on December 15, 16, 17, 18, 19, 21,22,23,24, and 25, 2010. The "Monthly Flow Report," dated January 2011, indicated no bowel elimination on January 14,15, 16, 17, 21,22,23,24,25,and 26, 2011. An "Assessment for Bowel and Bladder Training," dated 01/24/2011 indicated the resident was continent of bowel and bladder and was a good candidate for individual bowel and bladder elimination training. The Physician's Recapitulation dated 01/2011 indicated, "[MEDICATION NAME] EC 5 MG (milligram) TABLET GIVE 2 TABLETS (10 MG) ORALLY ONCE A DAY PRN (as needed) FOR [MEDICATION NAME] 10 MG (milligram) SUPPOSITORY INSERT 1 SUPPOSITORY RECTALLY ONCE A DAY PRN CONSTIPATION...FLEET ENEMA INSERT 133 ML (milliliters) RECTALLY ONCE A WEEK AS NEEDED FOR SEVERE CONSTIPATION/STOOL IMPACTION...MILK OF MAGNESIA SUSP (suspension) GIVE 15 ML (milliliters) ORALLY ONCE A DAY PRN FOR CONSTIPATION...." Documentation was lacking to indicate daily interventions for constipation were implemented or that the physician was notified when the resident did not have a bowel movement for more than 4 days. During an interview on 02/11/2011 at 9:30 a.m., RN # 20 indicated a prn (as needed) medication should have been given when a resident had not had a bowel movement for 3 days. During an interview on 02/11/2011 at 9:32 a.m., LPN # 21 indicated a prn medication should have been given and the physician notified when a resident had been more than 3 days without bowel elimination. She indicated the charge nurse reviewed the bowel elimination records daily and informed the medication nurses when a prn medication was needed to aid in bowel elimination. During an interview on 02/11/2011 at 9:35 a.m., LPN # 2 indicated the protocol for bowel elimination was to give a prn medication when a resident had been more than 3 days without a bowel movement. As of the exit interview on 2/14/11 at 5:45 p.m., no documentation was provided to indicate bowel interventions had been completed. A "BM (bowel movement) Protocol" was provided by the Executive Director on 02/11/2011 at 2:00 p.m. The protocol indicated, "...If no bowel movement is recorded for 2 days: the nurse will assess for signs and symptoms of constipations (SIC)...If no bowel movement is recorded for 3 days: Administer PRN laxative or enema as ordered by physician...After 4 days with no bowel movement or inadequate response to previous interventions, contact the physician...." 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure pressure ulcer prevention, assessment, intervention, and treatment was completed which resulted in the development of multiple stage II pressure ulcers for 2 of 4 residents reviewed with pressure ulcers in a sample of 13 residents. (Residents #7 and #17) Findings include: 1. During initial tour on 2/7/11 at 10:50 a.m., with LPN #1, Resident #17 was identified as having a [DEVICE] (gastrostomy tube) with continuous feeding 24 hours per day. He identified the resident as being unable to turn and reposition in bed on her own. The LPN indicated he was unsure as to whether the resident had any skin impairments at that time. During an observation on 2/7/11 at 12:55 p.m., and again at 2:08 p.m., Resident #17 was observed lying in bed on her back with the head of the bed elevated to 45 degrees. During an observation on 2/7/11 at 3:20 p.m., Resident #17 was observed lying in bed on her back with the head of the bed elevated to 30 degrees. During an observation on 2/8/11 at 12:24 p.m., 1:55 p.m., and 3:00 p.m., Resident #17 was observed lying in bed on her back with the head of the bed elevated to 30 degrees. During an observation on 2/9/11 at 10:50 a.m., Resident #17 was observed lying in bed on her back with the head of the bed elevated to 30 degrees. During an observation on 2/9/11 at 2:10 p.m., with the Director of Nursing and CNA #4 on 2/9/11 the following was observed: The resident was lying in bed on her back with the head of the bed elevated to 30 degrees. The resident's brief was removed and the resident was turned to her side. There were two open areas observed on the resident's left buttock. There was no dressing in place at the time of the observation. The resident had feces and urine on her buttocks, but there was no urine or feces evident on the open areas. The open areas were observed to be stage II pressure ulcers approximately 1 centimeter in diameter. The wound beds were red in appearance with no drainage or odor noted. During an interview with the CNA at the time of the observation she indicated the