Every finding on record at Majestic Care of Carmel

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Record Review (PASARR) was completed after new psychotropic medications were prescribed for 2 of 3 residents reviewed for PASARR. (Resident 35 and 13)Findings include:1. The clinical record for Resident 35 was reviewed on 7/22/25 at 2:52 p.m. The diagnoses included, but were not limited to, major depressive disorder, insomnia, and heart failure. A notice of PASARR level II outcome, dated 10/26/22, indicated Resident 35 had no mental health medications and if there was a significant change in physical or mental health, a new Level II evaluation would be needed. The nursing facility must submit an updated Level I screening to see if a further PASARR evaluation was needed. A physician's order, dated 7/1/25, indicated to administer Sertraline HCL (an antidepressant medication) 25 milligrams (mg) 3 tablets one time per day for depression. There was not another PASARR in the electronic medical record. During an interview, on 7/23/25 at 10:23 a.m., the Social Services Director (SSD) indicated another PASARR should have been completed if the resident was started on Sertraline. During an interview, on 7/23/25 at 2:48 p.m., the SSD indicated the facility would resubmit a PASARR if a new mental health medication was prescribed. The most recent PASARR did not include Sertraline. 2. The clinical record for Resident 13 was reviewed on 7/22/25 at 1:45 p.m. The diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, and schizophrenia. A notice of PASARR level I outcome, dated 9/27/24, indicated Resident 13 was not currently prescribed and had not been prescribed any medication for anxiety within the past six months. The document also indicated, if a status change occurred, then an updated Level I must be submitted by the nursing facility to report the change. A psychiatric visit note, dated 5/6/25, indicated Ativan (an anxiety medication) would be prescribed after staff had reported Resident 13 was experiencing increased anxiousness, paranoia, and tearfulness. A physician's order, dated 5/6/25, indicated Resident 13 was prescribed Ativan 0.5 milligrams, two times a day, for anxiety. A care plan, dated 5/7/25, indicated Resident 13 was at risk for adverse side effects related to the use of antianxiety medications. An updated Level I PASSAR which included the addition of Ativan was not found in the electronic health record. During an interview, on 7/23/25 at 2:51 p.m., the SSD indicated a new Level I PASSAR would need submitted after a mental health medication change. A new Level I had not been submitted after the addition of Ativan for Resident 13. A current facility policy, titled PASARR, dated as last revised on 4/17/25, and received from the Executive Director on 7/28/25 at 9:00 a.m., indicated .To coordinate assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs.The Social Services Director or designee shall be responsible for keeping track of each resident's/patient's PASARR screening status and referring to the appropriate authority.Any Level II resident/patient who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review.Any resident/patient who exhibits a newly evident or possible SMI, ID or RC will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to ensure the Medication and Treatment Administration Records were complete and accurately documented for 3 of 5 residents reviewed for complete and accurate medical records. (Resident 37, 2 and 41)Findings include: 1. The clinical record for Resident 37 was reviewed on 7/22/25 at 10:27 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), hypertension, and bipolar disorder. The Medication Administration Record (MAR) and Treatment Administration Record (TAR), for June 2025, were missing the following documentation for Resident 37: a. The administration of Aricept (a medication used to treat symptoms of Alzheimer's disease and dementia) 5 milligrams (mg) on 6/10/25 at 6:00 p.m. b. The administration of Ativan (an anxiety medication) 0.5 mg on 6/10/25 at 6:00 p.m. c. A completed skin evaluation on 6/11/25 for the evening shift. d. The administration of melatonin (a medication used to mimic the body's natural sleep hormone) 5 mg on 6/10/25 at 6:00 p.m. e. The administration of carvedilol (a medication used to treat cardiovascular conditions) 25 mg on 6/10/25 at 6:00 p.m. f. The administration of gabapentin (a medication used to treat seizures or neuropathic pain) 100 mg on06/10/25 at 6:00 p.m. g. The administration of Namenda (a medication used to treat moderate to severe Alzheimer's disease) 5 mg on 6/10/25 at 6:00 p.m. During an interview, on 7/25/25 at 8:46 a.m., LPN 4 indicated the MAR/TAR should be signed after the medications had been administered or the treatments had been completed. If the documentation had not been completed, the electronic system would show in yellow which meant something was left to be completed or red to indicate the charting was late. During an interview, on 7/25/25 at 8:49 a.m., LPN 4 indicated staff should have signed off the medications or treatments as they were administered. 2. The clinical record for Resident 2 was reviewed on 7/22/25 at 10:17 a.m. The diagnoses included, but were not limited to, hypertension, insomnia, and Parkinson's disease. The MAR and TAR, for June 2025, were missing the following documentation for Resident 2: a. The administration of melatonin (a medication used to mimic the body's natural sleep hormone) 10 mg on 6/10/25 at 6:00 p.m. b. The administration of carboxymethylcellulose sodium solution (a medication used to treat dry, irritated eyes) 0.5% eye drop on 6/10/25 at 6:00 p.m. c. The administration of galantamine hydrobromide (a medication used to treat symptoms of Alzheimer's disease and dementia) 4 mg on 6/10/25 at 6:00 p.m. d. The administration of Namenda (a medication used to treat moderate to severe Alzheimer's disease) 5 mg on 6/10/25 at 6:00 p.m. e. The administration of lisinopril (a medication used to control blood pressure) 10 mg on 6/19/25 at 6:00 a.m. The MAR and TAR, for July 2025, were missing the following documentation for Resident 2: a. The administration of carboxymethylcellulose sodium solution 0.5% eye drops on 7/18/25 at 6:00 p.m. b. The administration of galantamine hydrobromide 4 mg on 7/18/25 at 6:00 p.m. c. The administration of Namenda 5 mg on 7/18/25 at 6:00 p.m. d. The administration of Sinemet (a medication used to treat symptoms of Parkinson's disease) 25-100 mg on 7/20/25 at 2:00 p.m. 3. The clinical record for Resident 41 was reviewed on 7/22/25 at 10:48 a.m. The diagnoses included, but were not limited to, type 2 diabetes, depression, and congestive heart failure. Physician's orders, dated 1/28/25, indicated to monitor for signs and symptoms of hyperglycemia (high blood sugars) and hypoglycemia (low blood sugars) every shift, to monitor for side effects of diuretic medication use (a medication used to rid excess water and salt in your body) every shift, and to monitor for side effects of anticoagulant medication use (a medication used to prevent blood clots from forming) every shift. The TAR, for May, June and July 2025, were missing the documentation for the monitoring of hyperglycemia and hypoglycemia, anticoagulant and diuretic medication side effects for the following dates for Resident 41: a. On 5/16/25, for the night shift. b. On 5/17/25, for the day and evening shifts. c. On 5/20/25, for the evening shift. d. On 6/7/25, for the night shift. e. On 6/26/25, for the evening shift. f. On 7/1/25, for the night shift. g. On 7/7/25, for the evening shift. h. On 7/8/25, for the night shift. i. On 7/11/25, for the night shift. j. On 7/12/25, for the day shift. k. On 7/13/25, for the day shift. l. On 7/15/25, for the night shift. m. On 7/16/25, for the night shift. During an interview, on 7/24/25 at 11:37 a.m., LPN 4 indicated medication monitoring should be signed off on every shift. During an interview, on 7/24/25 at 11:43 a.m., the Clinical Support nurse indicated that staff should observe the side effects of the medications as ordered and document 3 times per day. A current facility policy, titled DOCUMENTATION IN THE MEDICAL RECORD, dated as last reviewed on 12/12/23 and received from the Executive Director on 7/24/25 at 1:50 p.m., indicated .Documentation shall be.complete. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident was assessed and provided pain management prior to the physician's ordered wound treatment for 1 of 1 resident reviewed for pain. (Resident 4)Findings include:During an observation, on 7/21/25 at 12:01 p.m., Resident 4 was sitting in bed with a wound VAC (vacuum assisted closure) (a device used to help close and heal wounds) in place on her left thigh.During an interview, on 7/21/25 at 12:01 p.m., Resident 4 indicated the pain during her wound VAC dressing changes was especially excruciating. She had told the staff every time someone messed with the wound VAC. She indicated the wound VAC was a torture device and the pain from the wound VAC has kept her from getting out of bed and doing things.During an observation, on 7/23/25 at 7:58 a.m., Resident 4 was in bed waiting for the dressing to be changed for her wound VAC. She appeared very anxious with her jaw tight, teeth clenched, and a grimace look on her face. She vocalized ouch multiple times during the treatment, winced and bit her lip. She indicated she did not like having the wound VAC dressing changed because it was extremely painful. She indicated she should at least get a bullet to bite on to help with the pain. She asked multiple times how long she would have the wound VAC. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) indicated the wound VAC had been in place for 10 to 11 weeks, was necessary, and was doing a great job of healing her wound. The resident indicated she wanted her wound to heal but she was tired of the pain.The clinical record for Resident 4 was reviewed on 7/22/25 at 1:30 PM. The diagnoses included, but were not limited to, dislocation of the internal left hip prosthesis, chronic obstructive pulmonary disease, atrial fibrillation, osteoarthritis, and depression.A care plan, initiated 4/2/25, indicated Resident 4 was at risk of pain due to the surgical incision. The goal was the resident would verbalize adequate pain relief with an intervention to administer medication as ordered.A physician's order, dated 4/17/25, indicated to give tramadol (a pain-relieving medication) 50 milligrams (mg) every 8 hours as needed for pain.A physician's order, dated 5/2/25 and discontinued 6/4/25, indicated to place a wound VAC to the left hip with 125 mmHg of continuous suction and to change the dressing every Monday, Wednesday, and Friday.A physician's order, dated 6/25/25, indicated to perform wound care to the left thigh every Monday, Wednesday, Friday, and as needed for a dislodged or vacuum malfunction by cleansing with wound cleanser, patting dry, applying skin prep to peri wound, laying drape, applying black foam to wound base, packing area of tunneling with black foam, applying [NAME] pad, and setting the vacuum to 125mHg continuous suction.A physician's order, dated 7/16/25, indicated staff were to teach the resident how to rate her pain associated with her wound, that her pain was what she defined it to be, the current pain management treatment available to her, and how often it was available.A Medication Administration Record (MAR), dated May 2025, indicated the resident did not receive tramadol for pain prior to her wound VAC dressing changes for 10 of the 13 available times.A MAR, dated June 2025, indicated the resident received tramadol for pain 3 times the entire month on June 12, 28, and 30, and she had received 30 wound dressing changes.A MAR, dated July 2025, indicated that the as needed tramadol for pain was not administered with any of the wound VAC dressing changes before the dressing change observation on July 23, 2025. The medication was not administered before July 23, 2025, during the month of July.A review of the progress notes, dated May through July 2025, lacked documentation there were assessments of pain before wound care was performed or documentation to show Resident 4 was offered pain medication prior to the wound VAC dressing changes.During an interview, on 7/23/25 at 8:08 a.m., the DON indicated he knew the wound VAC dressing change was painful for Resident 4 and she should have been pre-medicated with her pain medicine before every dressing change. He thought she had been receiving pain medication every time and thought she originally was receiving something even stronger than the tramadol 50 mg. He was not sure why her medication was changed or why it had not been given before each of the dressing changes. Resident 4 should have been given pain medication to help her tolerate the wound VAC dressing changes before the procedure.During an interview, on 7/28/25 at 9:37 a.m., Resident 4 indicated the pain medicine which had been given before her last couple of dressing changes had helped a little. It had hurt so much for so long, she would get herself all worked up worrying about the pain and had made herself nauseated these past few days. A current facility policy, titled Pain Management, dated 1/2/24 and provided by the Clinical Support Nurse on 7/23/25 at 2:45 p.m., indicated .to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated.Manage or prevent pain, consistent with the.plan of care, current professional standards of practice, and the resident's goals and preferences.A current facility policy, titled Administering Medications, dated April 2019 and provided by the DON on 7/23/25 at 11:10 a.m., indicated .Medications are administered in accordance with prescriber orders 3.1-37(a)

Based on interview and record review, the facility failed to ensure the State Long-Term Care Ombudsman was notified after a resident was discharged to the hospital for 2 of 3 residents reviewed for hospitalization. (Resident 13 and 6)Findings include:1. The clinical record for Resident 13 was reviewed on 7/22/25 at 1:45 p.m. The diagnoses included, but were not limited to, fracture of the right femur, dementia, and anxiety.The clinical record indicated Resident 13 was discharged to the hospital after a fall on 6/12/25 and was readmitted back into the facility on 6/19/25.A document, titled Admission/Discharge To/From Report, dated 6/1/25 to 6/30/25 did not have Resident 13 listed as a discharged resident in the month of June.2. The clinical record for Resident 6 was reviewed on 7/23/25 at 1:21 p.m. The diagnoses included, but were not limited to, hypotension (low blood pressure), dementia, and traumatic subdural hemorrhage.The clinical record indicated Resident 6 was discharged to the hospital on 2/16/25 and was readmitted back into the facility on 2/18/25.A document, titled Admission/Discharge To/From Report, dated 2/1/25 to 2/30/25 did not have Resident 6 listed as a discharged resident in the month of February.The clinical record also indicated Resident 6 was discharged to the hospital on 6/21/25 and was readmitted back into the facility on 6/23/25.A document, titled Admission/Discharge To/From Report, dated 6/1/25 to 6/30/25 did not have Resident 6 listed as a discharged resident in the month of June.During an interview, on 7/23/25 at 2:50 p.m., the Social Service Director (SSD) indicated Resident 13, and Resident 6 were not included on the discharged residents list for the month of June. During an interview, on 7/23/25 at 3:12 p.m., the SSD indicated Resident 13 and 6 were both a bed hold and not a discharge, therefore, neither were included on the discharge list for the Ombudsman to be notified.A current document, titled Family of Social Service Administration, last updated October 2024, indicated .CMS requires nursing facilities to notify the Long-Term Care (LTC) Ombudsman of the majority of residents' transfers and discharges .When a resident is transferred on an emergency basis to an acute care facility and expected to return, the SLTCO must be notified. Information from facilities regarding emergency transfers should be provided in a monthly list to the SLTCO, which should include residents' names, dates of transfer, facilities to which residents were transferred, and reasons for the transfers A current facility policy, titled TRANSFER NOTICE, dated 1/2/24 and received from the Executive Director on 7/28/25 at 9:00 a.m., indicated .A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.3.1-12(a)(6)(A)(iv)

Based on interview and record review, the facility failed to ensure the physician's orders related to medication hold parameters were followed for 3 of 3 residents reviewed for quality of care. (Resident 13, 2 and 4)Findings include: 1. The clinical record for Resident 13 was reviewed on 7/22/25 at 1:45 p.m. The diagnoses included, but were not limited to, hypertension (high blood pressure), anxiety disorder, and dementia. A physician's order, dated 12/28/22, indicated to administer metoprolol succinate ER (extended release) 25 milligrams (mg), one time a day, with instructions to hold the medication if the systolic blood pressure was below 120. The Medication Administration Record (MAR) for April 2025, June 2025, and July 2025 were reviewed and indicated metoprolol was administered below the ordered hold parameter of 120 on the following days: a. On 4/15/25, with a systolic blood pressure of 93. b. On 4/17/25, with a systolic blood pressure of 117. c. On 4/23/25, with a systolic blood pressure of 110. d. On 6/29/25, with a systolic blood pressure of 114. e. On 7/9/25, with a systolic blood pressure of 114. f. On 7/11/25, with a systolic blood pressure of 110. During an interview, on 7/23/25 at 11:01 a.m., LPN 5 indicated a check mark on the MAR meant the medication was administered. The metoprolol was administered with the systolic blood pressure below the physician's ordered hold parameters. The medication should have been held according to the physician's order. During an interview, on 7/23/25 at 11:04 a.m., the Director of Nursing (DON) indicated the medication had been administered below the physician's ordered hold parameter. 2. The clinical record for Resident 2 was reviewed on 7/22/25 at 10:17 a.m. The diagnoses included, but were not limited to, hypertension, insomnia, and Parkinson's disease. A care plan, dated 1/10/22, indicated Resident 2 had impaired cardiac output related to congestive heart failure, high blood pressure, and high cholesterol. The interventions included, but were not limited to, administering medications as ordered. A physician's order, dated 6/3/23, indicated to give lisinopril 10 mg orally once a day. The instructions indicated the medication should be held if the systolic blood pressure was below 120. The MAR for June 2025 and July 2025 were reviewed and indicated lisinopril was administered below the ordered hold parameter of 120 on the following days: a. On 6/9/25, with a systolic blood pressure of 109. b. On 6/29/25, with a systolic blood pressure of 115. c. On 7/12/25, with a systolic blood pressure of 107. During an interview, on 7/25/25 at 1:55 p.m., the Assistant Director of Nursing indicated staff should have followed the physician's order and if the systolic blood pressure was outside the parameters, the medication would be held and the physician notified. 3. The clinical record for Resident 4 was reviewed on 7/22/25 at 1:30 PM. The diagnoses included, but were not limited to, dislocation of internal left hip prosthesis, chronic obstructive pulmonary disease, atrial fibrillation, osteoarthritis, and depression. A physician's order, dated 4/1/25 and discontinued 6/23/25, indicated to give metoprolol 25 mg two times a day and to hold for a systolic blood pressure less than 120. A physician's order, dated 6/23/25, indicated to give metoprolol 25 mg two times a day and to hold for a systolic blood pressure less than 120. The MAR for May 2025, June 2025, and July 2025 were reviewed and indicated metoprolol was administered below the ordered hold parameter of 120 on the following days: a. On 5/2/25, in the morning, with a systolic blood pressure of 112.b. On 5/19/25, in the morning, with a systolic blood pressure of 117. c. On 6/16/25, in the evening, with a systolic blood pressure of 119. d. On 7/12/25, in the evening, with a systolic blood pressure of 117. e. On 7/13/25, in the evening, with a systolic blood pressure of 110. f. On 7/14/25, in the morning, with a systolic blood pressure of 114. g. On 7/19/25, in the evening, with a systolic blood pressure of 109.h. On 7/23/25, in the morning, with a systolic blood pressure of 116. i. On 7/24/25, in the morning, with a systolic blood pressure of 112. During an interview, on 7/23/25 at 11:04 a.m., the DON indicated the medication should not have been given with a systolic blood pressure below the physician's ordered hold parameter. A current facility policy, titled Administering Medications, dated April 2019 and provided by the DON on 7/23/25 at 11:10 a.m., indicated .Medications are administered in accordance with prescriber orders 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure catheter tubing was not touching the ground, oral care products were stored properly, and clean laundry and linen were stored and handled appropriately for 12 of 12 residents randomly observed for infection control. (Residents 34, 302, 4, 27, 11, 38, 13, 15, 4, 17, 9 and 30) Findings include: 1. During an observation, on 7/24/24 at 12:10 p.m., Resident 34's catheter tubing was touching the floor while she was in the commons area on the 1st floor. During an observation, on 7/29/24 at 1:27 p.m., Resident 34's catheter tubing was touching the ground. During an interview, on 7/29/24 at 1:28 p.m., the Director of Nursing (DON) indicated the catheter tubing was touching the ground and needed fixed. The clinical record for Resident 34 was reviewed on 7/26/24 at 9:55 a.m. The diagnoses included, but were not limited to, chronic kidney disease stage 3, neuromuscular dysfunction of the bladder, and dementia. A current physician's order, with a revision date of 5/29/24, indicated may anchor a 10ml/14fr Foley catheter. A current care plan, initiated on 6/3/24, indicated the resident was at risk for infection and complications related to an indwelling catheter. 2. During an observation, on 7/26/24 at 10:30 a.m., Resident 302 was being wheeled in a wheelchair by a staff member to the therapy room. The resident's catheter tubing was dragging on the ground as she was being wheeled to therapy. During an interview, on 7/26/24 at 10:32 a.m., the DON indicated he would address the catheter tubing dragging the ground. The clinical record for Resident 302 was reviewed on 7/29/24 at 2:41 p.m. The diagnoses included, but were not limited to, chronic kidney disease stage 4, obstructive and reflux uropathy, and unspecified dementia. A current physician's order, with a start date of 7/23/24, indicated may anchor a 30ml/16fr Foley catheter for the diagnosis of obstructive neuropathy. A current care plan, initiated on 7/24/24, indicated the resident was at risk for infection and complications related to an indwelling catheter. 49891 3. During an observation, on 7/24/24 at 10:43 a.m., in the bathroom of Residents 4 and 27, the toothbrushes were lying together on the sink behind the faucet. One was touching the surface of the sink, and the other was touching the wall. Neither toothbrush was labeled or had a covering for the bristles. The toothpaste was open with no lid. There was urine and toilet paper in the toilet. 4. During an observation, on 7/24/24 at 10:50 a.m., an uncovered toothbrush was lying on the sink touching the wall behind the faucet in the bathroom of Residents 11 and 38. 5. During an observation, on 7/26/24 at 10:26 a.m., uncovered and unlabeled toothbrushes were sitting on the sink next to the faucet in the bathroom of Residents 13 and 15. 6. During an observation, on 7/26/24 at 10:30 a.m., uncovered and unlabeled toothbrushes were lying together on the sink behind the faucet in the bathroom of Residents 4 and 17. Two tubes of toothpaste were unlabeled and did not have lids. During an interview, on 7/30/24 at 2:44 p.m., the DON indicated the toothbrush storage was a concern. 7. During an observation, on 7/25/24 at 9:44 a.m., two hangers with a shirt and pants were hanging on the handrail outside of Resident 11's room. LPN 1 took the clothing into the room and hung it in Resident 11's closet. 8. During an observation, on 7/29/24 at 9:37 a.m., two staff members transported clean towels and wash cloths on an open cart without any covering and placed the linen in closets on the 2nd floor unit. 9. During an observation, on 7/29/24 at 1:35 p.m., clean clothing was hung on the handrail in the hallway outside of the room of Resident 9 and 30. During an interview, on 7/30/24 at 2:44 p.m., the DON indicated all clean linen should be transported covered and protected. Clean clothing should not be hung on the handrails in the hallways. Covered linen carts were available and should be utilized. A current policy, titled Infection Control, dated 1/02/24 and received from the Executive Director (ED) on 7/24/24, indicated .The facility's infection prevention and control program (ICPC) is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections A current policy, titled INFECTION PREVENTION AND CONTROL PROGRAM, dated as last revised on 12/12/23 and received from the Clinical Support Nurse on 7/30/24 at 4:35 p.m., indicated .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines The facility did not provide a policy which included keeping catheter tubing off the ground by the time of exit. 3.1-18(b)(1) 3.1-18(b)(5) 3.1-19(g)(2)

