Every finding on record at Majestic Care of Lafayette

Based on observation, interview and record review, the facility failed to ensure food was prepared and served to conserve flavor and at a safe and appetizing temperature. This deficient practice had the potential to affect 91 of 92 residents whom received meal trays. Findings include:1. During an observation and interview, on 8/25/25 at 12:01 p.m., a meal tray was removed off a cart and placed on the counter at the nurses' station by Dietary Staff 3. Dietary Staff 3 removed the lid off the plate and proceeded to check the temperature of the food using a thermometer probe. The Salisbury steak registered at 92 degrees Fahrenheit, the whole kernel corn registered at 123.2 degrees Fahrenheit, and the sliced red potatoes registered at 85.2 degrees Fahrenheit. Dietary Staff 3 indicated the temperature of the food was not within range for serving, placed the tray back on the cart, and took it back to the kitchen to warm the food up. On 8/25/25 at 12:18 p.m., a sample tray was tasted. The whole kernel corn was bland, chewy, and cold. The peach cobbler was cold, dry, and lacked flavor. 2. During an observation and interview, on 8/22/25 at 12:38 p.m., Resident 25 was eating lunch in her room. She indicated her lunch was served cold. The food was always cold and had no flavor. During an observation and interview, on 8/25/25 at 12:10 p.m., Resident 25 was sitting on the side of the bed with her lunch in individual white foam containers. The resident was in contact isolation. She indicated she had just received her lunch tray. The potatoes and meat were ice-cold, and she wanted warm food. The resident indicated she had asked for a hamburger or her food warmed up. During an interview, on 8/25/25 at 12:12 p.m., Qualified Medication Aide (QMA) 16 indicated the resident's food would have to be warmed up. When asked about the resident being in contact isolation, QMA 16 indicated the kitchen would need to provide another tray. 3. During the resident council interview, on 8/28/25 at 1:36 p.m., three (3) residents indicated the food was served cold. One (1) resident indicated the food was cold whether you ate in the main dining room or in a dining room on the hall. One (1) resident indicated the eggs were like liquid. One (1) resident indicated the food sucks. During an interview, on 8/28/25 at 2:46 p.m., CNA 9 indicated everyday multiple residents would complain about cold food being served, the quality of the food, the food was not what they had ordered, or the food was not on the scheduled menu for the day. A current facility policy, titled Meal Distribution, dated as revised 2/2023 and received by the Clinical Support Nurse on 8/25/25 at 3:50 p.m., indicated .Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protect against contamination, and are delivered in a timely and accurate manner .All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences .All food items will be transported promptly for appropriate temperature maintenance .The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to resident/patients .Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-serving dining 3.1-21(a)(2)

Based on observation, interview and record review, the facility failed to ensure a clean and comfortable environment was provided in 14 of 27 rooms and common areas reviewed for environment. (room [ROOM NUMBER], 210, 213, 124, 131, 137, 102, 103, and 114)Findings include:During an observation, on 8/22/25 beginning at 12:24 p.m., the following were observed:1. room [ROOM NUMBER] had black scuff marks on the lower portion of the wall below the dry erase board.2. On the cedarwood unit, the shower room door had chipped paint which exposed the wood to the middle and lower portion of the door.3. room [ROOM NUMBER] did not have trim on the wall around the thermostat controlling units. The exposed wall did not have paint and had a black fuzzy growth.4. room [ROOM NUMBER] did not have trim on the wall around the thermostat controlling units. The exposed wall did not have paint and had black and gray discolorations.5. room [ROOM NUMBER] did not have trim on the wall around the thermostat controlling units. The exposed wall was unpainted and had discolored drywall.6. room [ROOM NUMBER] did not have trim on the wall around the thermostat controlling units. The exposed wall was unpainted and had discolored drywall.7. room [ROOM NUMBER] did not have trim on the wall around the thermostat controlling units. The exposed wall was unpainted and had discolored drywall.8. room [ROOM NUMBER] had peeling paint on the wall and trim across from the foot of the bed.9. room [ROOM NUMBER] had peeling paint to the lower portion of the entrance side of the door.10. room [ROOM NUMBER] had peeling paint on the trim of the door.11. The ceiling tile, outside of room [ROOM NUMBER], had a stained dark brown circle.12. Across from the birchwood nurses' station, the corner edge trim was splintered and broken in half.13. On the birchwood unit, the lower half of the door to the shower room had black scuff marks and peeling paint.14. On the birchwood unit, the blind in the medication room was broken and hanging at a slant.15. On the entrance doors to the therapy department, the lower half was dirty with brown spots and black scuff marks, paint peeling, gold toned foot plates which had the plastic covering peeling.16. The interior front double doors had black scuff marks, chipped paint, and gouged wood on the lower half.17. The exterior front double doors had gouged wood, peeled paint, and rotted wood to the outer edges of the lower half of the doors.18. The exterior and interior entrance double doors had no door seals.19. The birchwood dining room's overhead lights were dim.20. The cedarwood dining area overhead light bulb was not working.21. The main dining room, birchwood dining room, and cedarwood dining room had all the tables without tablecloths, placemat settings or any table decor. During an observation, on 8/25/25 at 12:17 p.m., the wall thermostat setting indicated the temperature was 68 degrees Fahrenheit on the cedarwood unit.During an interview, on 8/25/25 at 10:18 a.m., Resident 12 indicated it was cold in the facility.During an interview, on 8/25/25 at 11:17 a.m., Employee 4 indicated it was cold in the facility.During an interview, on 8/25/25 at 11:50 a.m., LPN 5 indicated it was cold in the facility.During an interview, on 8/25/25 at 12:09 p.m., Resident 77 indicated it was cold in the facility.During an interview, on 8/25/25 at 12:11 p.m., RN 6 indicated it was cold in the facility. During a tour of the cedarwood unit with the Maintenance Supervisor and the Executive Director (ED), the temperature