resident was turned and repositioned every two hours throughout the day. During an interview with the DoN at the time of the observation she indicated the areas on the resident's left buttock were more of a shear than an excoriation. She then indicated the areas could have been an incontinence [MEDICAL CONDITION] type skin condition. She then indicated she would have considered the areas as erupted blisters. She then indicated she would consider the areas pressure. She indicated they would be considered stage II pressure areas because they were open. She indicated there should have been a dressing in place. During an observation on 2/10/11 at 3:05 p.m., with the Director of Nursing, LPN #2, the Executive Director, and the corporate consultant the following was observed: The resident was lying on her back in bed with the head of the bed elevated to 30 degrees. The resident was turned on her side and the buttocks was exposed. There was no dressing in place to the resident's buttocks. The resident proceeded to have a bowel movement and was cleaned by the LPN. The open areas to the resident's left buttocks were measured by LPN #2 as follows: 1. 0.9 centimeters (cm) x 0.8 cm x 0.1 2. 0.9 cm x 0.6 cm with no depth Neither the DoN nor the LPN would identify what stage of pressure the areas were assessed to be at the time of the observation. During an interview with the corporate consultant immediately following the observation, she indicated the areas were currently stage II pressure ulcers. Resident # 17's record was reviewed on 2/8/11 at 10:00 a.m. [DIAGNOSES REDACTED]. Review of the resident clinical record indicated the resident had a history of [REDACTED]. A quarterly minimum data set assessment dated [DATE], indicated Resident #17 required extensive assist of two staff for bed mobility and transfers, extensive assist of one staff for toileting and hygiene, had upper and lower extremity impairment on one side of the body, was always incontinent of bowel and bladder, and was at risk for pressure ulcer development. The assessment further indicated the resident had a pressure reduction device on the bed and chair and was on a turning and repositioning program. A "Braden scale for predicting pressure score risk" dated 10/4/10 through 12/8/10, indicated the resident was at moderate to high risk for pressure ulcer development. Documentation was lacking to indicate a pressure ulcer prevention care plan was in place at the time of the record review. The nurses' notes indicated the following: "1/23/11 0430 (4:30 a.m.) res found c (with) 1 cm diameter open area on L upper buttocks..." "1/24/11 5:40 pm received n.o. (new order) to cleanse area on L buttock c soap and water then apply [MEDICATION NAME] cream to area TID (three times per day) et (and) PRN (as needed)...." Review of the medication administration records dated 1/24/11 through 2/8/11 indicated documentation was lacking related to the [MEDICATION NAME] cream having been applied for 20 of 48 shifts. A "Non-pressure skin condition record" indicated: "...condition type: excoriation, date first observed 1/24/11, location Lt (left) buttock..." Documentation indicated there were two areas identified on the body sketch on the form with x's. Documentation was lacking to indicate any measurements of the areas had been documented on the record. Documentation was lacking to indicate the areas had been measured from 1/24/11 through 2/7/11. "Date 2/8/11, site A, size in cm: 1 cm diameter, depth: .1 cm, drainage: none...color: pink/red...appearance of wound: clean (handwritten) response to treatment: improved (checkmark)..." The documentation was signed by LPN #2. Date 2/8/11, site B, size in cm: 1.4 cm diameter, depth: .1 cm, drainage: none...color: pink/red, non-blanchable...appearance of wound: clean (handwritten) response to treatment: improved (checkmark)..." The documentation was signed by LPN #2. A physician's orders [REDACTED]. Apply [MEDICATION NAME] and dry clean dressing one time daily and PRN x 14 days..." Review of the medication administration records dated 2/8/11 through 2/10/11 indicated documentation was lacking related to the treatment having been done. A daily care guide provided by the ED on 2/10/11 at 12:00 p.m., indicated "...B&B (bowel and bladder) total dependence on staff...check for incontinence every two hours...pressure reduction cushion in w/c (wheel chair)...pressure reduction mattress on bed...turn and reposition every two hours when in bed or chair...." The 1/11 Monthly Flow