Based on interview and record review, the facility failed to ensure staff followed the physician ordered hold parameters for a medication and failed to ensure treatments were documented in the Treatment Administration Record for 3 of 3 residents reviewed for quality of care. (Resident B, 34 and 46) Finding includes: The record for Resident B was reviewed on 7/26/24 at 9:00 a.m. Diagnoses included, but were not limited to, hypertension, dementia, hallucination, and major depressive disorder A physician's order, dated 3/23/23, indicated hydralazine (a blood pressure medication) 10 mg was to be given by mouth three times a day related to hypertension and to hold if the systolic blood pressure (SBP) was less than 160. The Medication Administration Record (MAR), dated 7/1/24 through 7/31/24, indicated the following: a. the morning administration of hydralazine 10 mg was given to Resident B six (6) times when the systolic blood pressure was below the physician ordered hold parameters. b. the afternoon administration of hydralazine 10 mg was given to Resident B two (2) times when the systolic blood pressure was below the physician ordered hold parameters. c. the evening administration of hydralazine 10 mg was given to Resident B fifteen (15) times when the systolic blood pressure was below the physician ordered hold parameters. During an interview, on 7/26/24 at 10:49 a.m., RN 5 indicated the check mark under the documented blood pressure on the MAR indicated the medication was administered. During an interview, on 7/26/24 at 11:05 a.m., the Director of Nursing (DON) indicated the check marks on the MAR indicated a medication had been administered. He indicated the medication should not have been administered outside the physician ordered hold parameters. 48525 2. The clinical record for Resident 34 was reviewed on 7/26/24 at 9:55 a.m. The diagnoses included, but were not limited to, chronic kidney disease stage 3, unspecified neuromuscular dysfunction of bladder, and dementia. A current physician's order, dated 5/29/24, indicated to assess the resident's vital signs every shift. A Treatment Administration Record (TAR) indicated the following days did not have vital signs for Resident 34 documented: On 7/2/24, there were no vital signs documented for the 1st and 2nd shift. On 7/3/24, there were no vital signs documented for the 3rd shift. On 7/4/24, there were no vital signs documented for the 1st, 2nd and 3rd shift. On 7/8/24, there were no vital signs documented for the 2nd shift. On 7/10/24, there were no vital signs documented for the 3rd shift. On 7/11/24, there were no vital signs documented for the 1st and 3rd shift. On 7/13/24, there were no vital signs documented for the 1st shift. On 7/16/24, there were no vital signs documented for the 3rd shift. On 7/17/24, there were no vital signs documented for the 1st shift and 3rd shift. On 7/18/24, there were no vital signs documented for the 2nd shift. On 7/19/24, there were no vital signs documented for the 2nd shift. On 7/22/24, there were no vital signs documented for the 2nd shift. On 7/24/24, there were no vital signs documented for the 2nd shift. On 7/25/24, there were no vital signs documented for the 2nd shift. On 7/26/24, there were no vital signs documented for the 3rd shift. A current physician's order, dated 5/29/24, indicated to complete Foley catheter care every shift. The TAR indicated the following days did not have Foley catheter care for Resident 34 documented: On 7/2/24, there was no Foley catheter care documented for the 1st and 2nd shift. On 7/3/24, there was no Foley catheter care documented for the 3rd shift. On 7/4/24, there was no Foley catheter care documented for the 1st, 2nd and 3rd shift. On 7/8/24, there was no Foley catheter care documented for the 2nd shift. On 7/10/24, there was no Foley catheter care documented for the 3rd shift. On 7/11/24, there was no Foley catheter care documented for the 1st and 3rd shift. On 7/16/24, there was no Foley catheter care documented for the 3rd shift. On 7/17/24, there was no Foley catheter care documented for the 1st shift and 3rd shift. On 7/18/24, there was no Foley catheter care documented for the 2nd shift. On 7/19/24, there was no Foley catheter care documented for the 2nd shift. On 7/22/24, there was no Foley catheter care documented for the 2nd shift. On 7/24/24, there was no Foley catheter care documented for the 2nd shift. On 7/25/24, there was no Foley catheter care documented for the 2nd shift. On 7/26/24, there was no Foley catheter care documented for the 1st and 3rd shift. 3. The clinical record for Resident 46 was reviewed on 7/26/24 at 9:55 a.m. The diagnoses included, but were not limited to, chronic kidney disease stage 3, dementia, neuromuscular dysfunction of bladder, and vitamin b12 deficiency anemia A current physician's order, with a start date of 6/10/24, indicated to observe Resident 46 for side effects of anticoagulant medication use every shift, and to document y if a side effect was observed and n if none were observed. The TAR indicated the following days did not have anticoagulant monitoring for Resident 46 documented: On 7/2/24, there was no anticoagulant monitoring documented for the 1st and 2nd shift. On 7/3/24, there was no anticoagulant monitoring documented for the 3rd shift. On 7/4/24, there was no anticoagulant monitoring documented for the 1st, 2nd, and 3rd shift. On 7/8/24, there was no anticoagulant monitoring documented for the 2nd shift. On 7/11/24, there was no anticoagulant monitoring documented for the 1st and 3rd shift. On 7/16/24, there was no anticoagulant monitoring documented for the 3rd shift. On 7/17/24, there was no anticoagulant monitoring documented for the 1st shift and 3rd shift. On 7/18/24, there was no anticoagulant monitoring documented for the 2nd shift. On 7/19/24, there was no anticoagulant monitoring documented for the 2nd shift. On 7/22/24, there was no anticoagulant monitoring documented for the 2nd shift. On 7/24/24, there was no anticoagulant monitoring documented for the 2nd shift. On 7/25/24, there was no anticoagulant monitoring documented for the 2nd shift. On 7/26/24, there was no anticoagulant monitoring documented for the 3rd shift. A current physician's order, with a start date of 6/10/24, indicated to observe for the side effects of antidepressant medication every shift, and document y if a side effect was observed and n if none were observed. The TAR indicated the following days did not have antidepressant medication monitoring for Resident 46 documented: On 7/2/24, there was no antidepressant medication monitoring documented for the 1st and 2nd shift. On 7/3/24, there was no antidepressant medication monitoring documented for the 3rd shift. On 7/4/24, there was no antidepressant medication monitoring documented for the 1st, 2nd, and 3rd shift. On 7/8/24, there was no antidepressant medication monitoring documented for the 2nd shift. On 7/11/24, there was no antidepressant medication monitoring documented for the 1st and 3rd shift. On 7/16/24, there was no antidepressant medication monitoring documented for the 3rd shift. On 7/17/24, there was no antidepressant medication monitoring documented for the 1st shift and 3rd shift. On 7/18/24, there was no antidepressant medication monitoring documented for the 2nd shift. On 7/19/24, there was no antidepressant medication monitoring documented for the 2nd shift. On 7/22/24, there was no antidepressant medication monitoring documented for the 2nd shift. On 7/24/24, there was no antidepressant medication monitoring documented for the 2nd shift. On 7/25/24, there was no antidepressant medication monitoring documented for the 2nd shift. On 7/26/24, there was no antidepressant medication monitoring documented for the 3rd shift. A current physician's order, with a start date of 6/7/24, indicated to observe for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) every shift. The TAR indicated the following days did not have hypoglycemia and hyperglycemia monitoring for Resident 46 documented: On 7/2/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 1st and 2nd shift. On 7/3/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 3rd shift. On 7/4/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 1st, 2nd, and 3rd shift. On 7/8/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 2nd shift. On 7/11/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 1st and 3rd shift. On 7/16/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 3rd shift. On 7/17/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 1st shift and 3rd shift. On 7/18/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 2nd shift. On 7/19/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 2nd shift. On 7/22/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 2nd shift. On 7/26/24, there was no hypoglycemia and hyperglycemia monitoring documented for the 3rd shift. A current physician's order, with a start date of 6/7/24, indicated to observe for the side effects of a diuretic medication every shift. The TAR indicated the following days did not have diuretic medication monitoring for Resident 46 documented: On 7/2/24, there was no diuretic medication monitoring documented for the 1st and 2nd shift. On 7/3/24, there was no diuretic medication monitoring documented for the 3rd shift. On 7/4/24, there was no diuretic medication monitoring documented for the 1st, 2nd, and 3rd shift. On 7/8/24, there was no diuretic medication monitoring documented for the 2nd shift. On 7/11/24, there was no diuretic medication monitoring documented for the 1st and 3rd shift. On 7/16/24, there was no diuretic medication monitoring documented for the 3rd shift. On 7/17/24, there was no diuretic medication monitoring documented for the 1st shift and 3rd shift. On 7/18/24, there was no diuretic medication monitoring documented for the 2nd shift. On 7/19/24, there was no diuretic medication monitoring documented for the 2nd shift. On 7/22/24, there was no diuretic medication monitoring documented for the 2nd shift. On 7/24/24, there was no diuretic medication monitoring documented for the 2nd shift. On 7/25/24, there was no diuretic medication monitoring documented for the 2nd shift. On 7/26/24, there was no diuretic medication monitoring documented for the 3rd shift. During an interview, on 7/29/24 at 1:25 p.m., the Director of Nursing (DON) indicated there were a lot of missing documentation in the TARs. A current facility policy, titled Medication Administration, dated 1/2/2024 and received from the DON on 7/29/24 at 10:54 a.m., indicated .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . A current facility policy, titled Charting and Documentation, dated as last revised in July 2017 and received from the Clinical Support Nurse on 7/30/24 at 4:35 p.m., indicated .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .The following information is to be documented in the resident medical record .Treatments or services performed 3.1-37(a)

Based on interview and record review, the facility failed to have an Infection Preventionist (IP) who was able to fulfill the role at least part-time and was not preforming the duties of the full-time Director of Nursing (DON) for 1 of 1 Infection Preventionist reviewed. Finding includes: During an interview, on 7/24/24 at 11:15 a.m., the Executive Director (ED) indicated the facility's Infection Preventionist (IP) was the Director of Nursing (DON). He indicated it was not a separate position and no other employees held an infection prevention certification. During an interview, on 7/30/24 at 2:45 p.m., the DON indicated he performed all the infection prevention tracking and duties along with all his DON duties. He indicated he was the only employee who held an infection prevention certification, and no other employees assisted him with the infection control duties. The facility's employee records did not contain an employee with the title of Infection Preventionist. A current policy, titled Infection Control, dated 1/02/24 and received from the Executive Director (ED) on 7/24/24, indicated .The facility's infection prevention and control program (ICPC) is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections A current policy, titled INFECTION PREVENTION AND CONTROL PROGRAM, dated as last revised on 12/12/23 and received from the Clinical Support Nurse on 7/30/24 at 4:35 p.m., indicated .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines 3.1-18(b)

Based on interview and record review, the facility failed to ensure a new PASARR (pre-admission screening and resident review) level 1 request was submitted when changes in medications and diagnoses occurred for 3 of 3 residents reviewed for PASARR. (Resident 35, 40 and 46) Findings include: 1. The clinical record for Resident 35 was reviewed on 7/26/24 at 10:22 a.m. The diagnoses included, but were not limited to, general anxiety disorder, recurrent depressive disorder, Parkinson's disease without dyskinesia (involuntary movements), puerperal psychosis, dementia in other disease mild without behavioral symptoms, psychotic or mood disturbance, and anxiety. A PASARR level 1, dated 2/17/22, indicated no level 2 was required due to no significant mental illness, intellectual disability, or related conditions. The level 1 screen indicated a PASARR disability was not present because of the following reason: There was no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occurred or new information refuted these findings, a new screen must be submitted. A physician's order, dated 10/5/23, indicated Nuplazid (an atypical antipsychotic medication) 34 mg (milligrams) daily for Parkinson's. During an interview, on 7/26/24 at 4:06 p.m., the DON (Director of Nursing) indicated a PASARR level 1 had not been requested for the new order of Nuplazid. 49891 2. The clinical record for Resident 40 was reviewed on 7/26/24 at 3:22 p.m. The diagnoses included, but were not limited to Parkinson's disease, depression, anxiety, and psychotic disorder with delusions. A Preadmission Screening and Resident Review (PASARR), dated 11/11/22, indicated the resident had diagnoses of depression and obsessive-compulsive disorder (OCD) with medications of olanzapine and quetiapine (Seroquel) for depression. A physician's order, dated 10/18/23 and discontinued 2/5/24, indicated risperidone (an antipsychotic medication) 0.5 mg, give 1 tablet two times a day for psychotic disorder with delusions. A physician's order, dated 3/21/24, indicated klonopin (an antianxiety medication) 0.5 milligram (mg), give 1 tablet by mouth two times a day for anxiety. A physician's order, dated 7/20/23 and discontinued 9/20/23, indicated sertraline (an antidepressant medication) 50 mg, give 1 tablet by mouth for anxiety. A physician's order, dated 10/19/23 and discontinued 6/14/24, indicated sertraline 50 mg, give for anxiety. A physician's order, dated 6/15/24, indicated sertraline 50 mg, give 1 tablet by mouth one time a day for anxiety. A physician's progress note, dated 4/8/24 at 1:25 p.m., indicated the resident's psychiatric history included anxiety and depression. The resident was prescribed klonopin and Ativan for anxiety and sertraline for depressive disorder. The clinical record did not include any additional PASRR after additional medications and diagnoses were added. 48525 3. The clinical record for Resident 46 was reviewed on 7/26/24 at 9:38 a.m. The diagnoses included, but were not limited to, major depressive disorder, Parkinsons disease without dyskinesia (abnormal body movements), and other sleep disorder. A notice of PASARR level 1 outcome, dated 5/30/24, indicated no mental health diagnoses were known or suspected and no mental health medications were known of. A medical diagnosis list indicated the resident had a diagnosis of major depressive disorder. A current physician's order, with a start date of 6/7/24, indicated the resident was to take Trazodone (an antidepressant medication) 50 mg tablet, take 0.5 tablet by mouth. A current physician's order, with a start date of 7/24/24, indicated the resident was to take Fluoxetine HCL (an antidepressant medication) 10 mg capsule by mouth. During an interview, on 7/26/24 at 10:37 a.m., the Minimum Data Set (MDS) Coordinator indicated the diagnoses and medications were not on the PASARR. A current policy, titled Pre-Admission Screening and Resident Review, dated as last revised in August 2020 and received from the Clinical Support Nurse on 7/30/24 at 4:35 p.m., indicated .Level 1 and Level 2 Assessments will be reviewed upon admission and are included in the resident's medical record .A level 1 Assessment is completed with any new mental health diagnoses, symptoms, psychiatric hospitalization s and/or related medications 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to provide a resident with a call light he was physically capable of activating for 1 of 1 resident reviewed for accommodation of needs. (Resident 40) Finding includes: During an observation, on 7/24/24 at 12:35 p.m., the resident was in the dining room. A nurse was assisting the resident to eat. The resident's hands were contracted with all fingers flat against his palms. He could not grip or use his thumbs. During an observation, on 7/25/24 at 9:50 a.m., the resident was in his room in his reclining Broda chair with a standard small push button call light clipped to his pant leg. The resident indicated he needed to go to the bathroom. He made multiple attempts to push the small red button on the call light. He tried several different ways but was never able to push the small button to activate the call system. The resident was visibly distressed and indicated he was frustrated because the call light did not work most of the time, so he had to call out for help. The resident's voice was low in volume and tone related to his Parkinson's disease. He could barely be heard just outside of his room with the door open. Staff were notified the resident needed assistance but could not operate the call light. The resident indicated he used to have a soft touch pad call button; however, staff had removed it a while ago because he would occasionally roll over on it when he was in bed. He indicated he needed the soft touch call button to be able to call for assistance and wanted it back. The clinical record for Resident 40 was reviewed on 7/26/24 at 3:22 p.m. The diagnoses included, but were not limited to, Parkinson's disease, depression, anxiety, psychotic disorder with delusions, muscle wasting and atrophy of the right hand, muscle wasting and atrophy of the left hand, muscle wasting and atrophy in the right upper arm, muscle wasting and atrophy in the left upper arm, and repeated falls. A care plan, initiated on 2/7/23, indicated the resident had impaired physical mobility related to contractures to his hands and Parkinson's disease. The use of a touch pad call light was initiated, on 7/29/24, after the resident was observed to be unable to use the standard call light. During an interview, on 7/26/24 at 1:30 p.m., LPN1 indicated she thought the resident had a soft touch pad call light. She knew he used to have one because he could not use a regular call light with his hand contractures. She did not know why it would have been taken out of his room and would notify maintenance and her manager to get a soft touch call light in his room. A current facility policy, titled Accommodation of Needs, not dated and received from the Director of Nursing (DON) on 7/30/24 at 6:15 p.m., indicated .The resident's individual needs and preferences, including the need for adaptive devices .shall be .reviewed on an ongoing basis 3.1-3(v)(1)