of the halls was 67 degrees Fahrenheit. The ED indicated the temperature level in the facility should be between 71-81 degrees Fahrenheit.During a tour of the facility with the Maintenance Supervisor and the Executive Director, they indicated the wall units in the rooms needed the trim placed around them, the other areas needed the paint touched up, trim replaced, lighting adjusted, ceiling tiles replaced, doors repaired and temperature settings adjusted in order to be maintained at the state regulation levels. A maintenance director job description, last updated 3/2021, indicated responsibilities included the supervision of the maintenance department and for the efficient function of physical and environmental systems.A current facility policy, dated 1/2/24, indicated the heating, ventilation and air conditioning system should be inspected semi-annually.The facility was unable to provide any further policies related to environment. This citation relates to Intake 2583804.3.1-19(f)(5)3.1-19(h)

Based on interview and record review, the facility failed to ensure the resident's representative received notification in writing of the facility's bed hold policy and the reason for the resident's transfer and discharge to the hospital for 1 of 3 residents reviewed for hospitalization. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 8/27/25 at 6:49 p.m. The diagnoses included, but were not limited to, diabetes mellitus, dementia, chronic kidney disease stage 3, hypertension, osteoarthritis, depression, anxiety, and hyperlipidemia. A nursing progress note, dated 3/14/25 at 6:59 p.m., indicated Resident 3 was hospitalized . The clinical record did not include documentation to indicate the bed hold policy or the reason for transfer was provided to the resident's representative in writing. During an interview, on 8/28/25 at 4:18 p.m., the Director of Nursing (DON) indicated there was no documentation the bed hold policy or the reason for transfer was provided to the resident representative in writing. A current facility policy, titled Holding Bed Space, dated as revised on 6/1/18 and received from the DON on 8/27/25 at 2:15 p.m., indicated .our facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy .a representative of the business office will provide information concerning our bed-hold policy to the resident and the resident representative .when emergency transfers are necessary, the facility will provide the resident, resident representative .with information concerning our bed-hold policy with the transfer .the bed-hold information will include any charges that the resident may incur 3.1-12(a)(6)(A)(i)3.1-12(a)(6)(A)(ii)3.1-12(a)(6)(A)(iii)

Based on interview and record review, the facility failed to ensure two step Tuberculous tests were completed following acceptable guidelines for 2 of 5 residents reviewed for infection control. (Resident 25 and 48) Findings include: 1. The clinical record for Resident 25 was reviewed on 8/28/25 at 10:30 a.m. The diagnoses included, but were not limited to, cutaneous abscess of the buttock, necrotizing fasciitis, diabetes mellitus, hypertension, bipolar disorder, anxiety disorder, depression, and chronic pain syndrome.The Electronic Health Record (EHR), for Resident 25, indicated:a. the first-step tuberculous test, dated 5/18/25 at 10:15 p.m., was marked as not applicable (NA). The test was documented as read on 5/18/25 at 10:04 p.m. b. the second-step tuberculous test was documented as administered on 5/31/25 at 3:56 a.m. and was read on 6/1/25 at 10:22 p.m., less than 48 hours. 2. The clinical record for Resident 48 was reviewed on 8/28/25 at 2:37 p.m. The diagnoses included, but were not limited to, diabetes mellitus, colostomy, depression, hypertension, and presence of a cardiac pacemaker. The Electronic Health Record (EHR), for Resident 48, indicated:a. the first-step tuberculous test was documented as administered on 2/19/25 at 2:03 p.m. The test was documented as read on 2/20/25 at 10:19 p.m., less than 48 hours.b. the second-step tuberculous test was documented as administered on 3/12/25 at 9:21 a.m. and was read on 3/13/25 at 10:46 p.m., less than 48 hours. During an interview, on 8/28/25 at 2:56 p.m., the Director of Nursing (DON) indicated the tuberculous tests for Residents 25 and 48 were not done correctly. The tests were read too soon and would need to be completed again. The tests needed to be read a minimum of 48 hours after they were administered. A current facility policy, titled Tuberculosis, Screening Residents, dated as revised 11/2016 and received from the DON on 8/28/25 at 3:22 p.m., indicated .This facility shall screen all residents for tuberculosis infection and disease (TB). In all cases, state regulation/law will supersede this policy. Clinical Testing Guidance for Tuberculosis: Tuberculin Skin Test (last dated January 31, 2025) and retrieved on 9/8/25 from The Centers for Disease Control and Prevention indicated .The skin test reaction should be read between 48 and 72 hours after administration by a health care worker trained to read TB skin results.A patient who does not return within 72 hours will need to be rescheduled for another skin test. There is no risk associated with repeated TB skin test placements. There is no contraindication to repeating the TB skin test. 3.1-18(e)

Based on interview and record review, the facility failed to ensure irregularities in the drug regimen were recognized, reported, and addressed for 2 of 5 residents reviewed for unnecessary medications. (Resident 8 and 28)Findings include:1. The clinical record for Resident 8 was reviewed on 8/25/25 at 12:53 p.m. The diagnoses included, but were not limited to, bipolar disorder, personal history of pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot), and anxiety disorder.a. A care plan, dated 9/11/22, indicated Resident 8 was at risk for increased bruising or bleeding due to anticoagulant therapy. An intervention indicated for the pharmacist to review the medication regime routinely.A physician's order, dated 12/21/23, indicated Resident 8 was to take apixaban (also known as Eliquis, an anticoagulant used to prevent blood clots) every twelve hours for post operative instructions.The medication regimen reviews (MMR), dated 1/1/25 to 8/3/25, were reviewed and there were no irregularities reported related to obtaining a supportive diagnosis or clarification for the medication ordered as a post operative instruction in 2023.b. A care plan, dated 9/11/22, indicated Resident 8 received psychotropic medications (or psychotropic like medications) and was at risk for adverse side effects of the mood stabilizer (Depakote).A care plan, dated 8/23/23, indicated Resident 