Report for Daily Care was reviewed. The report indicated there were 52 of 93 shifts with no documentation to indicate the resident was turned and repositioned every 2 hours. The 1/11 Monthly Flow Report for Daily Care was reviewed. The report indicated there were 81 of 93 shifts with no documentation to indicate the resident was provided incontinence care every 2 hours and PRN. The 2/11 Monthly Flow Report for Daily Care was reviewed. The report indicated there were 14 of 30 shifts with no documentation to indicate the resident was turned and repositioned every 2 hours. The 2/11 Monthly Flow Report for Daily Care was reviewed. The report indicated there were 25 of 30 shifts with no documentation to indicate the resident was provided incontinence care every 2 hours and PRN. During an interview with the DoN on 2/9/11 at 2:25 p.m., she indicated there was no pressure ulcer prevention care plan in place. She indicated there should have been a care plan in place due to the resident's history and risk for pressure. She indicated there should have been a dressing in place per the MD orders. She indicated the resident had a long history of skin impairment to the buttocks. She indicated the reason LPN #2 documented the areas as excoriation was because she had a history of [REDACTED]. She indicated "my thought is anything open like that is pressure." She indicated the LPN probably thought the assessment of excoriation was correct. She indicated the resident's skin impairment on the buttocks comes and goes. During an interview with LPN #2 on 2/10/11 at 2:45 p.m., she indicated she received training related to wounds 2-3 years ago when she was doing MDS assessments. She indicated she started the position as the facility wound nurse in January. She indicated at that time she received a book with wound staging information. She indicated "it's been a while" since she had 1 on 1 training related to wounds. She indicated the last time she looked at the resident's wound it looked like excoriation. She indicated on 2/8/11, there was no depth to the wound and the skin was intact. She indicated the area was pink and not blanchable. She indicated there was no drainage to the wound. She indicated the resident 's upper wound blanched and the bottom wound did not blanch. She indicated the wound wasn't open, but was "like a groove." She indicated she was "still learning" about pressure ulcers and staging. She indicated she was not sure if shearing was a form of pressure. She indicated the wound "could have graduated" from excoriation to pressure. During an interview with LPN #2 on 2/10/11 at 3:50 p.m., she indicated there should have been a dressing in place on the resident's buttocks. She indicated she was not made aware by staff the dressing was not in place. During an interview with LPN #9 on 2/10/11 at 3:55 p.m., she indicated she was not told by any staff resident #17 did not have a dressing in place on her buttocks. During an interview with LPN #2 on 2/10/11 at 5:15 P.M., She indicated if a blister was on a bony prominence she would consider it pressure. She indicated where the resident 's pressure was located it was not on a bony prominence it was on tissue. She indicated the resident has had new blisters that come up at times and then they "pop" and are gone. During an interview with the Executive Director (ED) on 2/11/11 at 10:50 a.m., she indicated the resident had a cushion in her wheel chair, a pressure reduction mattress on her bed, was turned and repositioned by staff every two hours, and was seen by therapy for positioning in the wheel chair. She indicated the resident had excoriations to the buttocks in the past, most recently in January. She indicated "today they appear to be in the area where pressure would be." She indicated if the areas were first identified as excoriation "then even if it worsens it is still an excoriation." The ED indicated LPN #2 had been provided a manual for wounds by the DoN. She indicated the DoN had received training on wounds from the corporate regional director. The ED indicated she understood the concerns with pressure. 2. The clinical record for Resident # 7 was reviewed on 2/11/11 at 2:30 P.M. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. An "Initial Data Collection Tool/Nursing Service", dated 12/21/10, indicated the resident had an open area on the right side of the buttocks. A nurse's note, dated 12/21/10 at 1:00 P.M., indicated, "... open area on (right) buttock/upper thigh junction..." A "Pressure Ulcer Status Record" form, dated 12/21/10, indicated the area on the resident's right posterior lower gluteal area was a Stage I. The area measured 2 centimeters by 3 centimeters. The wound was not measured again until 1/5/11, at which time the area was noted to be healed. A Braden Scale for Predicting Pressure Sore Risk, dated 12/21/10, indicated the resident was at high risk for the development of a pressure ulcer. An admission minimum data set (MDS) assessment, with an assessment reference date of 12/28/10, indicated the resident required extensive assistance from staff for her activities of daily living. An interim care plan for the resident, initially dated 12/21/10, indicated the resident was at risk for a break in her skin integrity and had a break in her skin integrity at the time of her admission to the facility. The care plan indicated the resident had a Stage II wound. An intervention related to this concern indicated the resident was to be repositioned every 2 hours when in bed and in the chair. The care plan also indicated the resident was to have a weekly skin check completed. The 12/10 Monthly Flow Report for Daily Care was reviewed. The report indicated there were 20 shifts with no documentation to indicate the resident was turned and repositioned every 2 hours as indicated on the plan of care. The 1/11 Monthly Flow Report for Daily Care was reviewed. The report indicated there were 61 shifts with no documentation to indicate the resident was turned and repositioned every 2 hours as indicated on the plan of care. Review of a "Weekly Skin Integrity Data Collection" form, initially dated 12/21/10, indicated the resident had skin assessments completed on 12/21/10, 1/20/11, 1/27/11, and 2/11/11. There was no documentation on the form to indicate a weekly skin assessment was completed. A nurse's note, dated 1/25/11 at 6:40 P.M., indicated, "Area found on (right) buttock notified MD (medical doctor)..." A "Pressure Ulcer Status Record" form, dated 1/25/11, indicated the resident had a pressure area which was identified on that date. On 1/25/11, the area measured 0.3 centimeters by 0.3 centimeters and was classified as a Stage II pressure area. The next measurement of the wound was 2/11/11, and at that time the wound was noted to be healed. There was no documentation on the form to indicate the wound was measured and assessed on a weekly basis. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Cleanse lower right buttock with soap and water and apply Selan (a cream to aid in wound healing) three times daily until healed There was no documentation in the clinical record to indicate the facility updated the resident's care plan to address the pressure area that developed on 1/25/11. During an interview with the Director of Nursing on 2/14/11 at 2:40 P.M., she indicated the resident there was no new care plan developed after the pressure area developed on 1/25/11. She indicated the area was now healed. A current facility policy, revised 10/7/10, provided by the Executive Director on 2/9/11 at 4:30 P.M., titled "Assessment and Monitoring of Healing" indicated, "...Pressure ulcers are assessed and monitored once a week to determine if the treatment plan is working or should be re-evaluated...update the resident care plan...chart observations and assessments on the flow sheet weekly...." 3.1-41(a)(1) 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure residents with symptoms of an active urinary tract infection, such as urinary urgency and urinary frequency, received timely antibiotic treatment. This deficient practice affected 3 of 9 residents reviewed for the timely treatment of [REDACTED]. (Residents # 11, # 17, and # 50) Findings include: 1. The clinical record for Resident # 50 was reviewed on 2/7/11 at 3:25 P.M. [DIAGNOSES REDACTED]. A significant change minimum data set assessment, with an assessment reference date of 1/20/11, indicated the resident required the extensive assistance of staff to complete her activities of daily living. The assessment indicated the resident required the extensive assistance of staff to use the toilet and to transfer. The assessment indicated the resident was occasionally incontinent of bladder. A "Fax Order Request/Notification Form", dated 11/26/10, indicated, "...Pt c/o (complained of) urinary urgency (and) frequency. May we have an order for [REDACTED]. A nurse's note, dated 11/27/10, indicated, "NO (new order) order (SIC) received for UA (urinalysis), urgency and frequency c/o (complaint)..." A