Based on interview and record review, the facility failed to develop a comprehensive care plan for the diagnoses of mental health conditions and the use of antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 19) Finding includes: The clinical record for Resident 19 was reviewed on 7/24/24 at 3:45 p.m. The diagnoses included, but were not limited to, bipolar type schizoaffective disorder, bipolar disorder, metabolic encephalopathy (a brain disorder caused by a chemical imbalance), intellectual disabilities, and type 2 diabetes mellitus. A physician's order, dated 6/28/24, indicated to give risperidone (an antipsychotic medication) 1 milligram (mg) two times a day related to schizophrenia. A psychiatry progress note, dated 7/23/24, indicated the resident was seen for ongoing monitoring and management of mood, behavior and cognition. The diagnoses included, but were not limited to, bipolar type schizoaffective disorder, bipolar disorder, and unspecified intellectual disabilities. The care plans did not include the mental health diagnoses of schizoaffective disorder or bipolar disorder and did not include the use of an antipsychotic medication. During an interview, on 7/29/24 at 2:00 p.m., the Minimum Data Set (MDS) Coordinator indicated the mental health diagnoses and medications should have been added to the care plan. During an interview, on 7/29/24 at 2:54 p.m., the MDS Coordinator indicated the comprehensive care plan should be started immediately upon admission and in place by 14 days. The resident had been in the facility for 31 days and had been on the risperidone for 31 days. A current policy, titled Comprehensive Care Plan, dated as last reviewed on 12/12/23 and received from the Director of Nursing on 7/29/24 at 3:24 p.m., indicated .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment .The comprehensive care plan will describe, at a minimum, the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Resident specific interventions 3.1-35(a)

Based on observation, interview and record review, the facility failed to ensure a resident was assessed to self-administer medications for 1 of 2 residents observed for medication administration. (Resident D) Findings include: During a random observation, on 11/14/23 at 9:51 a.m., a medication cup of pills was observed left on the bedside table. There were no qualified staff in the room at the time to observe the medication administration. Resident D was left to take her medication unattended. The record for Resident D was reviewed on 11/14/23 at 10:42 a.m. Diagnoses included, but were not limited to, Parkinson's disease, type 2 diabetes, and hypertension. Resident D did not have an order to self-administer medications in her record. Resident D did not have a self-administration assessment in her record to indicated she was able to safely self-administer medications. Resident D was not care planned to self-administer medications. During an interview, on 11/14/23 at 9:53 a.m., Resident D indicated staff did not always leave her medications with her and she was getting ready to take them. During an interview, on 11/14/23 at 9:57 a.m., the Assistant Director of Nursing indicated staff were not supposed to leave medications at the bedside without a nurse or QMA present. A current facility policy, titled Administering Medications, dated as last revised in April of 2019 and received from the Director of Nursing on 11/14/23 at 3:30 p.m., indicated, .Resident's may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely 3.1-11(a)

Based on observation, interview and record review, the facility failed to ensure a medication was administered per the physician's order for 1 of 2 residents observed for quality of care. (Resident B) Finding includes: During a random observation, on 11/14/23 at 10:16 a.m., Resident B was observed resting in bed. The resident had a Scopolamine transdermal patch (used to decrease secretions) behind his right ear. The patch had been dated 11/9/23. The record for Resident B was reviewed on 11/14/23 at 10:52 a.m. Diagnoses included, but were not limited to, paralytic syndrome following cerebrovascular disease (paralysis), dysphagia (difficulty swallowing), and persistent vegetative state. A physician's order, dated 12/31/20, indicated to administer a Scopolamine Patch 72 hour in the morning every three (3) days and remove per schedule. During an interview, on 11/14/23 at 10:22 a.m., LPN 1 indicated the patch was changed on the night shift and he was not sure how often the patch needed to be changed. He would check the medication order to see how often the patch needed to be changed. A current facility policy, titled Administering Medications, dated as last revised in April of 2019 and received from the Director of Nursing on 11/14/23 at 3:30 p.m., indicated .Medications are administered in accordance with prescriber orders, including any required time frame 3.1-37(a)

Based on interview and record review, the facility failed to ensure staff contacted the physician, dietitian, or nurse practitioner to get an order for nutritional formula administration for 1 of 2 residents reviewed for gastronomy tube feedings. (Resident C) Finding includes: The record for Resident C was reviewed on 11/14/23 at 1:08 p.m. Diagnoses included, but were not limited to, malignant neoplasm of laryngeal cartilage (throat cancer), emphysema, and bipolar disorder. A care plan, initiated on 10/19/23, indicated Resident C was at risk for fluid imbalance due to chronic kidney disease and NPO (nothing to be given orally) status. The October Medication and Treatment Administration record did not have any documentation to show Resident C had received any meals or fluids via the gastronomy tube, for approximately 15 hours, from 10/17/23 beginning at 6:00 p.m., until a grievance was filed and investigated on 10/18/23 at 9:30 a.m. The resident admitted to the facility on [DATE] at 5:37 p.m. The hospital discharge orders did not have an order for enteral tube feeding (a way to deliver nutrition to the stomach or small intestine). This resulted in the resident not being provided any meals or fluids between 10/17/23 at 6:00 p.m., to 10/18/23 at 9:30 a.m. A facility document, titled Report of Concern, with a concern date of October 17-October 18, 2023, between 6:00 p.m. to 9:00 a.m., indicated the grievance was reported by the family member of Resident C and indicated the resident had not been fed since she arrived in the facility. The findings documented on the form by facility staff indicated the resident did not have an order for a nutrition formula. The Nurse Practitioner and Registered Dietitian were notified on 10/18/23 at 9:30 a.m. The Registered Dietitian provided orders and the resident did receive the enteral nutrition after the order was received. During an interview, on 11/15/23 at 10:57 a.m., RN 2 indicated if a resident admitted to the facility with a gastronomy tube (a tube inserted into the stomach) and did not have orders, the physician needed to be contacted for nutritional orders. During an interview, on 11/15/23 at 12:26 p.m., the Director of Nursing indicated the policy for medication administration was all the facility had and it applied not only to inappropriate or excessive doses of medications but also applied if the order was absent. It applied to anyone receiving nutrition through a gastronomy tube. A current facility policy, titled Administering Medications, dated as last revised in April of 2019 and received from the Director of Nursing on 11/14/23 at 3:30 p.m., indicated .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences .contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concern This Federal Tag relates to Complaint IN00420094. 3.1-46(1) 3.1-46(2)

Based on observation, interview and record review, the facility failed to ensure documentation was correct in the resident record when the administration of a transdermal medication patch found on a resident was dated for 11/9/23 but charted as being changed on 11/12/23 for 1 of 3 residents reviewed for documentation in the medical record. (Resident B) Finding includes: During a random observation, on 11/14/23 at 10:16 a.m., Resident B was observed resting in bed. The resident had a Scopolamine transdermal patch (used to decrease secretions) behind his right ear. The patch had been dated 11/9/23. The record for Resident B was reviewed on 11/14/23 at 10:52 a.m. Diagnoses included, but were not limited to, paralytic syndrome following cerebrovascular disease (paralysis), dysphagia (difficulty swallowing), and persistent vegetative state. A physician's order, dated 12/31/20, indicated to administer a Scopolamine Patch 72 hour in the morning every three (3) days and remove per schedule. The Medication Administration Record indicated the Scopolamine patch was documented as changed on 11/12/23 at 5:00 a.m. During an interview, on 11/14/23 at 10:22 a.m., LPN 1 indicated the patch was changed on the night shift and he was not sure how often the patch needed to be changed. During an interview, on 11/14/23 at 10:37 a.m., LPN 1 indicated the Scopolamine patch was not correctly signed off in the Medication Administration Record. A current facility policy, titled Charting and Documentation, dated as last revised in July of 2017 and received from the Director of Nursing on 11/14/23 at 3:30 p.m., indicated .documentation in the medical record will be objective .complete and accurate 3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident was re-assessed for interventions to treat and prevent further contracture for 1 of 2 residents reviewed for limited range of motion. (Resident 3) Finding includes: During an observation, on 05/15/23 at 3:00 p.m., the resident was in his room lying in bed. The resident had contractures of both hands. During an observation, on 05/17/23 at 11:03 a.m., the resident was in his room lying in bed with rolled up washcloths in both hands. During an observation, on 05/18/23 at 12:23 p.m., the resident was in his room lying in bed with rolled up washcloths in both hands. The resident did not have elbow splints or hand splints during the observations. The record for Resident 3 was reviewed on 05/17/23 at 10:03 am. Diagnoses included, but were not limited to, persistent vegetative state, unspecified intercranial injury, cerebrovascular disease, paralytic syndrome, and chronic pain. A physician's order, dated 03/31/2016, indicated hand splints to be worn daily from 8:00 a.m. through 5:00 p.m. A physician's order, dated 07/28/2016, indicated elbow splints to be worn daily from 8:00 a.m. until bedtime. A physical therapy plan of treatment, dated 07/27/2021-09/24/2021, indicated the short-term goal included resident and caregivers would be able to demonstrate ROM safely 85% of the time in order to prevent further joint contractures. Another goal was for the resident and the caregivers to demonstrate 100% of the time safely performing ROM and proper positioning of the resident in bed in order to limit joint deformities. A contracture care plan, dated 04/24/2018 and revised on 02/02/2023, indicated the resident was at risk for further contractures due to immobility, muscle spasms, neuropathy, vegetative state, and cognition impairment. The goals included the resident would be free of any discomfort or adverse side effects from pain medication. The interventions included, but were not limited to, administer medication as ordered, monitor for increased risk for falls, monitor for altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress, sedation, urinary, passive range of motion and non-pharmacologic pain interventions: positioning, quiet environment, distraction, enjoy watching tv at times, and check for incontinence. The care plan was not updated to include the goals of physical therapy to prevent further joint contracture and to limit joint deformity. A care plan, dated 01/02/2011 and revised 02/02/2023, indicated the resident was at a risk for alteration in skin integrity. Goals indicated the resident would have decrease/minimize skin breakdown risk. Interventions included, but were not limited to, pressure redistributing device on bed/chair, provide preventative skin care routinely and prn, and turn and reposition every 2 hours. The care plan was not updated to include the goals of physical therapy to prevent further joint contracture and to limit joint deformity. The resident's census indicated hospice services were stopped on 01/22/2023. There were no orders for contracture prevention or recent therapy assessment following discharge from hospice. During an interview, on 05/18/23 at 12:14 p.m., Anonymous Staff 3 indicated the CNAs would do range of motion when changing him. They would put rolled washcloths in both hands. He was on hospice until a few months ago. He no longer qualified for hospice. During an interview, dated 05/18/23 at 12:23 p.m., Anonymous Staff 6 indicated staff would put washcloths in the resident's hands since the hands were contracted. During an interview, dated 05/19/23 at 2:30 p.m., the Director of Nursing indicated they did not do an assessment for contractures following the resident's release from hospice. The facility did not have a restorative program. A current policy, titled Repositioning, dated as revised May 2013 and received from the Regional Support Nurse on 05/19/2023 at 5:00 p.m., indicated .The purpose of this procedure is to provide guidelines for evaluation of resident repositioning needs, to aid in the development of the individualized care plan for repositioning to promote comfort for all bed or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents .Review the resident's care plan to evaluate for any special needs of the resident .A turning/repositioning program includes a continuous consistent program for changing for the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated .Steps in the procedure .Check the care plan, assignment sheet or the communication system to determine resident's specific positioning needs including special equipment, resident level of participation and the number of staff required to complete procedure 3.1-42(a)(2)

Based on interview and record review, the facility failed to ensure notices were given 48 hours prior to the Medicare benefits ending date and to ensure the residents chose an option for ongoing services for 3 of 3 residents reviewed for beneficiary notices. (Resident 153, 17 and 45) Findings include: 1. The NOMC (Notice of Medicare Non-Coverage) form for Resident 153 indicated the coverage of Medicare Part A services would end on 2/7/23. The daughter was telephoned, on 2/6/2 at 3:20 p.m., to notify her of the end of coverage date. During an interview, on 5/18/23 at 2:42 p.m., the BOM (Business Office Manager) indicated the Social Services Director was in charge of giving notices to the resident or resident representative. The notice should have been given on 2/5/23 for the required 48-hour notice. 2. A Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for Resident 17 indicated beginning on 2/2/23 the resident may have to pay out of pocked for care if there was no other insurance to cover the costs. The form included 3 options: 1. The resident wanted the care and wanted Medicare billed. 2. The resident wanted the care and did not want Medicare billed. 3. The resident did not want the care. The resident signed the form on 1/30/23 and did not check which option was chosen. During an interview, on 5/18/23 at 2:40 p.m., the BOM indicated the staff should ensure an option was chosen by the resident or representative and included in the documentation. 3. An SNFABN form for Resident 45 indicated on 3/15/23 the resident may have to pay out of pocked for care if there was no other insurance to cover the costs. The form included 3 options: 1. The resident wanted the care and wanted Medicare billed. 2. The resident wanted the care and did not want Medicare billed. 3. The resident did not want the care. The verbal consent from the resident's representative was documented on 3/10/23. The documentation did not include which option the representative chose. During an interview, on 5/18/23 at 2:44 p.m., the BOM indicated the facility documentation should have included which option the family representative chose. The facility had not provided a policy for beneficiary notices at time of exit from the facility. 3.1-4(f)(3)

Based on observation, interview and record review, the facility failed to offer a care plan meeting and to initiate a care plan for a urinary tract infection for 2 of 2 residents reviewed for care plans. (Resident 4 and 35) Findings include: 1. During an interview, on 5/15/23 at 12:45 p.m., Resident 4 indicated she had not been invited to a care plan meeting since she had been admitted to the facility. The record for Resident 4 was reviewed on 5/16/23 at 4:25 p.m. Diagnoses included, but were not limited to, congestive heart failure, anxiety disorder, depression, hypertension, post traumatic disorder, and chronic pain. A facility document, titled Interdisciplinary Team Care Plan Conference Summary, dated 9/22/22, indicated the form was not completed and the resident did not have a care plan conference. A progress note, dated 2/17/23 at 11:51 p.m., indicated the care plan was reviewed. The staff in attendance were the Minimum Data Set Coordinator (MDSC), Social Service Director (SSD), Unit Manager (UM), Registered Dietician (RD), and the Director of Nursing Services (DNS). The resident was being reviewed for accuracy of her plan of care, all parties reviewed and were satisfied with the plan of care. During an interview, on 5/19/23 at 2:46 p.m., the Regional Support Nurse indicated the resident was admitted on [DATE]. The facility should arrange a care plan meeting with the resident and resident's family within the first 72 hours of being admitted . He was not sure why the resident or resident's family was not included for the 2/17/23 care plan review. 48385 2. During an observation, on 05/16/23 at 12:01 p.m., Resident 35 was on contact isolation for Escherichia Coli (E. coli) and ESBL (Extended Spectrum Beta-Lactamase, a bacteria that could not be killed by many antibiotics which made it harder to treat) in the urine. The record for Resident 35 was reviewed on 05/17/2023 at 11:13 a.m. Diagnosis included, but were not limited to, schizophrenia, anxiety, essential hypertension, ischemic cardiomyopathy, bipolar disorder, heart failure, asthma, allergic rhinitis, personal history of covid-19, and sleep disorder. The facility matrix indicated the resident was in transmission-based precautions for ESBL. A physician's order, dated 05/07/23, indicated Amoxicillin-Pot Clavulanate (an antibiotic) tablet 875-125 mg (milligram) was started on 05/07/2023 and to give 1 tablet by mouth two times a day due to a UTI bacterial infection for 28 days. During an interview, on 05/18/23 at 2:47 p.m., the Regional Support indicated there was not a care plan for the UTI and there should have been one. A current policy, titled Care Planning- Interdisciplinary Team, dated as revised on 09/28/17 and received from the DNS on 05/19/23 at 3:31 p.m., indicated .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized care plan for each resident .The care plan will be read aloud to the resident, family and IDT team. A written summary or copy of the baseline care plan will be given to the resident and/or representative .Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family .The summary of the baseline and comprehensive care plan will be given to the resident and/or representative within 7 days of completion . 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to ensure a resident received twice weekly activities and a resident received the identified preference for the activity of their choice for 2 of 5 residents for activities. (Resident 3 and 253) Findings include: 1. During an observation, on 5/15/23 at 2:56 p.m., Resident 3 was in his room, lying in his bed, and the television (TV) was on. During an observation, on 5/16/23 at 11:12 a.m., the resident was in his room, lying in his bed, and the TV was on. Other residents were observed in the common area playing bingo. During an observation, 5/17/23 at 10:57 a.m., the resident was in his room, lying in his bed, and the TV was on. Other residents were observed in the dining room listening to live music. During an observation, on 5/18/23 at 3:09 p.m., the resident was in his room, lying in bed, and the TV was on. Other residents were observed in the common area. The record for Resident 3 was reviewed on 5/17/23 at 10:03 a.m. Diagnosis included, but were not limited to, persistent vegetative state, unspecified intercranial injury, cerebrovascular disease, paralytic syndrome, and chronic pain. An activity care plan, dated 1/13/2016 and revised on 9/16/2022, indicated the goal included the resident would attempt to respond with eye tracking and head movement during activities with staff, family, or community at least 2 times a week. The interventions included, but were not limited to, coordinate and display items in the room sent by his sister for visual stimulation and comfort, provide sensory stimulation with 1:1 visits, read family stories to him, and play music. An activity log, dated 4/03/23 through 5/15/23, indicated there were five (5) one to one activities completed. Three of the five one to one activities included watching TV. The resident did not receive twice weekly activities as indicated by the care plan. During an interview, on 5/18/23 at 2:35 p.m., Anonymous Staff 4 indicated the resident liked music and sometimes the staff would read to him. 46961 2. During an interview, on 5/15/23 at 2:57 p.m., Resident 253 indicated he spoke to the Activity Director and told her he liked books about ghost stories, but he had not received any at this time. He could not get out of his room for activities because of his wounds and weakness. During an observation, on 5/17/23 at 2:00 p.m., the resident was lying in bed with the head of the bed elevated. The resident was watching television. During an observation, on 5/18/23 at 2:26 p.m., the resident was lying in bed talking on the telephone. The television was on and there were no books in his room. The record for Resident 253 was reviewed on 5/16/23 at 4:33 p.m. Diagnoses included, but were not limited to, spina bifida, pressure ulcer of right buttock unstageable, pressure ulcer of left buttock unstageable, morbid obesity, sepsis, type 2 diabetes, bacteremia, and left BKA (below the knee amputation). There was no activity care plan in the electronic medical record. During an interview, on 05/18/23 at 3:15 p.m., Anonymous Staff 4 indicated the resident had been signed up for the library at home project. He would be able to pick the library books he wanted, but they would not come until June. She was not sure if he would be in the facility until June. He received the daily chronicles (a daily newsletter from the facility) and a monthly calendar, but he was not able to get out of his room. She had not given him in room activities. A current policy, titled Activity Programs, dated as revised on 7/2018 and received from the Director of Nursing on 05/19/23 at 5:35 p.m., indicated .Individualized and group activities are provided that: reflect the schedules, choices, and rights of the resident, are offered at hours of convenient to the residents, including evenings, holidays, and weekends, reflect the cultural and religious interests, hobbies, life experience, and personal preferences of the residents, appeal to men and women as well as those of various age groups residing in the facility . 3.1-33(a) 3.1-33(b)(8)