8 was at risk for alterations in mood and was taking a mood stabilizer. An intervention was for the pharmacist to review the medication regime and to notify the physician of recommendations.A physician's order, dated 8/31/22, indicated to administer Depakote Sprinkles (used to help treat manic episodes associated with bipolar disorder) twice a day related to bipolar disorder.A physician's order, dated 2/17/24, indicated the facility was to obtain a Depakote level laboratory blood draw every six months starting on the 17th.Resident 8's laboratory results indicated the Depakote level was last obtained on 12/5/24.A Depakote level for the month of June 2025 was not located in the electronic health record for when the blood sample would have been collected.A psychiatric nurse practitioner's note, dated 7/26/25, indicated there were no new labs available for review in the facility's electronic health record.The medication regimen reviews (MMR), dated 6/1/25 to 8/3/25, were reviewed and there were no irregularities reported related to obtaining the missing laboratory orders. During an interview, on 8/27/25 at 9:40 a.m., the Director of Nursing (DON) indicated the order for Apixaban was placed a couple of years ago after a surgical procedure. The diagnosis for the medication was no longer appropriate and should have been reported as an irregularity through the medication regimen review. She needed to review the electronic health record related to the laboratory order.2. The clinical record for Resident 28 was reviewed on 8/25/25 at 9:53 a.m. The diagnoses included, but were not limited to, chronic diastolic heart failure, paroxysmal atrial fibrillation, and type 2 diabetes mellitus with diabetic chronic kidney disease.A physician's order, dated 5/2/25, for Midodrine (a medication used to treat orthostatic hypotension or low blood pressure) did not include a supporting diagnosis which indicated the clinical need for the use of the medication.The medication regimen reviews (MMR), dated 1/1/25 to 8/3/25, were reviewed and there were no irregularities reported related to obtaining a supportive diagnosis or clarification for the medication ordered.During an interview, on 8/27/25 at 2:48 p.m., the DON indicated the medication was missing a diagnosis. She indicated she was not sure how the order got through the system without a supporting diagnosis.A current facility policy, titled Pharmacy Services, dated 1/2/24 and received from the DON on 8/27/25 at 11:23 a.m., indicated .It is the policy of this facility to ensure that pharmaceutical services.are consistent with state and federal requirements, and reflect current standards of practice.The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements.3.1-25(i)

Based on observation, interview and record review, the facility failed to ensure routine maintenance inspections which included following the manufacturers' recommendations and specifications for maintaining the bed rails were documented for 2 of 2 residents reviewed for bed rails. (Resident 8 and 10)Findings include:1. During an observation and interview, on 8/22/25 at 10:10 a.m., Resident 8's bed was observed to have bilateral bed rails. Resident 8 indicated the bedrail on the right side (the side of the bed she used to get in and out of the bed) was very loose. She could not recall the last time she had seen a staff member inspect her bedrails. She had not requested a work order for the loose bed rail but indicated the nurses and CNAs knew her bed rail was loose.The clinical record for Resident 8 was reviewed on 8/25/25 at 12:53 a.m. The diagnoses included, but were not limited to, fracture of the left lower leg, displaced fracture of the medial malleolus of the left tibia, and anxiety disorder.A physician's order, dated 9/19/22, indicated Resident 8 was to utilize bed rails as an enabler for turning and repositioning while in bed.Work orders submitted for maintenance by other staff members, from 5/26/25 to 8/26/25, did not include Resident 8's loose bed rail.During an observation and interview, on 8/26/25 at 12:12 p.m., the Maintenance Supervisor observed Resident 8's bed rail and indicated the right bed rail was loose when he grabbed onto the rail. The bed rails were well used and they become wiggly. He indicated he did not believe he had the manufactures instructions for the bed rail anymore.2. During an observation, on 8/22/25 at 9:20 a.m., Resident 10 was lying in bed. The bed had bilaterally padded side rails in the raised position.The clinical record for Resident 10 was reviewed on 8/26/25 at 8:57 a.m. The diagnoses included, but were not limited to, epilepsy, paranoid schizophrenia, and conversion disorder with seizures or convulsions.A physician's order, dated 7/31/24, indicated Resident 10 was to utilize padded bed rails as an enabler for safety.A care plan, dated as last revised on 3/2/25, indicated Resident 10 had a diagnosis of epilepsy with an intervention of padded side rails as ordered for seizure precautions.Documentation of routine maintenance inspections which followed the manufacturers' recommendations and specifications were not documented for in the clinical records for Resident 8 and 10.During an interview, on 8/26/25 at 12:05 p.m., the Maintenance Supervisor indicated inspecting bed rails was a monthly task performed for the entire building. He did not document which rooms or bed rails were inspected. If staff observed an issue with a bed rail, they would submit a work order to the maintenance department and the maintenance staff would follow up on the work order.A current facility policy, titled Bed Rails, dated 1/2/24 and received from the Director of Nursing (DON) on 8/12/25 at 11:24 a.m., indicated .If bed rails are used, the facility ensures correct installation, use and maintenance of the rails.The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes.Checking bed rails regularly to make sure they are still installed correctly, and have not shifted or loosened over time.Conducting routine preventative maintenance of bed and bed rails to ensure they meet currently safety standards and are not in need of repair.Ongoing monitoring and supervision.Responsibilities of ongoing monitoring and supervision are specified as follows.The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails.3.1-45(a)(1)3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure medications were held and laboratory tests were obtained according to the physician's orders for 2 of 6 residents reviewed for quality of care. (Resident 28 and 77)Findings include:1. The clinical record for Resident 28 was reviewed on 8/25/25 at 9:53 a.m. The diagnoses included, but were not limited to, chronic diastolic congestive