nurse's note, dated 11/27/10 at 1:00 P.M., indicated, "Cont. (continues) to c/o frequency-states usually large amt (amount) (with) no burning on urination-fluids encouraged-drinking cranberry juice...." A nurse's note, dated 11/28/10 at 12:00 P.M., indicated, "Less c/o frequency this AM (and) last PM-cont. to encourage fluids..." A nurse's note, dated 12/2/10 at 2:00 A.M., indicated, "Informed CNA (certified nursing aide) of need of UA (with) C+S (culture and sensitivity)..." A nurse's note, dated 12/2/10 at 4:05 P.M., indicated, "T (temperature) 99.1 (at) this time Res (resident) c/o not feeling well generally. N.O. (new order)[MEDICATION NAME](an antibiotic) will be initiated on eve (evening) shift tonight; res also c/o of frequency..." A laboratory results report, dated 12/2/10, indicated the resident's urine specimen was collected on 12/2/10. The report indicated the resident's urine was straw colored and turbid in appearance. The resident's urine contained trace amounts of protein, 2+ occult blood, and 1+ bacteria. A physician's orders [REDACTED]. Review of the nurse's notes indicated an assessment of the resident was completed related to the antibiotic use and urinary tract infection on 12/2/10, 12/3/10, and 12/4/10. An undated nurse's note, indicated, "Received results of urine C & S (culture and sensitivity) (with) new orders from (name of physician) to (change) antibiotic to [MEDICATION NAME] (an antibiotic) 500 mg (milligrams) TID (three times daily) x (times) 10 d (days) (and) then get U/A (and) C/S (culture and sensitivity)...." A laboratory results form indicated a handwritten physician's orders [REDACTED]. The handwritten order indicated staff were to discontinue [MEDICATION NAME] start [MEDICATION NAME] (an antibiotic) 500 milligrams by mouth three times a day for 10 days. Review of the nurse's notes indicated an assessment of the resident was completed related to the antibiotic and urinary tract infection on 12/7/10, 12/8/10, and 12/9/10. There was no additional documentation in the clinical record to indicate the resident was assessed after 12/9/10 related to the use of the antibiotic or the symptoms of the urinary tract infection. The antibiotic was to continue for 10 days after the order on 12/6/10. During an interview with the Corporate Nurse Consultant on 2/10/11 at 11:45 A.M., she indicated the protocol for assessments when a resident starts an antibiotic is for every shift for the first 72 hours. She indicated she would expect an assessment to be documented at least once per shift until the antibiotic was completed. She indicated she would want to see a temperature and other signs and symptoms documented if the staff were assessing a resident with urinary tract infection. At the time of exit from the facility on 2/14/11, the facility did not provide any additional documentation related to the delay in obtaining the urine specimen and the delay in treatment for [REDACTED]. 2. Resident #17's record was reviewed on 2/8/11 at 10:00 a.m. [DIAGNOSES REDACTED]. The nurse's note indicated the following: "1/23/11 1:55 p.m., resident has had some delusional episodes-has had in past. Dr. faxed for UA C+S (urinalysis with culture and sensitivity)." Documentation was lacking to indicate what the delusional episodes consisted of. "1/26/11 9:40 pm received order to UA, lab notified." "1/27/11 0400 (4:00 a.m.) res (resident) informed of need of U/A...sterile technique received cloudy pale yellow urine...." "1/31/11 7:30 [MEDICATION NAME](antibiotic) 250 mg po (orally) BID (two times per day) x (times) 10 days...." "2/1/11 9p Temp 98.7 cont (continues) on ATB (antibiotic) as ordered. 0 (no) s/s of adverse effects noted." Documentation was lacking to indicate a urinary assessment had been completed from 1/23/11 at the time the nursing staff indicated a need for a urinalysis through 2/2/11 at 3:15 a.m. Documentation was lacking to indicate oral fluid intake had been offered. The nurses' notes continue: "2/2/11 4:30 p T (temperature) 96.7. 0 s/s adverse reaction to ATB." Documentation was lacking to indicate the resident had experienced any [MEDICAL CONDITION] or a urinary assessment had been completed. Documentation was lacking to indicate oral fluids had been offered. "2/3/11 0245 (2:45 a.m.) T (temperature) 96.9. 0 s/s adverse affects r/t ATB." Documentation was lacking to indicate if the resident had experienced any [MEDICAL CONDITION] or a urinary assessment had been completed. Documentation was lacking to indicate oral fluids had been offered. "2/3/11 7:40 am Temp 98. cont on ATB as ordered. 