Based on observation, interview and record review, the facility failed to ensure the physician was notified of a weight gain as ordered for a resident who was diagnosed with congestive heart failure for 1 of 1 resident reviewed for edema. (Resident 41) Finding includes: During an observation, on 5/15/23 at 12:52 p.m., Resident 41 was sitting in her recliner with both legs elevated. The resident's bilateral legs and ankles were swollen. The record for Resident 41 was reviewed on 5/16/23 at 4:42 p.m. Diagnosis included, but were not limited to, congestive heart failure, hypertension, urine retention, and depressive disorder. A physician's order, dated 10/25/22, indicated daily weight and to notify the provider of a 3-pound weight gain in two days or a 5-pound weight gain in a week and to weigh before breakfast related to congestive heart failure. A physician's order, dated 1/4/23, indicated furosemide (a diuretic) 20 mg (milligrams) tablet give two tablets daily related to edema. During a record review, the physician was not notified for the following weight gains: a. 3/9/23 to 3/11/23, the resident had a 5-pound weight gain. b. 3/25/23 to 3/26/23, the resident had a 6-pound weight gain. c. 4/9/23 to 4/10/23, the resident had a 4.8-pound weight gain. d. 4/18/23 to 4/19/23, the resident had an 8-pound weight gain. e. 5/14/23 to 5/15/23, the resident had a 4-pound weight gain. A care plan, revised 3/16/23, indicated the resident was at risk for impaired cardiac output. The interventions included, but were not limited to, the resident would be observed for signs and symptoms of cardiac dysfunction, shortness of breath, and edema. During an interview, on 5/17/23 at 1:15 p.m., Anonymous Staff 2 indicated the resident's legs were swollen and the resident was weighed daily. The resident had a physician's order if the resident had a weight gain of more than 3 pounds in a day the Nurse Practitioner (NP) would be notified and asked if additional Lasix (a diuretic) would be needed. During an interview, on 5/20/23 at 4:15 p.m., the Regional Support Nurse indicated he did not know why the physician was not notified of the weight gains and did not find documentation the physician was notified of the weight gains. A current facility policy, titled Heart Failure - Clinical Protocol, dated as revised 11/2018 and provided by the Regional Support Nurse on 5/19/23 at 5:00 p.m., indicated .The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights .etc.) to monitor, when to report findings to the physician, etc .The physician will document information related to the individual's prognosis and current signs and symptoms .the presence of edema A current facility policy, titled Resident Weight Monitoring, dated 10/2018 and provided by the Director of Nursing on 5/18/23 at 3:38 p.m., indicated .Daily Weights: Orders for daily weights should include Physician call parameters such as +/- 3 lbs in 24 hours. Should be recorded on MAR or TAR using decimal point numeration such as 152.6 lbs. MAR and TAR should indicate if Physician was notified of parameter change 3.1-37(a)

Based on interview and record review the facility failed to call 911, as requested by the Power of Attorney, for a resident who displayed significant changes from baseline for 1 of 3 residents reviewed for quality of care. (Resident B) The resident was not sent to emergency room 911, but was sent out by another company resulting in a delay in treatment for [REDACTED]. Finding includes: During an interview with the daughter of Resident B, on 4/24/19 at 1:17 p.m., she indicated she wanted her mother to be sent out to the emergency room via 911 after she was made aware from her mother's personal caregiver of a neurological status change as well as an elevated blood pressure of 170/90. She also indicated she made this request to CNA 1 and LPN 2. During an interview with LPN 2, on 4/24/19 at 2:20 p.m., she indicated CNA 1 came to her and reported Resident B had left sided weakness and was less responsive than usual. LPN 2 entered the resident's room with CNA 1 to assess the resident's status. LPN 2 indicated she took the resident's vital signs at 11:15 a.m., and her blood pressure was 170/90. At that point, she indicated to the private caregiver to call the daughter, POA (power of attorney) and make her aware of her mother's change in status and elevated blood pressure. LPN 2 indicated the daughter requested her mother to be sent to the emergency room via 911. LPN 2 left the room and went to inform the Director of Nursing (DON) she was sending the resident out 911 per the family's request. LPN 2 indicated at that time, the DON wanted to do his own assessment of the resident prior to sending her out to the emergency room . LPN 2 and the DON entered the resident's room. LPN 2 observed the DON do his assessment of the resident which consisted of a sternal rub while attempting to verbally stimulate the resident. The only physical assessment she witnessed the DON perform of the resident was a sternal rub. LPN 2 and the DON left the room and went to the nurses station where the DON advised her to call EMS (Emergency Medical Services). LPN 2 indicated she called EMS and was told it would take 30 to 45 minutes for transport to the ER, she relayed this to the DON who asked her to inquire if this could be any quicker to which EMS replied 10 to 20 minutes, she again relayed this to the DON and he approved transport. LPN 2 indicated she became busy with another resident when the private caregiver informed her the POA requested to speak with her on Resident B's cell phone. LPN 2 indicated she referred the call to the DON at that time. During an interview, with CNA 1, on 4/24/19 at 2:27 p.m., she indicated while she provided care for Resident B she noticed her to be less alert and her left side did not feel as strong. Resident B usually resisted care and her strength was usually equal on both sides. CNA 1 indicated she reported her concerns to LPN 2 and she returned to the resident's room with LPN 2. She observed LPN 2 assess the resident and advice the private caregiver to call the residents daughter. CNA 1 indicated she heard the daughter request 911 transport. She exited the room with LPN 2 and indicated the DON took over at that time. She then went to care for her other residents and later returned to the resident's room where the private caregiver was still on the phone with the daughter. During an interview with the DON and Administrator, on 4/24/19 at 2:39 p.m., the DON indicated he received a report of Resident B's status change and the family was requesting the resident be sent to the emergency room (ER). He indicated at that point he went to Resident B's room to assess the resident himself. He did a sternal rub and the resident briefly opened her eyes and then closed them again. He then exited the resident's room with LPN 2 and instructed her to call EMS as opposed to 911. He indicated he was unaware of the daughter's request for the resident to be sent to the ER via 911, he further indicated he felt EMS could transport as fast as 911. He was present when LPN 2 called EMS but could not recall if he was made aware of the reported estimated EMS arrival time. EMS arrived and he entered the resident's room with them. The DON and Administrator indicated someone must have called 911 because they arrived as EMS was leaving. He further indicated he felt like EMS was an appropriate transport method for Resident B's presentation. The Administrator inquired at that time if a nursing assessment would override a family's request and indicated he first became aware of concern when Resident B's other daughter came to discuss it will him in his office. The daughter was irate and requesting to speak to the DON. The Administrator agreed to have a meeting with himself and the DON with her. The daughter voiced dissatisfaction and concern with 911 not being called. During an interview, with Resident B's private caregiver on 4/26/2019 at 10:15 a.m., she indicated CNA 1 came into the resident's room at approximately 10:30 a.m., to clean her up. She asked CNA 1 to check out the resident because her left leg was out straight in the bed and it was usually bent. She indicated CNA 1 was in the room for 15-20 minutes. CNA 1 asked her to go get LPN 2. LPN 2 came in to resident's room [ROOM NUMBER]-4 minutes later, looked at the resident and took her vital signs. At that point, LPN 2 told her to call Resident B's daughter. She called the daughter at: 11:17 a.m., and was told from the daughter she wanted the resident to be sent to the hospital 911, she gave the phone to LPN 2. At that time LPN 2 stepped out of the room. She stayed on the phone with the daughter. After 10 minutes went by the ambulance still had not arrived. LPN 2 came back into the resident's room with the DON. They were both in the room for 2-3 minutes and she remained on the phone with the daughter the whole time. Another 10-15 minutes go by and no paramedics had arrived so she went to the front desk and the DON if he called 911. He replied he had it all under control and he walked away. At that time she was still on the phone with the daughter who told her to go back in the resident's room and call 911. Per her cell phone she called 911 at 11:47 a.m. She spoke with the dispatcher and asked him if any other ambulance was dispatched she indicated the dispatcher replied NO. After hanging up from 911, the EMS paramedics came into the resident's room. The paramedics talked with CNA 1. The DON came in right after and asked CNA 1 to leave. The DON also asked her to leave but she refused and just got out of the way. She left the facility at the same time as the ambulance left with the resident and the ambulance did not use lights or sirens to the hospital. During an interview, with the paramedic from (name of private ambulance company), on 4/24/2019 at 5:03 p.m., he indicated the ambulance was located at(NAME)Rd & 38th street when they received a call from the facility for a pick up at 11:30 a.m. An estimated time of arrival (ETA) of 35 minutes was given to the facility and accepted. He indicated he knew Resident B from previous pick-ups. They arrived at the facility at 11:49 a.m. (19 minutes from when the call was made), entered Resident B's room and observed the private caregiver was on phone with POA as per usual for that resident. They left the facility at 12:05 p.m., and arrived at (name of hospital) at 12:27 p.m. During an interview, with a representative from The Carmel Fire Department (CFD) on 4/26/19 at 1:06 p.m., she indicated a 911 call was received from (name of facility) on 4/24/19 at 11:47 a.m. Emergency responders were dispatched from CFD Station 46 and arrived at the facility at 11:50 A.M., (3 minutes after the call was made). They proceeded to the second floor where they were informed a crew from (name of private ambulance company) was transporting the resident. During an interview, with the Medical Director on, 4/26/19 at 12:27 p.m., he indicated he was very familiar with Resident B and her family. He was notified of left upper and lower extremity weakness and neuro changes at around 11:00 a.m., and he wrote orders for her to be sent out to the ER. He indicated at that time he felt it to be an emergent situation and had the expectation the facility would send her out via 911. The record for Resident B was reviewed on 4/24/2019 at 3:00 p.m. [DIAGNOSES REDACTED]. Hospital records were reviewed on 4/25/19 at 9:30 a.m. A final ED (emergency room Department) physician's progress note dated 4/24/19 indicated the resident's reason for the visit was for altered mental status and a review of systems indicated focal weakness to the left upper and lower extremities. The resident's vital signs indicated her blood pressure was 217/64 and her condition was guarded. An assessment indicated an acute right ACA (anterior cerebral artery) stroke. A head CT (computerized tomography) scan dated 4/24/19 at 1:58 p.m., indicated since 4/20/19, there had been a development of a large acute infarction (stroke) of the right side of the brain. An admission note/history and physical final report dated 4/24/19 at 6:12 p.m., indicated on physical exam the resident had a left mouth droop and decreased movement to left upper extremity. The resident's blood pressure range was from 201-249 systolic (top number) and 67-82 diastolic (bottom number). It also indicated the need to discuss with the family about the placement of a feeding tube secondary to a neurological final progress note dated 4/24/19 at 7:03 p.m., which indicated the resident had impaired swallowing. It was documented the overall prognosis of the resident was poor given the new stroke. A facility document, titled, INDIANA PATIENT/RESIDENT BILL OF RIGHTS & RESPONSIBILITIES, provided by the Administrator on 4/26/2019 at 12:38 p.m., indicated, .You have the right to quality care and treatment .Relatives or legal representative may act on your behalf to exercise these rights when you are unable to do so yourself This Federal tag relates to complaint IN 422. 3.1-37(a)

Based on interview and record review the facility failed assess and to notify the physician for timely treatment for 1 of 1 resident's reviewed for quality of care (Resident G). Resident G was admitted to the hospital for severe ascites and abdominal pain and had 3.1 liters of fluid removed from the abdomen. Finding includes: The record review for Resident G was reviewed on 01/28/2019 at 12:36 p.m. [DIAGNOSES REDACTED]. A general progress note, dated 07/27/2018, indicated the nurse notified the NP (Nurse Practitioner) of Resident G's increasing shortness of breath, distended abdomen. The NP gave an order to schedule an appointment for an ultrasound guided paracentesis (a procedure in which extra fluid is removed from the peritoneum to increase comfort). A general progress note, dated 07/31/ (YEAR), indicated the appointment was made for 08/07/2018. There is no progress note indicating the NP was notified of the scheduled date for this appointment. A general progress note, dated 08/02/2018 at 1:13 p.m., indicated the resident's ammonia level (a gas that if found in the blood at high levels can cause severe liver damage) was 84 (above normal). A general progress note, dated 08/02/2018 at 3:00 p.m., indicated the family called the facility and stated the resident should be sent to the ER (emergency room ) as appointment for paracentesis is not until Tuesday. That the resident appears much larger in her abdomen .That the resident needed to be seen much sooner and wants resident seen in ER A general progress note, dated 08/02/2018 at 4:07 p.m., indicated the resident was sent to the ER for evaluation of ascites (an accumulation of fluid in the peritoneal cavity, causing abdominal swelling) and paracentesis. A (Name of Hospital) emergency room Note, dated 8/2/19 indicated .presents .secondary to increasing abdominal pain and ascites .She states that she has had increasing abdominal pain and firth for the past several years but specifically over the last 2 days She will need to be admitted because of the size of the ascites on (sic) her abdominal pain A (Name of Hospital) note, dated 8/13/18 indicated, the resident .who presented to the emergency room with complaints of abdominal pain, recurrent ascites and swelling. CT scan of the abdomen and pelvis was consistent with ascites and anasarca. She ultimately received a paracentesis with removal of 3.1 liters and was started on IV diuretics The record did not indicate assessments of abdominal girth or weight changes. During an interview with the NP, on 02/04/2019 at 12:45 p.m., the NP indicated she was not aware of the date and time of the resident's paracentesis and if she were aware she would have made different arrangements to provide this care for this resident sooner. No policy could be provided. This federal tag relates to Complaint IN 694. 3.1-37(a)