heart failure, paroxysmal atrial fibrillation, and type 2 diabetes mellitus with diabetic chronic kidney disease. A care plan, dated 1/24/25, indicated Resident 28 was at risk for impaired cardiac output and to administer medications as ordered, obtain vital signs as ordered, and to notify the physician of abnormalities. A care plan, dated 1/24/25, indicated Resident 28 was receiving Digoxin (a medication used to treat congestive heart failure) and to check the pulse prior to administering the medication. a. A physician's order, dated 1/8/25, indicated to administer Digoxin 125 milligrams (mg) by mouth once a day every Wednesday and Sunday, with instructions to hold the medication for a heartrate below 60 and to notify the physician. The Medication Administration Record (MAR) for June indicated Digoxin was given with a heart rate less than 60, on 6/15/25, with no physician notification documented. b. A physician's order, dated 5/2/25, indicated to administer midodrine (a medication used to treat orthostatic hypotension) 5 mg by mouth twice a day every 8 hours, with instructions to hold the medication for a systolic blood pressure greater than 140 and diastolic blood pressure greater than 100. The MAR for June indicated midodrine was administrated outside of the physician's ordered parameters on 6/3/25 in the morning, on 6/6/25 in the afternoon, on 6/15/25 in the morning, and on 6/22/25 in the morning. The medication was documented as held and not administered on 6/8/25 and 6/22/25 when the physician's ordered parameters were within normal limits. The MAR for July indicated midodrine was administrated outside of the physician's ordered parameters on 7/4/25 in the morning, on 7/8/25 in the morning, on 7/13/25 in the morning, on 7/14/25 in the morning, on 7/19/25 in the morning, and on 7/22/25 in the morning. The medication was documented as held and not administered on 7/14/25, 7/15/25, 7/20/25 and 7/25/25 when the physician ordered parameters were within normal limits. The MAR for August indicated midodrine was administrated outside of the physician's ordered parameters on 8/2/25 in the evening, on 8/10/25 in the evening, on 8/18/25 in the morning, and on 8/21/25 in the evening. The medication was documented as held and not administered on 8/24/25 when the physician's ordered parameters were within normal limits. c. A physician's order, dated 7/30/25, indicated to administer metoprolol (a medication used to treat blood pressure) 25 mg (a half tab) twice a day, with instructions to hold the medication for a systolic blood pressure less than 105 or a heart rate less than 60. The MAR for June indicated metoprolol was administrated outside of the physician's ordered parameters on 6/2/25 in the evening and 6/23/25 in the morning. The MAR for August indicated metoprolol was administrated outside of the physician's ordered parameters on 8/8/25 in the morning. The medication was documented as held and not administered on 8/1/25 and 8/13/25, when the physician's ordered parameters were within normal limits. During an interview, on 8/25/25 at 2:14 p.m., the Director of Nursing (DON) indicated a check mark documented on the MAR meant the medication was administered. The medications were being administered outside of the physician's ordered hold parameters. During an interview, on 8/27/25 at 10:05 a.m., Registered Nurse (RN) 15 indicated a check mark on the MAR indicated the medication was administered. If the medication was held or the order indicated to notify the physician, the nurse would document a 4 on the MAR and the notification to the physician would be documented in the progress notes. 2. The clinical record for Resident 8 was reviewed on 8/25/25 at 12:53 p.m. The diagnoses included, but were not limited to, bipolar disorder, major depressive disorder, and anxiety disorder. A physician order, dated 8/31/22, indicated to administer Depakote Sprinkles 125 mg twice a day for bipolar disorder. A physician's order, dated 2/17/24, indicated Depakote levels were to be obtained every six months, starting on the 17th. A review of Resident 8's laboratory results indicated a Depakote level was obtained on 12/5/24 and would be due again, according to the physician's order, in June 2025. A Depakote level in June 2025 was not located in the electronic health record. A psychiatric nurse practitioner progress note, dated 7/26/25, indicated there were no new labs available for review in the facility's electronic health record. During an interview, on 8/27/25 at 9:40 a.m., the DON indicated she needed to review the electronic health record. A current facility policy, titled Medication Administration, dated 1/2/24 and received from the DON on 8/27/25 at 11:22 a.m., indicated .When applicable, hold medication for those vital signs outside the physician's prescribed parameters. A current facility policy, titled Physicians Orders, dated 1/2/24 and received from the DON on 8/27/25 at 11:21 a.m., indicated .facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders .Qualified nursing personnel will submit timely requests for physician orders services (laboratory, radiology, consultations) to the appropriate entity 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure showers were given according to the scheduled shower days and were accurately documented for 1 of 5 residents reviewed for activities of daily living. (Resident C)Findings include:During an interview, on 8/21/25 at 10:40 a.m., Resident C indicated her shower days were scheduled in the morning every Tuesday and Thursday but due to the facility being short staffed, she had not been able to get into the shower to have her hair washed. Resident C indicated she needed a Hoyer lift for transferring which required two staff members. She indicated sometimes she did request a bed bath instead of a shower. Resident C indicated she had filed a grievance before related to not receiving a shower.The clinical record for Resident C was reviewed on 8/26/25 at 1:34 p.m. The diagnoses included, but were not limited to, major depressive disorder, metabolic encephalopathy, and type 2 diabetes mellitus.A care plan, dated 9/24/23 and last revised on 7/11/25, indicated Resident C preferred a bed bath. She would refuse showers and then tell her family she had not been given showers. The interventions included, but were not limited to, note refusals and offer a bed bath if the resident did not feel like taking a shower.A care plan, dated 5/7/25, indicated Resident C required assistance with activities of daily living (ADL) care with an intervention to assist with ADLs as needed.1. During an observation and interview, on 8/26/25 at 11:07 a.m., Resident C indicated the CNA had not come