0 adverse effects noted." Documentation was lacking to indicate if the resident had experienced any [MEDICAL CONDITION] or a urinary assessment had been completed. Documentation was lacking to indicate oral fluids had been offered. Documentation was lacking to indicate whether the resident had experienced any [MEDICAL CONDITION], a urinary assessment had been completed, or fluids had been offered from 2/3/11 at 7:40 a.m. through 2/8/11. During an interview with Director of Nursing on 2/8/11 at 5:00 p.m., she indicated a urinary assessment should have included the color and odor of the urine, pain upon urination, and vitals. She indicated any behaviors the resident was experiencing should have been documented as well. She indicated the resident was able to take fluids orally and fluids should have been offered, encouraged, and documented as to whether accepted or refused. She indicated the assessments and fluids should have been documented each shift in the nurses' notes. She indicated the assessments were inappropriate and lacking pertinent information. During an interview with LPN #2 on 2/8/11 at 5:45 p.m., she indicated assessments related to urinary tract infections which required antibiotic treatment include encouragement of fluids, cognitive status and any behaviors the resident was experiencing, frequency, burning, irritation during urination, pain, vitals which include blood pressure, temperature, and respirations. She indicated the assessment should be documented in the nurses' notes every shift. During an interview with RN #8 on 2/8/11 at 5:50 p.m., she indicated assessments related to urinary tract infections which required antibiotic treatment include encouragement of fluids, cognitive status and any behaviors the resident was experiencing, odor, frequency, burning, and irritation during urination, pain, and vitals. She indicated the assessment should be documented in the nurses' notes every shift while the resident is on antibiotics. During an interview with RN #7 on 2/8/11 at 6:00 p.m., she indicated assessments related to urinary tract infection should include encouragement of fluids, behaviors, urinary odor, frequency, pain, and burning upon urination, and vitals. She indicated the assessment should be documented every shift. During an interview with the Executive Director on 2/11/11 at 12:00 p.m., she indicated fluid intakes were not documented unless a physician's orders [REDACTED]. She indicated she had no documentation to provide related to fluid intake for the resident. 3. The clinical record for Resident # 11 was reviewed on 02/11/2011 at 2:30 p.m. [DIAGNOSES REDACTED]. Nurse's notes, dated 01/28/2010 at 5:45 p.m.,indicated, "N.O. (new order) received for U/A (urine analysis) C/S (culture and sensitivity)...." Nurse's notes, dated 02/01/2011 at 1:50 p.m., indicated, "U/A obtained et (and) sent to lab...." A laboratory report dated 02/01/2011 indicated the resident had a urinary tract infection. A physician's orders [REDACTED]." Documentation was lacking to indicate the resident had been assessed for symptoms of urinary tract infection, that additional nursing measures were implemented to restore or improve bladder function, or that the physician had been notified that the laboratory specimen was not collected for 4 days after receiving the order. During an interview on 02/11/2011 at 5:20 p.m., the DoN indicated she would not necessarily notify the physician of the inability to obtain a urine sample. The DoN indicated the resident wears incontinence briefs and leaks stool. She indicated this could have been the reason there was a delay in collecting the urine specimen. A document, titled "Urinary Tract Infection" was provided by the Executive Director on 02/09/2011 at 4:30 p.m. She indicated on 02/14/2011 at 3:00 p.m. that document came from the corporation web site and that there was no specific policy for urinary tract infections. The "Urinary Tract Infection " document indicated, "...lack of adequate fluids, bowel incontinence, immobility or decreased mobility, indwelling urinary catheters...place the person at increased risk for developing [MEDICATION NAME] (bladder infection)...Preventative measures may reduce symptoms and prevent recurrence of infection...Increase the intake of fluids encourages frequent urination that flushes the bacteria from the bladder. Avoid fluids that irritate the bladder, such as alcohol, citrus juices, and caffeine...." 3.1-41(a)(2)