Based on interviews and record review, the facility failed to supervise a resident with a known aspiration risk, after a meal tray was served in his room while he was in bed, not following an order to be in the dining room with supervision. The resident was served dinner in his room, unsupervised, choked, became unresponsive, required CPR (Cardiopulmonary Resuscitation) and was admitted to the hospital for 1 of 7 residents reviewed for accidents (Resident B). The Immediate Jeopardy bean on [DATE] at 6;30 p.m., when Resident B was left unsupervised in his room with his dinner tray. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 2:03 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore past noncompliance. Finding includes: During an interview on [DATE] at 12:15 p.m., LPN 1 indicated she was not present the evening Resident B choked, but she heard from others, his dinner tray was delivered by one CNA and left in his room for an undetermined amount of time before the other CNA came into his room to assist him to eat. She indicated before the second CNA arrived into the resident's room to assist him, he was already choking. The record for Resident B was reviewed on [DATE] at 2:00 p.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A progress note dated [DATE] at 6:57 p.m., indicated Resident B was choking during dinner and coughed up a piece of meat, but continued to choke. The CNA notified the nurse and the [MEDICATION NAME] maneuver was initiated. 911 was called. The resident was turning blue and he became unresponsive, so CPR was initiated. The Paramedics arrived and took over the resident's care and he was transferred to the hospital. An ER (emergency room ) Physician Exam note (from Name of Hospital) dated [DATE] at 7:15 p.m., indicated the resident choked on a very large piece of bread was getting CPR when the medics arrived. When they went to intubate Resident B they pulled out a very large amount of impacted bread from his oral pharynx. The Paramedics intubated the resident after 2 minutes of CPR. He started gagging against the breathing tube, so the Paramedics removed the breathing tube and placed him on a high concentration of oxygen. A Hospital Consultation Note from (Name of Hospital) dated [DATE], indicated .Chief Complaint: Choking, loss of consciousness, intubation .He was in his usual state of health until he was eating at his SNF (Skilled Nursing Facility) unit when he began to choke .CPR was administered by EMS (Emergency Medical Services). Upon arrival, they are able to remove this large wad of bread and continued to intubate. He was gagging against the tube during the CPR and the tube was removed, he was sent to the emergency room for overnight evaluation. While being observed overnight, the patient had an episode of respiratory distress and was reintubated since that time .The only time he will respond according to the nursing staff is when they are suctioning him and he will try to pull at the tubes. I have been called to see this patient to evaluate the prognosticate based on his [MEDICAL CONDITION] injury .Impression: the patient has [MEDICAL CONDITIONS] (a condition where brain tissue is deprived of oxygen and there is global loss of brain function). Prognosis for normal human interaction is abysmal (extremely bad) A Discharge Summary from (Name of Hospital) dated [DATE], indicated he had been eating when he began choking and suffered cardiopulmonary arrest. CPR was administered. EMS attempted to intubate on arrival, but found a large piece of bread obstructing his airway and removed it, then gave him CPR. He was transferred to the ER (emergency room ). He was admitted to the hospital. The next day he had been maintaining his airway, but then he began to have some respiratory distress and had to be intubated and placed on the ventilator. He was weaned off the ventilator and had a [MEDICAL CONDITION] (a surgically placed hole in the neck to allow a person to breathe easier) and a percutaneous gastrostomy (feeding tube to enable the resident to get nutrition since he was unable to take in nutrition by mouth) placed. He never really awakened. He was treated for [REDACTED]. He will end up on Hospice. He was dismissed from the hospital. A Speech Therapy summary of Skill note dated [DATE], indicated Resident B was in bed at the lunch meal. He needed alteration of solids and liquids to be able to completely clear his mouth of solid food items. He did have a productive cough when he ate bread. He did sometimes and was at risk for silent aspiration from his previous [MEDICAL CONDITION]. A Speech Therapy Discharge Summary note dated [DATE], indicated the resident reached his maximum functional potential for speech therapy at that time. The resident and the staff was trained for strategies such as positioning, rate, bite size and alternating liquids and solids to decrease risk of aspiration. Pt (Patient) and Caregiver Training: Instructed patient and primary caregivers in .positioning maneuvers, safe swallow techniques and safety sequencing techniques in order to facilitate functional independence in the absence of secondary medical complications [REDACTED]. Intake Protocol: Swallow Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies and /or maneuvers during oral intake: alternation of liquid/solids, rate modification, bolus size modifications, effortful swallow and general swallow techniques/precautions upright posture during meals and upright posture for > (greater) 30 mins (minutes) after meals. Supervision for Oral Intake=Close Supervision. A care plan addressing Resident B's risk for aspiration and recommended feeding techniques after being discharged from Speech Therapy and a Kardex and/or task information for the CNA's regarding his feeding techniques was not located in his record. A care plan addressing the resident's dysphagia was addressed. The review of the facility investigation of Resident B's choking incident on [DATE] was completed on [DATE] at 2:30 p.m., which indicated the following: During review of the facility investigation interview on [DATE], CNA 2 indicated on [DATE], she sat Resident B's dinner tray in front of him and left the room. CNA 3 came in to feed the resident while she went to attend to other tasks. She went to answer a light and when she came out of another room, she saw commotion. She indicated in the interview after the Paramedics left with the resident she was told it was a piece of bread and they left it in the sink. She indicated CNA 3 and her passed in the hallway and CNA 3 indicated to her she was on her way to feed Resident B. CNA 2 was not able to determine a length of time the resident was alone in his room with his dinner tray in front of him. When asked if she was aware that Resident B was supposed to eat all his meals in the dining room, she indicated No. During a review of the facility investigation interview on [DATE], LPN 5 indicated when asked if the staff attempted to get him up for dinner, she did not know. She indicated the Paramedics used a metal thing down his throat to remove the item blocking his airway and it was like bread and they put it in the sink. She indicated the facility had served wheat rolls for dinner that evening. During the review of the facility investigation phone interview on [DATE], CNA 3 indicated around 6:30 p.m. to 7:00 p.m., she was in the dining room and realized she needed to check on Resident B to see if he had been fed. When I went in the room, his head (of the bed) was down. When I raised his head (of the bed), I realized he had food in his mouth. And he started to cough a little. She continued to tell what happened the evening of [DATE] after the resident began choking. She indicated the only thing missing off his plate was his bread. She indicated I did not know that he wasn't supposed to eat in bed. When asked if she ever checked his Kardex or careplan, she indicated I did check, I didn't see that on there. An Employee Warning Notice dated [DATE], indicated CNA 2 received a third/final written warning. Describe the action that made it necessary to prepare this notice: On [DATE] CNA took food tray into patients room and did not remain in the room for supervision as stated in the mechanical soft diet policy . Describe the counseling received by the employee: CNA was educated on all mandatory education for incident An Employee Warning Notice dated [DATE], indicated CAN 3 received a discharge. Describe the action that made it necessary to prepare this notice: Investigation substantiated regarding inappropriate actions during choking incident that occurred on [DATE]. Describe the counseling received by the employee: Termination of Employment. A letter of explanation of termination was mailed on [DATE]. The letter contained the following, .the investigation that was concluded late on Thursday (MONTH) 17, substantiated inappropriate actions during a choking incident that occurred on (MONTH) 21, (YEAR) resulting in a A2 violation--comply with all health and safety rules, including rules prohibiting unsafe conduct or unsafe acts that jeopardize the health and safety of self or others or result in serious injury. An A violation is considered severe and has resulted in termination of your employment effective Friday (MONTH) 18 During an interview on [DATE] at 2:53 p.m., the Administrator indicated the two CNA's said there was a time span the resident was left alone with his dinner tray, but they were not able to determine the amount of time. During an interview on [DATE] at 5:23 p.m., RN 4 indicated Resident B was not supposed to be left unsupervised while he was eating. During a telephone interview on [DATE] at 10:42 p.m., while working her shift at the facility LPN 5 indicated she did not know if the staff attempted to get him up for dinner or he was left in his room to eat his meal. During an interview with the Administrator and the DON on [DATE] at 2:03 p.m., the information regarding the care plans for Resident B addressing the risk for aspiration and recommended feeding techniques after being discharged from Speech Therapy and the Kardex and/or task information for the CNA's regarding his feeding techniques was requested. During an interview on [DATE] at 4:35 p.m., the Administrator, Regional Director of Operations, Rehabilitation Director and the MDS (Minimum Data Set) Coordinator was in attendance. The Rehabilitation Director indicated when the therapists document the staff was educated on a residents therapy record for therapy it is referred to as on the spot training which means whatever staff were around the resident at that time the information was being taught for example, in the dining room while the Speech Therapist was assisting the resident to eat, would be given the instructions on the feeding techniques at that time. She indicated the resident's therapist did not do a facility wide nursing inservice on that education, it was expected that nursing would communicate the education to one another. The MDS Coordinator indicated the education would be communicated to all the staff in the form of the resident's care plans, Kardex and tasks information, so all the nurses and CNA's would have access to it. The MDS Coordinator indicated Resident B's care plan for his risk for aspiration and feeding techniques and the kardex and tasks information was not available because when a resident was dismissed to the hospital all the care plans, Kardex and tasks information was wiped out of the computer and she had to start fresh with their new admission information, so that was why there was no Kardex or tasks information available. A current policy titled Meal Service: In Patient Room dated ,[DATE] and updated ,[DATE], provided by the Administrator on [DATE] at 2:00 p.m., contained the following, .PR[NAME]EDURE: 7. If patient requires assistance with eating, do not serve tray until able to stay and give that assistance .8. Assistance with eating: Provide supervision, limited assistance, extensive assistance or total assistance as required by current level of self-performance in eating The past noncompliance immediate jeopardy began on [DATE] at 6:30 p.m. The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: Residents on mechanical soft diets were no longer to receive dinner rolls meals, All staff were educated on the following subjects: mechanically altered diets, reporting, residents eating in rooms, Emergency management, CPR, Obstructed airway management and AED (Automated external defibrillator). Mock codes were being completed on all shifts. Careplans were to be reviewed to ensure all Careplans match the Kardex. Diet orders audited to ensure correct and they match care plans and kardexs. Special instructions were placed on careplans, kardexs and tray cards. Meal services will be audited 5 times a week for 6 weeks. Current records were reviewed, staff interviewed, and observation made during several meal times without current concerns. This Federal tag relates to Complaint IN 147. 3XXX,[DATE](2)

Based on observation, record review and interview the facility failed to ensure a a resident who entered the facility with a reddened area, and a resident who acquired a pressure ulcer after being admitted to the facility received treatment and services to promote healing and prevention of the development of additional pressure ulcers for 3 of 6 sampled residents reviewed for pressure ulcers. The nursing staff failed to recognize the full extent of the wound and involvement of surrounding tissue and which extended in depth to resident "A's" spine. This deficient practice resulted in the death of the resident. (Residents "A", "B" and "C"). Findings include: 1. The record for Resident "A" was reviewed on [DATE] at 12:20 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION]. A review of the record indicated the resident returned to the facility after a hospitalization on [DATE]. The nurses progress notes dated [DATE] at 21:32 (9:32 p.m.), indicated the resident was "readmitted to Summer Trace this evening. Resident is resting well and seems to be adjusting pleasantly to the facility. Resident is alert and oriented times 2. [MEDICAL CONDITION] is intact. Lungs are clear per auscultation. Bowel sounds present. Skin is warm to touch and normal in color." The assessment lacked any concern related to a pressures ulcer. A "Clinical Assessment Report for Pressure Ulcer," dated [DATE] indicated the resident "has open area measuring 3 cm (centimeters) by 1 cm, stage 2 (partial thickness loss) moisture associated." The resident "requires staff assistance to move, is confined to a bed/chair all or most of time, needs special mattress/seat cushion, requires regular schedule for turning, is persistently wet from incontinence/wound drainage/perspiration, was immobile and had cognitive loss." A review of the resident's MDS (minimum data set) assessment, dated [DATE] indicated the resident had 1 stage 2 pressure ulcer. The assessment further indicated, "(Resident) currently has mositure <sic> associated skin damage." The resident's plan of care, dated [DATE], indicated "has open area on coccyx." Interventions included "follow up care with physician as ordered, report evidence of infection such as purulent drainage, swelling, localized heat, increased pain etc. Notify physician prn (as needed)." The clinical record indicated a physician order [REDACTED]." This assessment lacked measurements or a description of the area to be treated. The Nurses Progress notes indicated the following: "[DATE] at 9:15 a.m... Has 3 cm (centimeter) by 1 cm open area on coccyx, stage 2 without drainage... Incontinent of urine. Has [MEDICAL CONDITION] with brown stool noted. Screamed aloud when turned. Resident has incontinence dependency on staff for all adl's (activities of daily living). Family and MD (Medical Doctor) aware." "[DATE] at 21:45 (9:45 p.m.) No ulcers or incicions <sic> present." "[DATE] at 8:07 a.m. Resident has open area on coccyx measuring 4 (cm) by 2.5 cm. Wound bed is red tissue. No drainage and is shear like is <sic> formation. Family and MD area of area. No drainage noted." "[DATE] at 10:24 a.m. Coccyx wound present." "[DATE] at 8:20 a.m. Area on coccyx measures 4 (cm) by 3 cm. Area has beefy red tissue noted. Resident is incontinent of urine and frequently wet. Area is most likely moisture associated." "[DATE] at 21:54 (9:54 p.m.) No ulcers or incisions." "[DATE] at 15:14 (3:14 p.m.) Coccyx wound present." "[DATE] at 11:15 a.m. DSG (dressing) changed to coccyx earlier. Wound bed white with not <sic> drainage noted. New dsg. applied without difficulty." A physician order [REDACTED]. Cleanse coccyx with normal saline - apply Santyl. Moist gauze then apply dry dressing daily." Nurses note dated [DATE] at 12:40 p.m., indicated "Area on coccyx <sic> measures 3 (cm) by 4 cm. Area is necrotic and unstageable. Has foul odor. Did complain of discomfort when turned. Family and MD aware of area." "[DATE] at 19:36 (7:36 p.m.) Wound continue <sic> to have foul odor with drainage noted. Wound has in center some necrotic tissue with surrounding areas being pinkish/red. Resident is alert with confusion noted." "[DATE] at 17:47 (5:17 p.m.) Ulcer on coccyx is being changed daily." "[DATE] at 7:08 a.m. Resident has open area on coccyx measuring 5 (cm) by 3 (cm) by 3 cm. Area remains with necrosis and slough. Large amount of foul greenish yellow drainage noted on old dressing. Due to slough and necrosis area not yet stageable. Area has foul odor. Resident did not complaint of pain when area touched by did hollar <sic> out when turned over." "[DATE] at 17:46 (5:46 p.m.) coccyx wound has no change." "[DATE] at 21:14 (9:14 p.m.) coccyx wound has no change." "[DATE] at 13:15 (1:15 p.m.) DSG. to coccyx dry and intact this a.m." "[DATE] at 18:47 (6:47 p.m.) Ulcer on coccyx is still present and necrotic. Dressing changed tonight, Santyl applied as ordered." "[DATE] at 8:03 a.m. Resident has large necrotic area on coccyx. Area measures 7 (cm) by 6 (cm) by 5 cm. Not able to stage yet due to large amounts of eschar tissue. Area is deep." "[DATE] at 20:17 (8:17 p.m.) Aids notified me this evening of two large blisters on resident's heels. One appears to be blood filled. The other seems to be clear. Allevy <sic> patches were put on bilaterally with heels floated with pillow. Skin sheet completed and placed in book." The record lacked physician notification for possible intervention. "[DATE] at 14:17 (2:17 p.m.) Examined both heels. Removed allevyn and left heel is dark in collor <sic>, slightly fluid filled and measures 6 cm by 6 cm. Right heel has clear fluid filled area measuring 8 cm by 8 cm. Heels floated off bed. Cried when nonskid slippers removed but did not cry, flich <sic> or groan when heels touched." "[DATE] at 00:24 (12:24 a.m.) Pressure area to coccyx that is being treated with Santyl and wet-dry dressing. Area is malodorous." "[DATE] at 20:18 (8:20 p.m.) Resident seemed more weak this evening, and less responsive to cues. Resident usually responds to questions and she did very little this evening." "[DATE] at 3:47 a.m. Pt. (patient) is is <sic> not A & O (alert and oriented), only responds with moans when being repositioned during the shift. Pt. had denied to open mouth or swallow any medications. Generalized weakness presnt <sic> in all extermities <sic>. Foul order <sic> present to coccyx wound & no improvement noted. Has made MD aware of this awaiting CB (call back) from NP (nurse practitioner)." "[DATE] at 5:40 a.m. Right heel has dark area, prior old blister, intact. Left heel is also dark, partially filled blister measuring 5 (cm) by 4 cm. coccyx has large area filled with dark tissue measuring 7 (cm) by 6 (cm) by 5 cm. Can feel coccyx bone when area probed. Has large amount of foul smelling drainage noted. Family and MD aware of areas." The record indicated a physician order [REDACTED]. cleanse right heel with normal saline and apply Allevyn dressing every 72 hours." "[DATE] at 8:57 a.m. Patient's daughter here in facility requesting patient to be sent out to (name of local area hospital) for wound evaluation and treatment. Dtr. (daughter) already aware of new orders form yesterday but stating she saw wound last night and wants her to be sent to hospital for further treatment. Spoke with NP for (name of physician) regarding request and okay to send patient to hospital for eval. (evaluation) and tx. (treatment)." During an interview on [DATE] at 1:50 p.m., the wound care nurse indicated she did not notify the resident's family for notification of changes for any resident who resided on the first floor, but did notify the resident family members of those residents who resided on the second floor. "Those nurses (who worked on the first floor) do that." Resident "A" resided on the first floor of the facility. During an interview on [DATE] at 8:32 a.m., a concerned family member indicated she had been told about a small red spot on the resident's back. The family member indicated she noticed a difference in the resident's responsiveness and when she asked the staff if everything was alright, the staff assured her that everything was "fine." The family member further indicated another family member had been told by a staff member on Tuesday ([DATE]) there was "something we needed to see." The family member indicated the resident was turned to her side and an odor came from the resident that filled the room. "The stench was horrific, and I couldn't believe what I was seeing. I could see gauze and it looked saturated with fluid. The drainage was greenish brown and the odor terrible. I didn't know if the drainage was coming from the pouch ([MEDICAL CONDITION] bag)." The family member indicated she questioned whether the resident should be sent to the hospital that night and the "nurse told me that (resident) was stable and there wasn't anything the hospital could do that they couldn't do at Summer Trace. It was very cold that night, about 1 degree outside, and I didn't want to expose her to the cold, but the next morning I wanted her to go to the hospital." During interview the family member indicated the facility didn't give her a chance to make a decision about further treatment for [REDACTED]. Had I known, I would have liked the chance to at least know about what was going on and what were our options for her care. If anyone came to me and said we need to do something I would have done it. I didn't know anything about the ulcer or her heels. At no time did anyone red flag me about this thing on my (resident's) back." A review of the Skin Alteration Record for the area on the resident's coccyx indicated the following measurements and description of the ulcer: "[DATE] measurements 3 cm (centimeters) in length and 3 cm in width - Edges approximated with clear serous drainage, and reddened skin surrounding the area." "[DATE] measurements 4 cm in length by 2.5 cm in width - Edges approximated with clear serous drainage, and reddened skin surrounding the area." "[DATE] measurements - no documentation. The resident continued with "Edges approximated with clear serous drainage, and reddened skin surrounding the area." "[DATE] measurements 4 cm in length by 4 cm in width. The area was identified with 'slough (moist yellow or gray necrotic tissue),' with a moderate amount of clear serous drainage with a foul odor." "[DATE] measurements 5 cm in length by 3 cm in width by 3 cm in depth. The area continued with slough and had a moderate amount of purulent (creamy white to yellow) drainage with a foul odor." "[DATE] measurements 7 cm in length by 6 cm in width by 5 cm in depth. The area continued with slough and had a moderate amount of purulent drainage with a foul odor." A review of the "pressure ulcer healing chart" for the area on the resident's coccyx indicated the exudate was assessed as "heavy" from [DATE] through [DATE] and the "tissue type" was assessed as "necrotic" from [DATE] through [DATE]. A review of the Skin Alteration Record for the area on the resident's heels indicated the following measurements and description of the bilateral heels: "[DATE] measurements 6 cm in length by 5 cm in width - intact and edges approximated. No drainage." "[DATE] right heel measurements - 5 cm in length by 3 cm in width and scant amount of clear serous drainage." "[DATE] left heel open area - 5 cm in length by 4 cm in width dark pink/red tissue." The "pressure ulcer healing chart," dated [DATE] indicated the "tissue type" was "dark deep tissue." A review of the physician progress notes [REDACTED]. The [DATE] notation indicated the resident had an elevated white blood cell count of 15.5 (normal range of 4.5 to 10.8), but then further indicated the resident had "no s/s (sign or symptom) of infection" even though the resident's ulcer was now assessed as necrotic with a "moderate amount of purulent drainage with a foul odor." The record indicated the resident was sent to the local area hospital on [DATE]. A review of the hospital record on [DATE] at 1:00 p.m., indicated the following: "Pre-arrival Summary - Coming from Summer Trace per family request to have coccyx wound evaluated. ECF (extended care facility) nurse reports that pt. (patient) wound was recently cultured but results not back yet. Also reports pt. has been 'more sleepy' for past 2 days." "Emergency Medicine - The patient presents with from ECF (extended care facility) with complaints of decreased LOC (level of consciousness) times one day and purulent material from her coccyx wound. Unknown duration of wound. Location: back. The character of symptoms is pain. The degree at onset was unknown, The degree at present is severe. Physical Examination: large wound to coccyx with foul smelling discharge. Differential Diagnosis: [REDACTED]." The physician ordered laboratory testing to include a complete blood count. The hospital testing of the white blood cell count on [DATE] indicated a result of 22.4 HI (high) (reference range 3.6 - 10.6). "Impression and Plan" Stage IV (full thickness tissue loss with exposed bone, tendon or muscle - slough or eschar may be present on some parts of the wound bed - often includes undermining and tunneling)." The Emergency Department physician also ordered a "wound culture" of the coccyx. The "Final Report" of the wound culture indicated the resident had "3+ (many) escherichia coli, 3+ (many) and Proteus mirabilis in the wound." "Supplemental info (information): Patient resides at Summer Trace ECF (extended care facility), dx. (diagnoses) of SIRS (systemic [MEDICAL CONDITION] response syndrome),[MEDICAL CONDITION], decreased responsiveness. Patient arrived with extensive coccyx wounds, wound care nurse consult. Leukocytosis, loose green stools, differential includes urinary tract infection, bacteremia." The physician progress "consult" note, dated [DATE] indicated the resident had a "CT (computed tomography) scan of her abdomen and pelvis showed soft decubitus ulceration over the sacrum extending to her bone. Assessment : 1.[MEDICAL CONDITION]ly related to infected sacrococcygeal wound, 2. Deep sacrococcygeal wound with soft tissue gas in extension to sacral bone." An "Addendum" note, dated [DATE], indicated the "pt. has likely necrotizing infection of sacral ulcer extending throughout her left gluteal muscle. This is a life threatening infection which can only be treated with aggressive surgical debridement - pt. is not a candidate for this due to her age. Local wound care and abx (antibiotics) will not be able to treat this. Proteus and E. Coli in wound are sensitive to [MEDICATION NAME] (an antibiotic) but without extensive debridement - care is likely futile. Extensive necrotic/dead tissue throughout very large stage IV ulcer with foul odor, extension of [DIAGNOSES REDACTED] along left buttock to posterior left thigh." The hospital "wound description" dated [DATE] indicated the following: "Left coccyxgeal wound including [DIAGNOSES REDACTED] is approx. (approximately) 12 cm by 12 cm and actually open area 6 cm by 6 cm. Unable to visualize wound bed. Undermining of at least 7 cm noted from approx. (approximately) 5 - 8 and 11 - 2 o'clock. Wound edges black in color drainage is same color as stool draining from [MEDICAL CONDITION]. Strong foul odor noted. Size: 6 cm by 6 cm by depth unknown but can easily palpate spinal processes, color black, tunneling, periwound macerated with [DIAGNOSES REDACTED]. Coccyx wound is very concerning. Would question infection to the bone based on black necrotic tissue that is visible along with extremely foul smelling drainage that has same appearance as the contents of the ostomy bag. Spent about 45 minutes speaking with (family member) about (resident). She (family member) is very upset about the state of the wound on her (resident's) coccyx." "Right heel with approx. 4 cm by 6 cm round black to brown hard eschar covered and left heel approx. 3.6 cm by 5 cm roundish black to brown hard eschar covered. 1st metatarsal joint left 2nd toe with .3 cm dark eschar. During an interview on [DATE] at 11:00 a.m., the Nurse who first examined the resident in the Emergency Department at the local area hospital indicated she donned gloves and could palpate bone when assessing the ulcer. "There was dead necrotic tissue, and the drainage was dark and the body was trying to get rid of the dead tissue. The slough was a combination of dark and black. There was tunneling but I couldn't see the wound base, but when I reached in I could touch bone. I could take my hand and put it inside and tunneling was significant. I could take my index finger and go all the way around into the tunneling." A second hospital wound nurse who was also involved with the care of the resident was interviewed on [DATE] at 1:25 p.m. The nurse indicated, "It was one of the worst bed sores I've seen in my life. The edges were black and necrotic and inside of the wound was black. Stool was coming from the wound the same color and consistency coming from the [MEDICAL CONDITION]. I could put my finger in the wound and could feel every single process of the spine. There was undermining towards the left hip and I could stick my index finger in there. Each heel had eschar and it was black. What blew me away was that the wound had stool in the cavity with stringy black slough. I could put my fist in it to give you a sense of how big it was." During an interview on [DATE] at 11:20 a.m., the family friend (a nurse who indicated she was a wound nurse) of the resident and daughter of the resident indicated she was with the resident's daughter in the Emergency Department on [DATE]. "I saw the wound on the coccyx. It had necrotic black tissue with yellow slough. The drainage was purulent and profusely odoriferous. The stench was horrific." The resident expired at the local area hospital on [DATE]. 2. The record for Resident "B" was reviewed on [DATE] at 1:40 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] after recent surgery to the left extremity amputation. A review of the MDS, dated [DATE] indicated the resident was at risk for developing pressure ulcers secondary to requiring assistance with bed mobility, having incontinent and having current skin alterations and ulcers. "Skin is currently intact with deep tissue ulcer on right heel and necrotic tissue on right foot." The current plan of care, dated [DATE] indicated the resident had "alteration in skin integrity with deep tissue injury at right heel and right great toe and moisture related skin issues on upper thighs related to diabetes, impaired mobility, incontinence and [MEDICAL CONDITIONS]." Interventions to this plan of care included "administer treatment per physician orders." A review of the nurses progress notes, dated [DATE] at 10:46 a.m. indicated "Right foot assessed due to crying out when moved. Blister on heel found, skin sheet created. N.O. (new order) from NP (nurse practitioner) for allevyn to be applied to toe and heel Q (every) 3 days. Writer unable to locate allevyn in facility, wrapped with kerlix and elevated off bed with pillow. Pedal pulses weak." A review of the clinical record lacked documentation of the physician order. In addition, a review of the [DATE], and February 2014 treatment administration record indicated the resident did not receive the treatment as ordered by the physician until [DATE]. 3. The record for Resident "C" was reviewed on [DATE] at 12:20 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident currently receives evaluation at a local wound care clinic. A review of the resident's MDS, dated [DATE] indicated the resident had an unstageable pressure ulcer to left buttocks - unstageable and measured 5.0 cm by 4.0 cm with slough present. The MDS documentation further indicated the resident "needs special mattress or seat cushion to reduce or relieve pressure." In addition the resident was assessed as incontinent, and had immobility. "Utilizes gel cushion in wheelchair and APM (antipressure mattress) on bed. Currently has 1 unstageable pressure ulcer and 1 deep tissue injury on heels and 1 unstageable ulcer on ischium. Being seen at (name of wound care clinic)." The resident's plan of care, dated [DATE], indicated the resident "Has open area on left buttock impaired mobility incontinence and two dark heels." Interventions included "Administer treatment per physician orders, use pillows and/or positioning devices as needed, special mattress on bed, encourage and assist as needed to turn and reposition: use assistive devices as needed." The wound care clinic report dated [DATE] instructed the facility nursing staff to use a "ROHO wheelchair cushion (a pressure relief cushion) - do not use donut type devices." The subsequent wound clinic report dated [DATE] also indicated the need for "off loading - use wheelchair cushion. Do not use donut-type devices. ROHO. Use specialty mattress - low air loss alternating pressure mattress." During an observation on [DATE] at 11:00 a.m. the resident was observed lying in bed. The resident's "air mattress" controls had been turned to the "off" position. During interview licensed nurse #6 indicated she was unfamiliar with the current APM on the resident's bed. A subsequent observation on [DATE] at 12:40 p.m. the resident was seated in the wheelchair. The resident did not have the ROHO cushion to prevent pressure to the ischial area. Licensed nurse #5 verified the resident did not have the cushion as ordered. This Federal tag relates to Complaint IN 429. 3XXX,[DATE](a)(2)