to ask if she would like to have her shower yet. Resident C indicated she wanted to get a shower today so her hair could be washed. Resident C's hair was observed to be slightly greasy. Resident C indicated she was going to turn on her call light and ask about her shower.During an observation and interview, on 8/26/25 at 2:35 p.m., Resident C indicated she still had not received a shower, and she had asked CNA 13 if she would get her shower today. Resident C stated CNA 13 told her She didn't know because state was in the building, and she has a lot of things to do. Resident C's hair was still observed to be slightly greasy.During an interview, on 8/26/25 at 2:39 p.m., the Assistant Director of Nursing indicated it was currently change of shift and CNA 13 had already left the building for the day. She was not sure if Resident C had a shower today.A review of the CNA tasks in the electronic health record indicated CNA 13 documented at 1:59 p.m., Resident C had been given a shower with the physical support of two people.During an interview, on 8/26/25 at 2:45 p.m., the Assistant Director of Nursing indicated a shower sheet could not be located for Resident C's shower on 8/26/25.During an interview, on 8/27/25 at 12:15 p.m., CNA 13 indicated she did not give Resident C a shower on 8/26/25. She thought she documented the shower as did not occur. CNA 13 indicated she did not have enough time after lunch to get all her stuff done, which was why Resident C did not receive a shower. The shower sheets had been moved, and she did not have time to look for them, so she did not complete a shower sheet for any showers she had given on 8/26/25.2. A review of the resident council meeting minutes indicated in the month of May 2025; residents were not receiving showers on their scheduled shower days.A facility document, titled C.N.A. Shower & Skin Care Alert Sheet, dated 7/3/25, was signed by CNA 16 and indicated Resident C was given a shower on 7/3/25.A facility grievance, dated 7/7/25, indicated Resident C reported she did not receive her scheduled shower on 7/3/25. The findings indicated Resident C did not receive a shower on 7/3/25. She was offered a shower on 7/4/25 but declined and would continue her previous shower schedule. The corrective action taken for the grievance was staff education.During an interview, on 8/26/25 at 3:08 p.m., the Director of Nursing indicated staff should complete a shower sheet with every shower or bed bath provided. If a resident refused a shower or bed bath, three separate attempts would be made to provide the shower or bed bath. If the resident refused all three attempts, the resident, CNA and the nurse would sign the shower sheet as refused. The Director of Nursing indicated she had been made aware staff were documenting showers which had not been done. She did not know why CNA 13 documented Resident C's shower had been given if the CNA did not actually give Resident C her shower and this was unacceptable.A CNA job description, dated 3/2025 and received from the Director of Nursing on 8/27/25 at 11:23 a.m., indicated .Essential responsibilities.to perform or assist the resident with completing Activities of Daily Living (ADL).Maintain effective communication with residents, families and community staff.documentation of room visits.perform other tasks as assigned.This position requires for the care team member to be able to perform and complete each essential duty satisfactorily.A current facility policy, titled Activities of Daily Living (ADLs), dated 1/2/24 and received from the Director of Nursing on 8/27/25 at 11:23 a.m., indicated .Care and services will be provided for the following activities of daily living.Bathing, dressing, grooming and oral care.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.A current facility policy, titled Resident Rights, dated 1/2/24 and received from the Director of Nursing on 8/27/25 at 11:23 a.m., indicated .The resident has the right to be informed of, and participate in, his or her treatment, including.the right to receive the services and/or items included in the plan of care.The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living.This citation relates to Intakes 1818839, 1818840 and 2583804.3.1-38(a)(2)(A)3.1-38(a)(3)(B)3.1-38(b)(2)3.1-38(b)(3)

Based on interview and record review, the facility failed to ensure pneumococcal vaccines were administered according to the signed consent form for 4 of 7 residents reviewed for immunizations. (Resident I, 9, 41 and 84) Findings include: 1. The clinical record for Resident I was reviewed on 10/21/24 at 9:56 a.m. The diagnoses included, but were not limited to, sepsis, acute cystitis with hematuria, cellulitis, type 2 diabetes mellitus with diabetic chronic kidney disease, acute kidney failure, chronic kidney disease stage 3, paroxysmal atrial fibrillation, anemia, long term current use of insulin, and essential primary hypertension. An informed consent form for the pneumococcal vaccine, dated 8/19/24, indicated the resident consented to receiving the vaccination. The electronic medical record did not include any record of the administration of the pneumococcal vaccination after the signed consent form on 8/19/24. During an interview, on 10/22/24 at 10:11 a.m., the Director of Nursing (DON) indicated the immunization should have been provided soon after the consent was signed, but it had not been ordered or given. 2. The clinical record for Resident 9 was reviewed on 10/21/24 at 9:56 a.m. The diagnoses included, but were not limited to, chronic bronchitis, asthma, chronic kidney disease stage 3, other forms of acute ischemic heart disease, chronic diastolic congestive heart failure, anemia, unspecified right bundle-branch block (disruption of the heart's electrical signal to the right side of the heart), essential primary hypertension, and obesity. An informed consent form for the pneumococcal vaccine, dated 1/31/24, indicated the resident consented to receiving the vaccination. The electronic medical record did not include any record of the administration of the pneumococcal vaccination after the signed consent form on 1/31/24. During an interview, on 10/22/24 at 10:11 a.m., the DON indicated the immunization should have been provided soon after the consent was signed, but it had not been ordered or given. 3. The clinical record for Resident 41 was reviewed on 10/21/24 at 9:56 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, acquired absence of left leg below the knee, peripheral vascular disease, severe morbid obesity, current long-term use of anticoagulants, and current long-term use of opiate analgesic. An informed consent form for the pneumococcal vaccine, dated 4/19/23, indicated the resident did not consent to receiving the vaccination. A physician's order, dated 10/25/23, indicated Pneumococcal 20-Valent Conjugate Vaccine 0.5 milliliters (ml) injected intramuscularly (IM) one time for immunization. A medication administration record (MAR), dated 10/1/23 through 10/31/23, indicated 0.5 ml pneumococcal 20-valent conjugate vaccine was administered IM, on 10/25/23 at 1:54 p.m., to the resident. A medication administration record (MAR), dated 10/1/23 through 10/31/23, indicated to monitor the resident for side effects from the pneumonia vaccine every shift for 3 Days starting 10/25/2023 at 2:00 p.m. During an interview, on 10/23/24 at 11:28 a.m., the DON indicated the pneumococcal consent form for Resident 41 indicated the resident had declined the vaccination. She indicated she did not find a signed consent for the vaccine administration on 10/25/23. 4. The clinical record for Resident 84 was reviewed on 10/21/24 at 9:56 a.m. The diagnoses included, but were not limited to, end stage renal disease, chronic pulmonary edema, acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic polyneuropathy, metabolic encephalopathy, severe morbid obesity, peripheral vascular disease, anemia, paraplegia, dependence on renal dialysis, pleural effusion, and bradycardia. An informed consent form for the pneumococcal vaccine, dated April 2024, indicated the resident consented to receiving the vaccination. An informed consent form for the pneumococcal vaccine, dated 8/19/24, indicated the resident consented to receiving the vaccination. The electronic medical record did not include any record of the administration of the pneumococcal vaccination after the signed consent form in April or August 2024. During an interview, on 10/22/24 at 10:11 a.m., the DON indicated the immunization should have been provided soon after the consent was signed, but it had not been ordered or given after the April or August consents. A current policy, titled Infection Prevention & Control Program, dated 1/2/24 and received from the DON upon entrance, indicated .Documentation will reflect the education provided and details whether or not the resident received the immunizations A current policy, titled Pneumococcal Vaccination, dated 1/2/24 and received from the Clinical Support on 10/22/24 at 4:05 p.m., indicated .It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations .A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record 3.1-18(b)(5)

Based on interview and record review, the facility failed to ensure Covid-19 vaccines were provided when requested for 3 of 7 residents reviewed for immunizations. (Resident 65, 83 and 84) Findings include: 1. The clinical record for Resident 65 was reviewed on 10/21/24 at 9:56 a.m. The diagnoses included, but were not limited to, recurrent moderate major depressive disorder, vitamin D deficiency, vitamin B12 deficiency anemia, prolonged grief disorder, generalized anxiety disorder, essential primary hypertension, and age-related physical debility. An informed consent form for the Covid-19 vaccine, dated 1/13/23, indicated the resident consented to receiving the vaccination. An informed consent form for the Covid-19 vaccine, dated 11/20/23, indicated the resident consented to receiving the vaccination. The electronic medical record did not include any record of a Covid-19 vaccination after the signed consent form in January or November 2023. During an interview, on 10/22/24 at 10:11 a.m., the Director of Nursing (DON) indicated the immunization should have been provided soon after the consent was signed, but it had not been ordered or given. 2. The clinical record for Resident 83 was reviewed on 10/21/24 at 9:56 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, essential primary hypertension, dysphagia, epilepsy not intractable without status epilepticus, aphasia, and recurrent major depressive disorder. An informed consent form for the Covid-19 vaccine, dated 12/18/23, indicated the resident consented to receiving the vaccination. An informed consent form for the Covid-19 vaccine, dated 12/22/23, indicated the resident consented to receiving the vaccination. The electronic medical record did not include any record of a Covid-19 vaccination after the signed consent form on 12/18/23 or 12/22/23. During an interview, on 10/22/24 at 10:11 a.m., the DON indicated the immunization should have been provided soon after the consent was signed, but it had not been ordered or given. 3. The clinical record for Resident 84 was reviewed on 10/21/24 at 9:56 a.m. The diagnoses included, but were not limited to, end stage renal disease, chronic pulmonary edema, acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic polyneuropathy, metabolic encephalopathy, severe morbid obesity, peripheral vascular disease, anemia, paraplegia, dependence on renal dialysis, pleural effusion, and bradycardia. An informed consent form for the Covid-19 vaccine, dated 8/19/24, indicated the resident consented to receiving the vaccination. The electronic medical record did not include any record of a Covid-19 vaccination after the signed consent form on 8/19/24. During an interview, on 10/22/24 at 10:11 a.m., the DON indicated the immunization should have been provided soon after the consent was signed, but it had not been ordered or given after the 8/19/24 consent. A current policy, titled Infection Prevention & Control Program, dated 1/2/24 and received from the DON upon entrance, indicated .Documentation will reflect the education provided and details whether or not the resident received the immunizations A current policy, titled Covid-19 Prevention and Management, dated 1/2/24 and received from the DON upon entrance, indicated .Resident Vaccination 1. Each resident will be offered the Covid-19 vaccine .The resident's medical record will include documentation that indicates .the date each dose of Covid-19 vaccine administered to the resident This citation relates to Complaint IN00441551. 3.1-18(b)(5)