Based on record review and interview the facility failed to ensure neglect did not occur, in that when a resident was identified with a pressure area the facility failed to ensure the resident received appropriate treatment and services as the pressure ulcer continued to deteriorate and the nursing staff failed to recognize the extensive wound which resulted in the resident being transported to the local area hospital for treatment for 1 of 6 sampled residents reviewed for pressure ulcers, and which resulted in death. (Resident "A"). Findings include: The record for Resident "A" was reviewed on [DATE] at 12:20 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION]. A review of the record indicated the resident returned to the facility after a hospitalization on [DATE]. A review of the nurses progress notes dated [DATE] at 21:32 (9:32 p.m.), indicated the resident was "readmitted to Summer Trace this evening. Resident is resting well and seems to be adjusting pleasantly to the facility. Resident is alert and oriented times 2. [MEDICAL CONDITION] is intact. Lungs are clear per auscultation. Bowel sounds present. Skin is warm to touch and normal in color." The assessment lacked any concern related to a pressures ulcer. A review of the resident's MDS (minimum data set) assessment, dated [DATE] indicated the resident had 1 stage 2 pressure ulcer. The assessment further indicated, "(Resident) currently has moisture <sic> associated skin damage." The resident's plan of care, dated [DATE], indicated "has open area on coccyx." Interventions included "follow up care with physician as ordered, report evidence of infection such as purulent drainage, swelling, localized heat, increased pain etc. Notify physician prn (as needed)." The "clinical assessment report for pressure ulcer," dated [DATE] indicated the resident "has open area measuring 3 cm (centimeters) by 1 cm, stage 2 (partial thickness loss) moisture associated." The resident "requires staff assistance to move, is confined to a bed/chair all or most of time, needs special mattress/seat cushion, requires regular schedule for turning, is persistently wet from incontinence/wound drainage/perspiration, was immobile and had cognitive loss." The clinical record indicated a physician order [REDACTED]." This assessment lacked measurements or a description of the area to be treated. The Nurses Progress notes indicated the following: "[DATE] at 9:15 a.m.,... Has 3 cm (centimeter) by 1 cm open area on coccyx, stage 2 without drainage... . Incontinent of urine. Has [MEDICAL CONDITION] with brown stool noted. Screamed aloud when turned. Resident has incontinence dependency on staff for all adl's (activities of daily living). Family and MD (Medical Doctor) aware." "[DATE] at 21:45 (9:45 p.m.) No ulcers or incicions <sic> present." "[DATE] at 8:07 a.m. Resident has open area on coccyx measuring 4 (cm) by 2.5 cm. Wound bed is red tissue. No drainage and is shear like is <sic> formation. Family and MD area of area. No drainage noted." "[DATE] at 10:24 a.m. Coccyx wound present." "[DATE] at 8:20 a.m. Area on coccyx measures 4 (cm) by 3 cm. Area has beefy red tissue noted. Resident is incontinent of urine and frequently wet. Area is most likely moisture associated." "[DATE] at 21:54 (9:54 p.m.) No ulcers or incisions." "[DATE] at 15:14 (3:14 p.m.) Coccyx wound present." "[DATE] at 11:15 a.m. DSG (dressing) changed to coccyx earlier. Wound bed white with not <sic> drainage noted. New dsg. applied without difficulty." A physician order [REDACTED]. Cleanse coccyx with normal saline - apply Santyl. Moist gauze then apply dry dressing daily." Nurses note dated [DATE] at 12:40 p.m., indicated "Area on coccyx <sic> measures 3 (cm) by 4 cm. Area is necrotic and unstageable. Has foul odor. Did complain of discomfort when turned. Family and MD aware of area." "[DATE] at 19:36 (7:36 p.m.) Wound continue <sic> to have foul odor with drainage noted. Wound has in center some necrotic tissue with surrounding areas being pinkish/red. Resident is alert with confusion noted." "[DATE] at 17:47 (5:17 p.m.) Ulcer on coccyx is being changed daily." "[DATE] at 7:08 a.m. Resident has open area on coccyx measuring 5 (cm) by 3 (cm) by 3 cm. Area remains with necrosis and slough. Large amount of foul greenish yellow drainage noted on old dressing. Due to slough and necrosis area not yet stageable. Area has foul odor. Resident did not complaint of pain when area touched but did hollar out when turned over." "[DATE] at 17:46 (5:46 p.m.) coccyx wound has no change." "[DATE] at 21:14 (9:14 p.m.) coccyx wound has no change." "[DATE] at 13:15 (1:15 p.m.) DSG to coccyx dry and intact this a.m." "[DATE] at 18:47 (6:47 p.m.) Ulcer on coccyx is still present and necrotic. Dressing changed tonight, Santyl applied as ordered." "[DATE] at 8:03 a.m. Resident has large necrotic area on coccyx. Area measures 7 (cm) by 6 (cm) by 5 cm. Not able to stage yet due to large amounts of eschar tissue. Area is deep." "[DATE] at 20:17 (8:17 p.m.) Aids notified me this evening of two large blisters on resident's heels. One appears to be blood filled. The other seems to be clear. Allevy <sic> patches were put on bilaterally with heels floated with pillow. Skin sheet completed and placed in book." The record lacked physician notification for possible intervention. "[DATE] at 14:17 (2:17 p.m.) Examined both heels. Removed allevyn and left heel is dark in collor <sic>, slightly fluid filled and measures 6 cm by 6 cm. Right heel has clear fluid filled area measuring 8 cm by 8 cm. Heels floated off bed. Cried when nonskid slippers removed but did not cry, flich <sic> or groan when heels touched." "[DATE] at 00:24 (12:24 a.m.) Pressure area to coccyx that is being treated with Santyl and wet-dry dressing. Area is malodorous." "[DATE] at 20:18 (8:20 p.m.) Resident seemed more weak this evening, and less responsive to cues. Resident usually responds to questions and she did very little this evening." "[DATE] at 3:47 a.m. Pt. (patient) is is <sic> not A & O (alert and oriented), only responds with moans when being repositioned during the shift. Pt. had denied to open mouth or swallow any medications. Generalized weakness presnt <sic> in all extermities <sic>. Foul order <sic> present to coccyx wound & no improvement noted. Has made MD aware of this awaiting CB (call back) from NP (nurse practitioner)." "[DATE] at 5:40 a.m. Right heel has dark area, prior old blister, intact. Left heel is also dark, partially filled blister measuring 5 (cm) by 4 cm. Coccyx has large area filled with dark tissue measuring 7 (cm) by 6 (cm) by 5 cm. Can feel coccyx bone when area probed. Has large amount of foul smelling drainage noted. Family and MD aware of areas." The record indicated a physician order [REDACTED]. cleanse right heel with normal saline and apply Allevyn dressing every 72 hours." "[DATE] at 8:57 a.m. Patient's daughter here in facility requesting patient to be sent out to (name of local area hospital) for wound evaluation and treatment. Dtr. (daughter) already aware of new orders from yesterday but stating she saw wound last night and wants her to be sent to hospital for further treatment. Spoke with NP for (name of physician) regarding request and okay to send patient to hospital for eval. (evaluation) and tx. (treatment)." During an interview on [DATE] at 1:50 p.m., the wound care nurse indicated she did not notify the resident's family for notification of changes for any resident who resided on the first floor, but did notify the resident family members of those residents who resided on the second floor. "Those nurses (who worked on the first floor) do that." Resident "A" resided on the first floor of the facility. During an interview on [DATE] at 8:32 a.m., a concerned family member indicated she had been told about a small red spot on the resident's back. The family member indicated she noticed a difference in the resident's responsiveness on [DATE], and when she inquired about the resident's condition, the licensed nurse said the resident was "fine." The family member further indicated another family member had been told by a staff member on Tuesday ([DATE]) there was "something we needed to see." The family member indicated the resident was turned and an odor came from the resident that filled the room. "The stench was horrific, and I couldn't believe what I was seeing. I could see gauze and it looked saturated with fluid. The drainage was greenish brown and the odor terrible. I didn't know if the drainage was coming from the pouch ([MEDICAL CONDITION] bag)." The family member indicated she questioned whether the resident should be sent to the hospital that night ([DATE]) and the "nurse told me that (resident) was stable and there wasn't anything the hospital could do that they couldn't do at Summer Trace. It was very cold that night, about 1 degree outside, and I didn't want to expose her to the cold, but the next morning I wanted her to go to the hospital." The family member indicated the facility didn't give her a chance to make a decision about further treatment for [REDACTED]. Had I'd known, I would have liked the chance to at least know about what was going on and what were our options for her care. If anyone came to me and said we need to do something I would have done it. I didn't know anything about the ulcer on her heels. At no time did anyone red flag me about this thing on my (resident's) back." A review of the Skin Alteration Record for the area on the resident's coccyx indicated the following measurements and description of the ulcer: "[DATE] measurements 3 cm (centimeters) in length and 3 cm in width - Edges approximated with clear serous drainage, and reddened skin surrounding the area." "[DATE] measurements 4 cm in length by 2.5 cm in width - Edges approximated with clear serous drainage, and reddened skin surrounding the area." "[DATE] measurements - no documentation. The resident continued with "Edges approximated with clear serous drainage, and reddened skin surrounding the area." "[DATE] measurements 4 cm in length by 4 cm in width. The area was identified with 'slough (moist yellow or gray necrotic tissue),' with a moderate amount of clear serous drainage with a foul odor." "[DATE] measurements 5 cm in length by 3 cm in width by 3 cm in depth. The area continued with slough and had a moderate amount of purulent (creamy white to yellow) drainage with a foul odor." "[DATE] measurements 7 cm in length by 6 cm in width by 5 cm in depth. The area continued with slough and had a moderate amount of 'purulent (creamy white to yellow) drainage with a foul odor." A review of the "pressure ulcer healing chart" for the area on the resident's coccyx indicated the exudate was assessed as "heavy" from [DATE] through [DATE] and the "tissue type" was assessed as "necrotic" from [DATE] through [DATE]. A review of the Skin Alteration Record for the area on the resident's heels indicated the following measurements and description of the bilateral heels: "[DATE] measurements 6 cm in length by 5 cm in width - intact and edges approximated. No drainage." "[DATE] right heel measurements - 5 cm in length by 3 cm in width and scant amount of clear serous drainage." "[DATE] left heel open area - 5 cm in length by 4 cm in width dark pink/red tissue." The "pressure ulcer healing chart," dated [DATE] indicated the "tissue type" was "dark deep tissue." A review of the physician progress notes [REDACTED]. The [DATE] physician progress notation indicated the resident had an "elevated white blood cell count of 15.5 (normal range of 4.5 to 10.8)," but then further indicated the resident had "no s/s (sign or symptom) of infection" even though the resident's ulcer was now assessed with [REDACTED]." The record indicated the resident was sent to the local area hospital on [DATE]. A review of the hospital record on [DATE] at 1:00 p.m., indicated the following: "Pre-arrival Summary - Coming from Summer Trace per family request to have coccyx wound evaluated. ECF (extended care facility) nurse reports that pt. (patient) wound was recently cultured but results not back yet. Also reports pt. has been 'more sleepy' for past 2 days." "Emergency Medicine - The patient presents with from ECF (extended care facility) with complaints of decreased LOC (level of consciousness) times one day and purulent material from her coccyx wound. Unknown duration of wound. Location: back. The character of symptoms is pain. The degree at onset was unknown, The degree at present is severe. Physical Examination: large wound to coccyx with foul smelling discharge. Differential Diagnosis: [REDACTED]." The physician ordered laboratory testing to include a complete blood count. The hospital testing of the white blood cell count on [DATE] indicated a result of 22.4 HI (high) (reference range 3.6 - 10.6). "Impression and Plan" Stage IV (full thickness tissue loss with exposed bone, tendon or muscle - slough or eschar may be present on some parts of the wound bed - often includes undermining and tunneling)." The Emergency Department physician also ordered a "wound culture" of the coccyx. The "Final Report" of the wound culture indicated the resident had "3+ (many) eschera coli, 3+ (many) and Proteus mirabilis in the wound." "Supplemental info (information): Patient resides at Summer Trace ECF (extended care facility), dx (diagnoses) of SIRS (systemic [MEDICAL CONDITION] response syndrome),[MEDICAL CONDITION], decreased responsiveness. Patient arrived with extensive coccyx wounds, wound care nurse consult. Leukocytosis, loose green stools, differential includes urinary tract infection, bacteremia." The physician progress "consult" note, dated [DATE] indicated the resident had a "CT (computed tomography) scan of her abdomen and pelvis showed soft decubitus ulceration over the sacrum extending to her bone. Assessment: 1.[MEDICAL CONDITION]ly related to infected sacrococcygeal wound, 2. Deep sacrococcygeal wound with soft tissue gas in extension to sacral bone." An "Addendum" note, dated [DATE], indicated the "pt. has likely necrotizing infection of sacral ulcer extending throughout her left gluteal muscle. This is a life threatening infection which can only be treated with aggressive surgical debridement - pt. is not a candidate for this due to her age. Local wound care and abx (antibiotics) will not be able to treat this. Proteus and E. Coli in wound sensitive to [MEDICATION NAME] (an antibiotic) but without extensive debridement - care is likely futile. Extensive necrotic/dead tissue throughout very large stage IV ulcer with foul odor, extension of [DIAGNOSES REDACTED] along left buttock to posterior left thigh." The hospital "wound description" dated [DATE] indicated the following: "Left coccyx wound including [DIAGNOSES REDACTED] is approx. (approximately) 12 cm by 12 cm and actually open area 6 cm by 6 cm. Unable to visualize wound bed. Undermining of at least 7 cm noted from approx. (approximately) 5 - 8 and 11 - 2 o'clock. Wound edges black in color drainage is same color as stool draining from [MEDICAL CONDITION]. Strong foul odor noted. Size: 6 cm by 6 cm by depth unknown but can easily palpate spinal processes, color black, tunneling, periwound macerated with [DIAGNOSES REDACTED]. Coccyx wound is very concerning. Would question infection to the bone based on black necrotic tissue that is visible along with extremely foul smelling drainage that has same appearance as the contents of the ostomy bag. Spent about 45 minutes speaking with (family member) about (resident). She (family member) is very upset about the state of the wound on her (resident's) coccyx." "Right heel with approx. 4 cm by 6 cm round black to brown hard eschar covered and left heel approx. 3.6 cm by 5 cm roundish black to brown hard eschar covered. 1st metatarsal joint left 2nd toe with .3 cm dark eschar." During an interview on [DATE] at 11:00 a.m., the Nurse who first examined the resident in the Emergency Department at the local area hospital indicated she donned gloves and could palpate bone when assessing the ulcer. "There was dead necrotic tissue, and the drainage was dark and the body was trying to get rid of the dead tissue. The slough was a combination of dark and black. There was tunneling but I couldn't see the wound base, but when I reached in I could touch bone. I could take my hand and put it inside and tunneling was significant. I could take my index finger and go all the way around into the tunneling." A second hospital wound nurse who was also involved with the care of the resident was interviewed on [DATE] at 1:25 p.m. The nurse indicated, "It was one of the worst bed sores I've seen in my life. The edges were black and necrotic and inside of the wound was black. Stool was coming from the wound the same color and consistency coming from the [MEDICAL CONDITION]. I could put my finger in the wound and could feel every single process of the spine. There was undermining towards the left hip and I could stick my index finger in there. Each heel had eschar and it was black. What blew me away was that the wound had stool in the cavity with stringy black slough. I could put my fist in it to give you a sense of how big it was." During an interview on [DATE] at 11:20 a.m., a family friend (who was a nurse and indicated she was a wound nurse) of the resident and daughter of the resident indicated she was with the resident's daughter in the Emergency Department on [DATE]. "I saw the wound on the coccyx. It had necrotic black tissue with yellow slough. The drainage was purulent and profusely odoriferous. The stench was horrific." The resident expired at the local area hospital on [DATE]. This Federal tag relates to Complaint IN 429. 3XXX,[DATE](a)