Based on observation and interview, the facility failed to ensure incontinence products and personal items were stored appropriately, light bulbs were in working use, and trash was not on the ground for 5 of 70 rooms reviewed for environment (Rooms 112, 123, 134, 138, and 233). Findings include: 1. During an observation, on 10/16/24 at 11:07 a.m., room [ROOM NUMBER] had incontinence products, and an opened package of briefs stored on the bed next to the resident. 2. During an observation, on 10/16/24 at 10:29 a.m., room [ROOM NUMBER] had a foul smell and the light above the bed had 2 light bulbs not working. 3. During an observation, on 10/16/24 at 10:49 a.m., room [ROOM NUMBER] had paint on the floor, clothes not hung up, the closet was a mess, and items were on the floor. 4. During an observation, on 10/16/24 at 10:46 a.m., room [ROOM NUMBER] had briefs stored on the ground in the bathroom, a toothbrush and a hairbrush with other supplies were stored in a wire basket on the back of the toilet. 5. During an observation, on 10/16/24 at 11:17 a.m., room [ROOM NUMBER] had trash on the floor, food from breakfast, and a filled urinal on the bedside table. An environmental tour and interview were completed with the Maintenance Supervisor, the ED (Executive Director), and Housekeeping on 10/20/24 at 1:42 p.m. They indicated they needed to replace some of the light bulbs, redo the flooring where the paint was on the ground, and keep up with the trash on the ground in the rooms. Incontinence products should not be stored on the ground, and they could get a 3-level shelf to store some of the incontinence products on. A facility policy, titled RESIDENT RIGHTS, dated 1/2/24 and received from the Clinical Support on 10/16/24 at 3:03 p.m., indicated .The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely This citation relates to Complaint IN00439138. 3.1-19(f)(5)

Based on observation, interview and record review, the facility failed to ensure a resident was assisted and received dental services for 1 of 1 resident reviewed for dental services. (Resident 8) Finding includes: During an observation, on 10/16/24 at 11:27 a.m., Resident 8 had missing teeth. During an interview, on 10/16/24 at 11:27 a.m., Resident 8 indicated she wanted new dentures. She previously lost a large amount of weight, and her old dentures no longer fit. She indicated she would like to get new ones, but staff had not helped her to find a provider in her insurance network when she asked for assistance. The clinical record for Resident 8 was reviewed on 10/16/24 at 3:02 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, peripheral vascular disease, chronic diastolic heart failure, post-traumatic stress disorder, hyperlipidemia, and age-related physical debility. A physician's order, dated 9/19/22, indicated Resident 8 may be seen by a podiatrist, dentist, optometrist, audiologist, psychiatrist, and psychologist. A care plan, dated 9/11/22, indicated Resident 8 was at risk for oral and dental health problems due to being edentulous (having missing teeth). Interventions included, but were not limited to, coordinate arrangements for dental care, transportation as needed and as ordered. A care plan, revised on 9/30/24, indicated Resident 8 needed assistance with activities of daily living. Interventions included, but were not limited to, staff to assist and encourage oral care twice daily. A dental note, dated 7/31/23, indicated Resident 8 had no teeth or dentures present. Her oral tissue was within normal limits and the resident wanted dentures made. A dental note, dated 3/12/24, indicated Resident 8 wanted new upper and lower complete dentures. A dental note, dated 8/7/24, indicated Resident 8 was fully edentulous with no removable appliances present. The resident stated she would like dentures made. Her oral tissue was generalized healthy with no significant findings on visual exam. During an interview, on 10/21/24 at 11:20 a.m., the Social Services Assistant (SSA) indicated she did not know Resident 8 wanted dentures. During an interview, on 10/22/24 at 11:23 a.m., the Director of Nursing (DON) indicated it was the social services' responsibility to follow up with any recommendations from dental providers. During an interview, on 10/23/24 at 10:50 a.m., the DON indicated she was unsure why it had taken so long to address Resident 8's request for dentures. A current policy, titled Dental Services, dated 1/2/24 and received from the DON on 10/23/24 at 1:31 p.m., indicated .It is the policy of this facility to assist residents in obtaining routine .and emergency dental care .Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care .Referrals to .dental provider shall be made as appropriate .The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location 3.1-24(a)(3) 3.1-24(b)

Based on interview and record review, the facility failed to ensure care given to a resident was not completed by a particular staff member according to the resident's preference for 1 of 1 resident reviewed for resident rights. (Resident D) Finding includes: During an interview, on 10/16/24 at 10:14 a.m., Resident D indicated he did not want RN 7 to take care of him and he had informed management staff. RN 7 was still taking care of him. During an interview, on 10/22/24 at 10:12 a.m., the Director of Nursing (DON) indicated she was aware RN 7 was not supposed to be taking care of Resident D. She was assigned to the hall often but was not to take care of Resident D. The clinical record for Resident D was reviewed on 10/17/24 at 3:29 p.m. The diagnoses included, but were not limited to, schizoaffective disorder, bipolar type, anxiety disorder and problem related to unspecified psychosocial circumstances. A Medication Administration Record (MAR) indicated RN 7 administered Resident D's medications on 9/1, 9/3, 9/4, 9/6, 9/7, 9/8, 9/9, 9/11, 9/20, 9/21, 9/22, 9/23, 10/5, 10/6, 10/12, and 10/16/24. A vitals tab indicated RN 7 obtained vital signs for Resident D on 9/1, 9/3, 9/4, 9/6, 9/8, 9/9, 9/11, 9/20, 9/21, 9/22, 9/23, 10/5, 10/6, 10/12, and 10/16/24. During an interview, on 10/23/24 at 10:00 a.m., LPN 8 indicated the resident had been expressing he did not want RN 7 to take care of him ever since she started working here. During an interview, on 10/23/24 at 11:25 a.m., the DON indicated it did appear as if RN 7 had been taking care of the resident. A facility policy, titled RESIDENT RIGHTS, dated 1/2/24 and received from the Clinical Support on 10/16/24 at 3:03 p.m., indicated .The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: a. The resident has the right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part This citation relates to Complaint IN00430580. 3.1-3(t)