Based on record review and interview the facility failed to ensure a physician and family member were immediately notified, in that when a resident acquired a pressure ulcer to the coccyx, and bilateral heels, the nursing staff failed to ensure the physician was notified timely for possible intervention when a pressure ulcer progressed in size and appearance with necrotic tissure, odor and increased draingage and the development of new pressure ulcers to the residents heels and failed to ensure a concerned family member was notified for the development and continued deterioration and possible family decision for additional intervention for 1 of 6 sampled residents. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 03-12-14 at 12:20 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident had a [MEDICAL CONDITION]. A review of the record indicated the resident returned to the facility after a hospitalization on [DATE]. A review of the nurses progress notes dated 01-02-14 at 21:32 (9:32 p.m.), indicated the resident was "readmitted to Summer Trace this evening. Resident is resting well and seems to be adjusting pleasantly to the facility. Resident is alert and oriented times 2. [MEDICAL CONDITION] is intact. Lungs are clear per auscultation. Bowel sounds present. Skin is warm to touch and normal in color." Further review of the record indicated a physician order dated 01-02-14 to "cleanse open area with normal saline and apply dry sterile dressing till (until) assessed by wound nurse." Additional record review indicated the following:"01-03-14 at 9:15 a.m.,...Has 3 cm (centimeter) by 1 cm open area on coccyx, stage 2 without drainage...Incontinent of urine. Has [MEDICAL CONDITION] with brown stool noted. Screamed aloud when turned. Resident has incontinence dependency on staff for all adl's (activities of daily living). Family and MD (Medical Doctor) aware." "01-07-14 at 21:45 (9:45 p.m.) No ulcers or incicions <sic> present." "01-10-14 at 8:07 a.m. Resident has open area on coccyx measuring 4 (cm) by 2.5 cm. Wound bed is red tissue. No drainage and is shear like is <sic> formation. Family and MD area of area. No drainage noted." "01-13-14 at 10:24 a.m. Coccyx wound present." "01-20-14 at 8:20 a.m. Area on coccyx measures 4 (cm) by 3 cm. Area has beefy red tissue noted. Resident is incontinent of urine and frequently wet. Area is most likely moisture associated." "01-21-14 at 21:54 (9:54 p.m.) No ulcers or incisions." "01-23-14 at 15:14 (3:14 p.m.) Coccyx wound present." "01-25-14 at 11:15 a.m. DSG (dressing) changed to coccyx earlier. Wound bed white with not <sic> drainage noted. New dsg. applied without difficulty." A physician order was not obtained until 01-27-14 for "Santyl (a medication used in wound debridement), apply to coccyx topically Q (every) HS (bed time) for wound. Cleanse coccyx with normal saline - apply Santyl. Moist gauze then apply dry dressing daily." Nurses note dated 02-03-14 at 12:40 p.m., indicated "Area on coccyx <sic> measures 3 (cm) by 4 cm. Area is necrotic and unstageable. Has foul odor. Did complain of discomfort when turned. Family and MD aware of area." "02-04-14 at 19:36 (7:36 p.m.) Wound continue <sic> to have foul odor with drainage noted. Wound has in center some necrotic tissue with surrounding areas being pinkish/red. Resident is alert with confusion noted." "02-10-14 at 17:47 (5:17 p.m.) Ulcer on coccyx is being changed daily." "02-12-14 at 7:08 a.m. Resident has open area on coccyx measuring 5 (cm) by 3 (cm) by 3 cm. Area remains with necrosis and slough. Large amount of foul greenish yellow drainage noted on old dressing. Due to slough and necrosis area not yet stageable. Area has foul odor. Resident did not complaint of pain when area touched but did hollar out when turned over." "02-12-14 at 17:46 (5:46 p.m.) coccyx wound has no change." "02-13-14 at 21:14 (9:14 p.m.) coccyx wound has no change." "02-15-14 at 13:15 (1:15 p.m.) DSG to coccyx dry and intact this a.m." "02-17-14 at 18:47 (6:47 p.m.) Ulcer on coccyx is still present and necrotic. Dressing changed tonight, Santyl applied as ordered." "02-18-14 at 8:03 a.m. Resident has large necrotic area on coccyx. Area measures 7 (cm) by 6 (cm) by 5 cm. Not able to stage yet due to large amounts of eschar tissue. Area is deep." "02-18-14 at 20:17 (8:17 p.m.) Aids notified me this evening of two large blisters on resident's heels. One appears to be blood filled. The other seems to be clear. Allevy <sic> patches were put on bilaterally with heels floated with pillow. Skin sheet completed and placed in book." The record lacked physician notification for possible intervention. "02-19-14 at 14:17 (2:17 p.m.) Examined both heels. Removed allevyn and left heel is dark in collor <sic>, slightly fluid filled and measures 6 cm by 6 cm. Right heel has clear fluid filled area measuring 8 cm by 8 cm. Heels floated off bed. Cried when nonskid slippers removed but did not cry, flich <sic> or groan when heels touched." "02-22-14 at 00:24 (12:24 a.m.) Pressure area to coccyx that is being treated with Santyl and wet-dry dressing. Area is malodorous." "02-23-14 at 20:18 (8:20 p.m.) Resident seemed more weak this evening, and less responsive to cues. Resident usually responds to questions and she did very little this evening." "02-24-14 at 3:47 a.m. Pt. (patient) is is <sic> not A & O (alert and oriented), only responds with moans when being repositioned during the shift. Pt. had denied to open mouth or swallow any medications. Generalized weakness presnt <sic> in all extermities <sic>. Foul order <sic> present to coccyx wound & no improvement noted. Has made MD aware of this awaiting CB (call back) from NP (nurse practitioner)." "02-25-14 at 5:40 a.m. Right heel has dark area, prior old blister, intact. Left heel is also dark, partially filled blister measuring 5 (cm) by 4 cm. coccyx has large area filled with dark tissue measuring 7 (cm) by 6 (cm) by 5 cm. Can feel coccyx bone when area probed. Has large amount of foul smelling drainage noted. Family and MD aware of areas." The record indicated a physician order dated 02-25-14 and instructed the nursing staff to perform "wound culture on coccyx for wound infection, UA (urinalysis) C & S (culture and sensitivity), cleanse left heel with normal saline and apply Allevyn dressing every 72 hours. cleanse right heel with normal saline and apply Allevyn dressing every 72 hours." "02-26-14 at 8:57 a.m. Patient's daughter here in facility requesting patient to be sent out to (name of local area hospital) for wound evaluation and treatment. Dtr. (daughter) already aware of new orders from yesterday but stating she saw wound last night and wants her to be sent to hospital for further treatment. Spoke with NP for (name of physician) regarding request and okay to send patient to hospital for eval. (evaluation) and tx. (treatment)." During an interview on 03-13-14 at 1:50 p.m., the wound care nurse indicated she did not notify the resident's family for notification of changes for any resident who resided on the first floor, but did notify the resident family members of those residents who resided on the second floor. "Those nurses (who worked on the first floor) do that." Resident "A" resided on the first floor of the facility. During an interview on 03-14-14 at 8:32 a.m., a concerned family member indicated she had been told about a small red spot on the resident's back. The family member indicated she noticed a difference in the resident's responsiveness on 02-25-14, and when she inquired about the resident's condition, the licensed nurse said the resident was "fine." The family member further indicated another family member had been told by a staff member on Tuesday (02-25-14) there was "something we needed to see." The family member indicated the resident was turned to her side and an odor came from the resident that filled the room. "The stench was horrific, and I couldn't believe what I was seeing. I could see gauze and it looked saturated with fluid. The drainage was greenish brown and the odor terrible. I didn't know if the drainage was coming from the pouch ([MEDICAL CONDITION] bag)." The family member indicated she questioned whether the resident should be sent to the hospital that night but the "nurse told me that (resident) was stable and there wasn't anything the hospital could do that they couldn't do at Summer Trace. It was very cold that night, about 1 degree outside, and I didn't want to expose her to the cold, but the next morning I wanted her to go to the hospital." During interview the family member indicated the facility didn't give her a chance to make a decision about further treatment for [REDACTED]. Had I known, I would have liked the chance to at least know about what was going on and what were our options for her care. If anyone came to me and said we need to do something I would have done it. I didn't know anything about the ulcer or her heels. At no time did anyone red flag me about this thing on my (resident's) back." Review of the facility policy on 03-13-14 at 9:30 a.m., titled "Change in Condition: when to report to the MD/NP/PA (Medical Doctor - Nurse Practitioner - Physician Assistant)," indicated the following: "...Immediate Notification - Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and (underscored), a marked change in relation to usual symptoms or signs, or (underscored) unrelieved by measures already prescribed... Non-Immediate Notification - new or worsening symptoms that do not meet above criteria... Confusion - Immediate - abrupt significant change form usual, or a change in level of consciousness. Non-Immediate - abrupt persistent change from usual with no other significant symptoms... Consciousness, altered - Immediate - Sudden change in level of consciousness or responsiveness. Non-Immediate - Gradual but persistent recent change in level of consciousness or responsiveness... Pressure sore - Immediate New onset T (temperature) > (greater than) 100.5 (degrees) F (Fahrenheit) in someone with Grade 2 or higher score. Non-Immediate New onset Grade 2 or higher pressure sore, OR progression of pressure sore despite interventions...." This Federal tag relates to Complaint IN 429. 3.1-5(a)

Based on record review and interview the facility failed to ensure the necessary care and services for a resident to maintain the highest practicable physical, mental and psychosocial well being in regard to a safe and orderly discharge from the facility, in that when a resident who was unable to ambulate/transfer and required ancillary services at the time of discharge, which included durable medical equipment and coordination of services with other agencies, to include occupational therapy and nursing services, the facility failed to take appropriate steps for the discharge of 1 of 1 resident reviewed for discharge and who had special needs which resulted in a resident confined to one area of the home and defecating on self due to inability to transfer from a recliner in a sample 5. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 05-16-13 at 9:41 a.m. [DIAGNOSES REDACTED]. The resident weighed 524 lbs. at the time of discharge These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] after surgery which included a left [MEDICAL CONDITION]. A review of the resident's plan of care, originally dated 12-24-12 indicated the "patient shows potential for discharge and patient expresses wish for discharge." The "goal" for this focus indicated, "Will be discharged to home when clinical and rehabilitation goals are met." "Interventions" included "Assess future placement setting to determine if resident's needs can be met, discuss with patient, family, and/or representative the discharge planning process, investigate need for special equipment, home health physician follow up, and make referrals as needed." Review of the resident's Minimum Data Set Assessment, dated 02-14-13 indicated the resident was not able to move "on/off the toilet" or "surface to surface transfer" without the assistance of another person. The assessment also indicated the resident was "frequently incontinent of bowel and bladder, and required extensive assistance with transfer and bed mobility." A review of a "Local Mental and Behavioral Health Visit Note," dated 02-15-13 indicated the resident "is concerned that rehab. (rehabilitation) has ended sooner than he expected and he will be discharged when he does not feel prepared. He stated the accommodation to his home are not complete, as well as having worries about his continued healing process. Pt. (patient) has experienced a significant physical impairment that he was not prepared for. He has adjusted well, but he is now faced with the reality that he will be discharged back to him home. Recommendations for staff - Keep pt. informed of tx. (treatment) and d/c (discharge) planning to reduce worry." The resident was originally discharged from the facility on 03-19-13 after the completion of therapy services and wound care, and subsequently returned to the facility the same date due to inadequate discharge planning. Review of the physician "Progress Note," dated -3-19-13 indicated "Pt. (patient) apparently discharging today to hotel (home)." A review of the State Form "Notice of Transfer or Discharge," dated 03-19-13 indicated the resident was "being transferred to a private residence." Interview on 05-16-13 at 11:00 a.m., the Social Service Director indicated in regard to the resident transfer "The freight elevator (at the apartment complex) was going to be out of service for 30 days and when therapy ended the apartment complex said they would put him up at a hotel until the freight elevator was repaired. He couldn't fit through the door (at the hotel) because it wasn't handicapped accessible. We depended on the apartment complex since he couldn't go back home and they were paying for it. When the situation at the hotel wasn't working out, the ambulance took him to (name of hospital) but they couldn't keep him so they brought him back here. He came back to us and actually went back into the same room. Shortly after he returned to us we received a call the the freight elevator was fixed and he could return home to his apartment. When the ambulance service came here to pick him up they actually called the apartment complex to make sure they didn't run in to the same problem as before. The Home Health agency didn't come out and evaluate him because they are in a different county. He had a bariatric bed in his apartment and I thought all his needs were set up. I don't know about a bed side commode or a sliding board. I don't know how his bathroom was set up, but the amputation was new for him. As far as I know we didn't send orders to the Home Health Agency and they didn't ask for one." Interview on 05-16-13 at 1:15 p.m., the Therapy Director indicated, "We discharged him from therapies the middle of February (02-13-13). He met his goals with us, but still had a skilled need with his amputation." When interviewed if anyone in therapy does a home evaluation prior to the discharge of a resident, the Therapy Director indicated, "We generally work off the 'floor plan.' We'll go if there seems to be a problem, but if we do, we assess the resident's ability to get around the apartment/home, not the apartment/home itself. I would say that, if for example we discharged twenty residents a month we might go to the home for one resident. At the time (name of resident) was discharged from therapy we didn't know where he was going. It wasn't until afterwards that we found out he was going to a hotel because of the broken freight elevator." Review of the "Occupational Therapy Summary," dated 02-13-13 indicated "Patient reached maximum functional potential at this time. He can now transfer with SBA (stand by assistance) of 1 and a sliding board and to a bedside commode with SBA...and should have a power chair, home O.T. (occupational therapy) home evaluation for home environment. D/C (discharge) recommendations wheelchair BSC (bedside commode) sliding board, hospital bed." A record review on 05-16-13 at 10:00 a.m., titled "Interdisciplinary Team Discharge Summary, dated 03-19-13, indicated the resident received skilled nursing observation and/or treatment and rehabilitative care. The section titled "nursing services" indicated "none" for the area specific to "special treatments or procedures planned for discharge." A subsequent handwritten notation on "side two" of this "Interdisciplinary Discharge Summary," indicated "D/C'd (discharged ) to (name of local area hotel) on 03-14-13 (sic) Anderson Indiana. Hotel couldn't meet needs. He readmitted on [DATE] (sic) and discharged on [DATE] to apartment complex named (name of apartment complex)." "VA (veterans administration) benefits, Home Healthcare in place upon discharge. (Name of ambulance company) to transport resident back home. (Name of area home health agency) will be the home care company." On 05-16-13 at 12:37 p.m., the Director of Nurses for the Home Health Agency was interviewed and indicated the following: "The whole thing was a mess. He originally lived on the fourth floor of the apartment complex. He needed to use the freight elevator to get from the ground floor to his apartment. When the freight elevator had not been repaired, they (employees at the apartment complex) decided to put him at (name of local area motel). When he was released all they (the facility) did was tell them (apartment) he was going to be discharged and the lady at the (name of motel) was told he needed a handicapped accessible room. Supposedly he was only to be there over a weekend. He needed a bariatric bed, a trapeze, siderails and other things a new [MEDICAL CONDITION] needs. When I called the motel they told me they couldn't get him or the wheelchair through the front door or any other door at the motel. He (the resident) called to tell me what was going on and my understanding is that the ambulance crew took him to (name of local area hospital). The hospital couldn't keep him so they took him back to Manor Care in Carmel. When I talked to them (at the facility) I told them the next time you guys release him make sure that when he comes home he can function and maneuver around the apartment, he is not mobile and if there had been a fire he would be history. They (ambulance crew) got him up to his apartment and they had to put him in his recliner because his wheelchair was too wide to get through the bedroom or bathroom doorway. You don't just throw someone in an apartment. He had a urinal next to the recliner, but if he had a bowel movement, he couldn't get out of the recliner to take care of himself. When they discharged him they never even sent us orders. The nursing home just didn't do their part." During interview on 05-17-13 at 12:00 p.m., the Director of Nurses indicated that at the time of the resident "first" discharge, the resident was "picked up from the facility at 1:30 p.m., left the (name of the motel) at 4:22 p.m., left (name of the local area hospital) at 6:30 p.m., and returned to ManorCare at 8:35 p.m." A review of the "Home Health Nursing Visit Record," dated 03-22-13 after the resident was discharged a second time from the facility, indicated the following "skilled intervention" nurses note: "Had left BKA ([MEDICAL CONDITION]) at Indy VA, then spent time at ECF (extended care facility) for Rehab. (rehabilitation). Able to use urinals next recliner in living room. Confined to living room due to wheelchair is 40 inches wide and doorways only 36 inches. Currently wearing adult brief in case bowels have to move. Has no prosthetic for left leg and is unable to use walker. Comfortable in recliner and has items he may need within reach. Phone and emergency button within reach. Has friend upstairs if he needs something minor. Glad to be home but unhappy he's unable to go thru doorways and is confined to living room at this time." A subsequent notation, dated 03-24-13 indicated the resident was unable to do "board transfers and stays in his chair." Review of a packet of information on 05-17-13 at 11:30 a.m., provided by the facility Social Worker, in regard to the facility "team approach to discharge planning," indicated the following: "The way a patient moves from a facility to the post discharge environment leaves a [MEDICATION NAME] impression." "The interdisciplinary team process is organized around the patient's expectations and needs. The team's goal is to work cooperatively with the patient to create a discharge plan that: * Results in a stable clinical and functional status pre-discharge, *Supports the patient's success in the post discharge environment, *Minimizes the possibility of re-hospitalization within 30 days after discharge from the SNF (skilled nursing facility). For the goal to be realized the interdisciplinary team members need to actively support each other as the patient moves toward a successful outcome." "A well planned discharge boosts patient and family confidence, increases patient safety, and gives the staff a sense of accomplishment. Focusing on patients being completely prepared to manage their care following discharge defines a successful discharge strategy." "Each interdisciplinary team member has an equally important role in the discharge planning process and contributes to the patient being completely prepared at discharge." "Rehabilitation Services is responsible to restore the patient's functioning to the highest practicable level. Ideally this is the level at which the patient functioned before the event that resulted in hospitalization . It is also the functioning level that will allow the patient to physically manage daily needs in the post discharge environment. Determining needed home adaptations and equipment is another Rehab. (Rehabilitation) concern. Therefore it is important to know the patient's post discharge environment and the obstacles the patient needs to learn to navigate." "Social services has the responsibility to act as a patient advocate. This involves: understanding the patient's expectations about returning to the post discharge environment, talking with the patient about the discharge date , focusing the patient on the overall goal of being completely prepared to manage care following discharge, communicating on the patient's behalf with the team and community resources to keep the patient's options flexible, evaluating the patient's post discharge care and service needs, setting up needed community resources to the patient has support in the post discharge environment." "The Administrator monitors the team's process and ensures everyone is playing their part to benefit the patient." "Think strategically about anticipated discharges and bring structure to the way they are planned. This helps minimize last minute notifications and the patient benefits from the smooth transition." This Federal tag relates to Complaint IN 860. 3.1-23(a)(2)

Based on record review and interview the facility failed to ensure appropriate and safe discharge of a resident, in that when a resident who was unable to ambulate and required ancillary services to include durable medical equipment and coordination of services with other agencies, the social service director failed to take appropriate steps to ensure the safe and orderly discharged on two separate discharge date s for the resident. This inappropriate discharge process resulted in the resident being returned to the facility due to inappropriate accommodations and at the time of the second discharge the resident was confined to one area of the apartment, unable to access the bedroom or bathroom, and resulted in the resident sleeping in a recliner and defecating on self for elimination needs. This deficient practice affected 1 of 1 resident resident with [DIAGNOSES REDACTED]. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 05-16-13 at 9:41 a.m. [DIAGNOSES REDACTED]. The resident weighed 524 lbs. at the time of discharge. These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] after surgery which included a left below the knee amputation. Review of the resident's Minimum Data Set Assessment, dated 02-14-13 indicated the resident was not able to move "on/off the toilet" or "surface to surface transfer" without the assistance of another person. The assessment also indicated the resident was "frequently incontinent of bowel and bladder, and required extensive assistance with transfer and bed mobility." A review of the "Local Mental and Behavioral Health Visit Note," dated 02-15-13 indicated the resident "is concerned that rehab. (rehabilitation) has ended sooner than he expected and he will be discharged when he does not feel prepared. He stated the accommodation to his home are not complete, as well as having worries about his continued healing process. Pt. (patient) has experienced a significant physical impairment that he was not prepared for. He has adjusted well, but he is now faced with the reality that he will be discharged back to him home. Recommendations for staff - Keep pt. informed of tx. (treatment) and d/c (discharge) planning to reduce worry." The resident was originally discharged from the facility on 03-19-13 after the completion of therapy services and wound care, and subsequently returned to the facility the same date due to inadequate discharge planning. During interview on 05-17-13 at 12:00 p.m., the Director of Nurses indicated that at the time of the resident "first" discharge, the resident was "picked up from the facility at 1:30 p.m., left the (name of the motel) at 4:22 p.m., left (name of the local area hospital) at 6:30 p.m., and returned to ManorCare at 8:35 p.m." Review of the physician "Progress Note," dated -3-19-13 indicated "Pt. (patient) apparently discharging today to hotel (home)." A review of the State Form "Notice of Transfer or Discharge," dated 03-19-13 indicated the resident was "being transferred to a private residence." Interview on 05-16-13 at 11:00 a.m., the Social Service Director indicated in regard to the resident transfer "The freight elevator (at the apartment complex) was going to be out of service for 30 days and when therapy ended the apartment complex said they would put him up at a hotel until the freight elevator was repaired. He couldn't fit through the door (at the hotel) because it wasn't handicapped accessible. The apartment complex employee said they checked it out and the hotel was handicapped accessible. We depended on the apartment complex since he couldn't go back home and they were paying for it. When the situation at the hotel wasn't working out, the ambulance took him to (name of hospital) but they couldn't keep him so they brought him back here. He came back to us and actually went back into the same room. His therapy had ended because he met his goals and therefore he didn't have a skilled need to be in a Medicare bed when he returned. We didn't have a Medicaid bed available and the Administrator got involved and the apartment complex agreed to pay the 'private rate' in the Medicare bed until the freight elevator was fixed. Shortly after he returned to us we received a call the the freight elevator was fixed and he could return home to his apartment. When the ambulance service came here to pick him up they actually called the apartment complex to make sure they didn't run in to the same problem as before. The Home Health agency didn't come out and evaluate him because they are in a different county. With a Home Health agency what we like them to do is to come out for the assessment because they need the orders anyway. They already knew him and were just going to re-open his case. He had a bariatric bed in his apartment and I thought all his needs were set up. I don't know about a bed side commode or a sliding board. I don't know how his bathroom was set up, but the amputation was new for him. As far as I know we didn't send orders to the Home Health Agency and they didn't ask for one." Interview on 05-16-13 at 1:15 p.m., the Therapy Director indicated, "We discharged him from therapies the middle of February (02-13-13). He met his goals with us, but still had a skilled need with his amputation." When interviewed if anyone in therapy does a home evaluation prior to the discharge of a resident, the Therapy Director indicated, "We generally work off the 'floor plan.' We'll go if there seems to be a problem, but if we do we assess the resident's ability to get around the apartment/home, not the apartment/home itself. I would say that, if for example we discharged twenty residents a month we might go to the home for one resident. At the time (name of resident) was discharged from therapy we didn't know where he was going. It wasn't until afterwards that we found out he was going to a hotel because of the broken freight elevator." Review of the "Occupational Therapy Summary," dated 02-13-13 indicated "Patient reached maximum functional potential at this time. He can now transfer with SBA (stand by assistance) of 1 and a sliding board and to a bedside commode with SBA...and should have a power chair, home O.T. (occupational therapy) home evaluation for home environment. D/C (discharge) recommendations wheelchair BSC (bedside commode) sliding board, hospital bed." A record review on 05-16-13 at 10:00 a.m., titled "Interdisciplinary Team Discharge Summary, dated 03-19-13, indicated the resident received skilled nursing observation and/or treatment and rehabilitative care. The section titled "nursing services indicated "none" for the area specific to "special treatments or procedures planned for discharge." A subsequent handwritten notation on "side two" of this "Interdisciplinary Discharge Summary," indicated "D/C'd (discharged ) to (name of local area hotel) on 03-14-13 (sic) Anderson Indiana. Hotel couldn't meet needs. He readmitted on [DATE] (sic) and discharged on [DATE] to apartment complex named (name of apartment complex). "VA (veterans administration) benefits, Home Healthcare in place upon discharge. (Name of ambulance company) to transport resident back home. (Name of area home health agency) will be the home care company." On 05-16-13 at 12:37 p.m., the Director of Nurses for the Home Health Agency was interviewed and indicated the following: "The whole thing was a mess. He originally lived on the fourth floor of the apartment complex. He needed to use the freight elevator to get from the ground floor to his apartment. When the freight elevator had not been repaired, they (employees at the apartment complex) decided to put him at (name of local area motel). When he was released all they (the facility) did was tell them (apartment) he was going to be discharged and the lady at the (name of motel) was told he needed a handicapped accessible room. Supposedly he was only to be there over a weekend. He needed a bariatric bed, a trapeze, siderails and other things a new amputee needs. When I called the motel they told me they couldn't get him or the wheelchair through the front door or any other door at the motel. He called to tell me what was going on and my understanding is that the ambulance crew took him to (name of local area hospital). The hospital couldn't keep him so they took him back to Manor Care in Carmel. When I talked to them (at the facility) I told them the next time you guys release him make sure that when he comes home he can function and maneuver around the apartment, he is not mobile and if there had been a fire he would be history. They got him up to his apartment and they had to put him in his recliner because his wheelchair was too wide to get through the bedroom or bathroom doorway. You don't just throw someone in an apartment. He had a urinal next to the recliner, but if he had a bowel movement, he couldn't get out of the recliner to take care of himself. When they discharged him they never even sent us orders. The nursing home just didn't do their part." A review of the "Home Health Nursing Visit Record," dated 03-22-13 after the resident was discharged a second time from the facility, indicated the following "skilled intervention" nurses note: "Had left BKA (below the knee amputation) at Indy VA, then spent time at ECF (extended care facility) for Rehab. (rehabilitation). Able to use urinals next recliner in living room. Confined to living room due to wheelchair is 40 inches wide and doorways only 36 inches. Currently wearing adult brief in case bowels have to move. Has no prosthetic for left leg and is unable to use walker. Comfortable in recliner and has items he may need within reach. Phone and emergency button within reach. Has friend upstairs if he needs something minor. Glad to be home but unhappy he's unable to go thru doorways and is confined to living room at this time." A subsequent notation, dated 03-24-13 indicated the resident was unable to do "board transfers and stays in his chair." Review of the job description for Social Worker on 05-17-13 at 8:30 a.m., indicated the following: "Job Summary - Responsible to provide medically related social work services so that each resident/patient may attain or maintain the highest practicable level of physical, mental and psychosocial well-being." "Social Worker Responsibilities - Communicates effectively with the interdisciplinary team, resident/patients, families, and community agencies. Makes appropriate referrals to other consultants, community agencies or Center departments in order to facilitate the resident's/patient's maximum use of resources, and to promote the resident/patients increased level of social functioning." Review of a packet of information on 05-17-13 at 11:30 a.m., provided by the facility Social Worker, in regard to the facility "team approach to discharge planning," indicated the following: "The way a patient moves from a facility to the post discharge environment leaves a lasting impression." "A well planned discharge boosts patient and family confidence, increases patient safety, and gives the staff a sense of accomplishment. Focusing on patients being completely prepared to manage their care following discharge defines a successful discharge strategy." "Social services had the responsibility to act as a patient advocate. This involves: understanding the patient's expectations about returning to the post discharge environment, talking with the patient about the discharge date , focusing the patient on the overall goal of being completely prepared to manage care following discharge, communicating on the patient's behalf with the team and community resources to keep the patient's options flexible, evaluating the patient's post discharge care and service needs, setting up needed community resources to the patient has support in the post discharge environment." "Think strategically about anticipated discharges and bring structure to the way they are planned. This helps minimize last minute notifications and the patient benefits from the smooth transition." Interview on 05-17-13 at 9:00 a.m., the Administrator indicated the person who was mainly responsibility to ensure a safe and orderly transfer of a resident was "the Social Worker." This Federal tag relates to Complaint IN 860. 3.1-34(a)

Based on record review and interview the facility failed to ensure sufficient preparation and the safe discharge of a resident, in that when a resident who was unable to ambulate and required ancillary services to include durable medical equipment and coordination of services with other agencies, the facility failed to take appropriate steps to ensure the safe discharge on two separate occasions for 1 of 1 resident reviewed for discharge from the facility , and who required special needs in a sample of 5. (Resident "A"). Findings include: The record for Resident "A" was reviewed on 05-16-13 at 9:41 a.m. [DIAGNOSES REDACTED]. The resident weighed 524 lbs. at the time of discharge These [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] after surgery which included a left [MEDICAL CONDITION]. A review of the resident's plan of care, originally dated 12-24-12 indicated the "patient shows potential for discharge and patient expresses wish for discharge." The "goal" for this focus indicated, "Will be discharged to home when clinical and rehabilitation goals are met." "Interventions" included "Assess future placement setting to determine if resident's needs can be met, discuss with patient, family, and/or representative the discharge planning process, investigate need for special equipment, home health physician follow up, and make referrals as needed." A review of the "Local Mental and Behavioral Health Visit Note," dated 02-15-13 indicated the resident "is concerned that rehab. (rehabilitation) has ended sooner than he expected and he will be discharged when he does not feel prepared. He stated the accommodation to his home are not complete, as well as having worries about his continued healing process. Pt. (patient) has experienced a significant physical impairment that he was not prepared for. He has adjusted well, but he is now faced with the reality that he will be discharged back to his home. Recommendations for staff - Keep pt. informed of tx. (treatment) and d/c (discharge) planning to reduce worry." Review of the physician "Progress Note," dated 03-19-13 indicated "Pt. (patient) apparently discharging today to hotel (home)." A review of the State Form "Notice of Transfer or Discharge," dated 03-19-13 indicated the resident was "being transferred to a private residence." Interview on 05-16-13 at 11:00 a.m., the Social Service Director indicated in regard to the resident's discharge, "The freight elevator (at the apartment complex) was going to be out of service for 30 days and when therapy ended the apartment complex said they would put him up at a hotel until the freight elevator was repaired. He couldn't fit through the door (at the hotel) because it wasn't handicapped accessible. We depended on the apartment complex since he couldn't go back home. When the situation at the hotel wasn't working out, the ambulance took him to (name of hospital) but they couldn't keep him so they brought him back here. He came back to us and actually went back into the same room. He had a bariatric bed in his apartment and I thought all his needs were set up. I don't know about a bed side commode or a sliding board. I don't know how his bathroom was set up, but the amputation was new for him. As far as I know we didn't send orders to the Home Health Agency and they didn't ask for one." Interview on 05-16-13 at 1:15 p.m., the Therapy Director indicated, "We discharged him from therapies the middle of February (02-13-13). He met his goals with us, but still had a skilled need with his amputation." When interviewed if anyone in therapy does a home evaluation prior to the discharge of a resident, the Therapy Director indicated, "We generally work off the 'floor plan.' We'll go if there seems to be a problem, but if we do, we assess the resident's ability to get around the apartment/home, not the apartment/home itself. I would say that, if for example we discharged twenty residents a month we might go to the home for one resident. At the time (name of resident) was discharged from therapy we didn't know where he was going. It wasn't until afterwards that we found out he was going to a hotel because of the broken freight elevator." Review of the "Occupational Therapy Summary," dated 02-13-13 indicated "Patient reached maximum functional potential at this time. He can now transfer with SBA (stand by assistance) of 1 and a sliding board and to a bedside commode with SBA...and should have a power chair, home O.T. (occupational therapy) home evaluation for home environment. D/C (discharge) recommendations wheelchair BSC (bedside commode) sliding board, hospital bed." A record review on 05-16-13 at 10:00 a.m., titled "Interdisciplinary Team Discharge Summary, dated 03-19-13, indicated "none" for the area specific to "special treatments or procedures planned for discharge." On 05-16-13 at 12:37 p.m., the Director of Nurses for the Home Health Agency was interviewed and indicated the following: "The whole thing was a mess. He originally lived on the fourth floor of the apartment complex. He needed to use the freight elevator to get from the ground floor to his apartment. When the freight elevator had not been repaired, they (employees at the apartment complex) decided to put him at (name of local area motel). When he was released all they (the facility) did was tell them (apartment) he was going to be discharged and the lady at the (name of motel) was told he needed a handicapped accessible room. Supposedly he was only to be there over a weekend. He needed a bariatric bed, a trapeze, siderails and other things a new [MEDICAL CONDITION] needs. When I called the motel they told me they couldn't get him or the wheelchair through the front door or any other door at the motel. He (in regard to the resident) called to tell me what was going on and my understanding is that the ambulance crew took him to (name of local area hospital). The hospital couldn't keep him so they took him back to Manor Care in Carmel. When I talked to them (at the facility) I told them the next time you guys release him make sure that when he comes home he can function and maneuver around the apartment, he is not mobile and if there had been a fire he would be history. The next time he was discharged , the ambulance crew got him up to his apartment and they had to put him in his recliner because his wheelchair was too wide to get through the bedroom or bathroom doorway. You don't just throw someone in an apartment. He had a urinal next to the recliner, but if he had a bowel movement, he couldn't get out of the recliner to take care of himself. When they discharged him they never even sent us orders. The nursing home just didn't do their part." During interview on 05-17-13 at 12:00 p.m., the Director of Nurses indicated that at the time of the resident "first" discharge, the resident was "picked up from the facility at 1:30 p.m., left the (name of the motel) at 4:22 p.m., left (name of the local area hospital) at 6:30 p.m., and returned to ManorCare at 8:35 p.m." A review of the "Home Health Nursing Visit Record," dated 03-22-13 after the resident was discharged a second time from the facility, indicated the following "skilled intervention" nurses note: "Had left BKA ([MEDICAL CONDITION]) at Indy VA, then spent time at ECF (extended care facility) for Rehab. (rehabilitation). Able to use urinals next recliner in living room. Confined to living room due to wheelchair is 40 inches wide and doorways only 36 inches. Currently wearing adult brief in case bowels have to move. Has no prosthetic for left leg and is unable to use walker. Comfortable in recliner and has items he may need within reach. Phone and emergency button within reach. Has friend upstairs if he needs something minor. Glad to be home but unhappy he's unable to go thru doorways and is confined to living room at this time." A subsequent notation, dated 03-24-13 indicated the resident was unable to do "board transfers and stays in his chair." Review of a packet of information on 05-17-13 at 11:30 a.m., provided by the facility Social Worker, in regard to the facility "team approach to discharge planning," indicated the following: "The way a patient moves from a facility to the post discharge environment leaves a [MEDICATION NAME] impression." "A well planned discharge boosts patient and family confidence, increases patient safety, and gives the staff a sense of accomplishment. Focusing on patients being completely prepared to manage their care following discharge defines a successful discharge strategy." "Social services has the responsibility to act as a patient advocate. This involves: understanding the patient's expectations about returning to the post discharge environment, talking with the patient about the discharge date , focusing the patient on the overall goal of being completely prepared to manage care following discharge, communicating on the patient's behalf with the team and community resources to keep the patient's options flexible, evaluating the patient's post discharge care and service needs, setting up needed community resources to the patient has support in the post discharge environment." "Think strategically about anticipated discharges and bring structure to the way they are planned. This helps minimize last minute notifications and the patient benefits from the smooth transition." Review of facility policy on 05-17-13 at 12:00 p.m. at the Exit Conference, titled "Discharge Home or Non-Institutional Settings," dated 12-2009 indicated the following: "PURPOSE (bold type and underscored): To provide safe departure from center to home or non-institutional setting." "PROCEDURE (bold type and underscored) - PRIOR TO DAY OF DISCHARGE - 1. Assess patient's health needs for discharge including nursing history, care plan and on-going assessments. 2. Ask patient/family for suggestions on ways to prepare for discharge, 3. Assess patient/family acceptance of health problems and related restrictions, 4. Assess patient/family needs for health teaching related to therapies to be continued at home, restrictions with self care activities, 5. Consult with other members of interdisciplinary team - registered dietitian, social worker, therapy, etc. regarding patient's needs on discharge, 6. Collaborate with physician and social worker in assessing need for referral to home health or other supportive agencies, 7. Offer patient/family information about community health care resources, 8. Complete referral forms indicating health care needs as well as existing functional abilities, 9. Suggest methods for altering physical arrangement of home environment to meet patient's needs." This Federal tag relates to Complaint IN 860. 3.1-12(a)(21)