Based on interview and record review, the facility failed to ensure staff notified the Social Service Director and the resident's physician immediately after the resident expressed suicidal thoughts for 1 of 1 resident reviewed for notification. (Resident 81) Finding includes: During an interview, on 10/21/24 at 10:06 a.m., Resident 81 indicated she told a nurse, on 10/19/24, she felt like killing herself and wanted to get help. She had increased feelings of depression and anxiety and was very upset nothing was done. The clinical record for Resident 81 was reviewed on 10/12/22 at 11:25 a.m. The diagnoses included, but were not limited to, major depressive disorder and general anxiety. A physician's order, dated 5/18/24, indicated to give 60 milligrams (mg) of duloxetine delayed release for depression daily. A physician's order, dated 10/2/24, indicated to give 10 mg of buspirone for anxiety three times a day. A care plan, dated 7/23/24, indicated the resident was on a psychotropic medication. Interventions included, but were not limited to, monitor for side effects of antidepressant medication and suicidal thoughts. During an interview, on 10/21/24 at 11:18 a.m., the Social Service Assistant (SSA) indicated the resident came to her and indicated she wanted help. During an interview, on 10/21/24 at 11:21 a.m., the SSA indicated she was notified, at 11:00 a.m., by the resident she had suicidal thoughts over the weekend, and she had told her nurse. The procedure when a resident voiced suicidal thoughts was to put them on 15-minute checks and to immediately call the Director of Nursing (DON) and SSA. The DON and SSA were not notified until 10/21/24 at 11:00 a.m. During an interview, on 10/21/24 at 11:28 a.m., the Executive Director asked the SSD if the resident told staff about the incident and the SSA indicated the resident told a nurse. During an interview, on 10/21/24 at 1:39 p.m., the DON indicated she was unaware the resident had voiced suicidal thoughts over the weekend. The resident had increased anxiety. The procedure when a resident voiced suicidal thoughts was to call the DON and SSD first thing so they could start a plan. She should have been notified and was not. There was no documentation to indicate the DON, SSA or physician were notified of Resident 81's suicidal thoughts. A current policy, titled Suicidal Thoughts & Ideations, dated 1/2/24 and received from the Clinical Support Nurse on 10/21/24 at 10:16 a.m., indicated .All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent .Objectively document the resident's mood and behaviors, as well as all actions taken, in the medical records A current policy, titled Change in Condition/Physician Notification, dated 1/2/24 and received from the Director of Nursing on 10/16/24 at 3:30 p.m., indicated .The nurse will notify the physician/NP/PA and the resident/resident's representative when: A significant change in the resident's physical, mental, or psychosocial status 3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to administer the correct amount of oxygen as ordered by the physician for 1 of 1 resident reviewed for respiratory care. (Resident 5) Finding includes: During an observation, on 10/16/24 at 11:15 a.m., Resident 5's oxygen concentrator (a device used to provide supplemental oxygen therapy) was set on 2 liters per minute (L). During an observation, on 10/17/24 at 9:57 a.m., Resident 5's oxygen concentrator was set on 2.5L. During an observation, on 10/18/24 at 11:31 a.m., Resident 5's oxygen concentrator was set on 2L. The clinical record for Resident 5 was reviewed on 10/17/24 at 3:30 p.m. The diagnoses included, but were not limited to, end stage renal disease, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, chronic kidney disease, interstitial pulmonary disease, chronic pulmonary edema, personal history of malignant neoplasm of other sites of lip, oral cavity and pharynx, gastrostomy status, and dependence on renal dialysis. A care plan, dated 7/12/23, indicated the resident was on oxygen therapy. Interventions included, but were not limited to, observe for signs of respiratory distress and administer oxygen per order. A physician's order, dated 6/21/24, indicated the resident was to receive 1L of oxygen continuously. During an interview, on 10/18/24 at 11:39 a.m., QMA 4 indicated the resident's oxygen concentrator was on 2L. She was unsure of the resident's ordered liter flow. During an interview, on 10/18/24 at 11:43 a.m., LPN 3 indicated the resident's order was for 1L. During an interview, on 10/23/24 at 11:23 a.m., the Director of Nursing (DON) indicated Resident 5's oxygen liter flow was previously at the wrong setting and staff should have followed the physician's orders. A current policy, titled Oxygen Administration, dated 12/12/23 and received from the Clinical Support on 10/18/24 at 2:05 p.m., indicated .Oxygen is administered to residents who need it, consistent with professional standards of practice .Oxygen is administered under orders of a physician 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure staff accurately documented on the narcotic count sheets, documented medication administration in the Medication Administration Record, and properly documented the disposal of medication for 1 of 2 residents reviewed for pain management. (Resident E) Findings include: The clinical record for Resident E was reviewed on 10/16/24 at 11:46 a.m. The diagnosis included, but were not limited to, chronic pain syndrome and non-pressure chronic ulcer of foot. a. The following entries were documented in the month of August on a narcotic medication count sheet for Oxycodone (a narcotic medication to treat pain) 5 milligrams: 1. An entry, dated 8/3/24 at 5:00 a.m., indicated one Oxycodone was administered. This administration was not documented in the Medication Administration Record (MAR). 2. An entry, dated 8/3/24 at 6:20 p.m., indicated one Oxycodone was administered. This administration was not documented in the MAR. 3. An entry, dated 8/3/24 at 3:15 p.m., indicated one Oxycodone was administered. This administration was not documented in the MAR, had a single line strike through the entry, and was not initialed by the nurse. The documentation did not indicate 2 nurses' signatures were documented to show the medication was wasted and the medication was not documented in the MAR indicating the medication had been administered. On 8/3/24, two entries were out of chronological order. An entry was made for at 6:20 p.m., with a subsequent entry made at 3:15 p.m. During an interview, on 10/22/24 at 11:21 p.m., the Assistant Director of Nursing (ADON) indicated if a narcotic medication needed to be wasted, two nurses would sign the narcotic count sheet, and the medication would be destroyed. 4. An entry, dated 8/4/24 at 7:14 p.m., indicated one Oxycodone was administered. This administration was not documented in the MAR. 5. A physician order, with a start date of 8/21/24 and end date of 8/28/24, indicated Oxycodone HCI Oral Tablet 10 mg, give 1 tablet by mouth every 6 hours as needed for chronic pain for 7 days, may use two 5 milligram tabs until 10 milligrams arrived. The MAR indicated, on 8/21/24, Oxycodone 10 milligrams was administered. The documentation on the narcotic count sheet indicated, on 8/21/24 at 11:52 a.m., one Oxycodone 5 milligram was administered, indicating an incorrect documentation of the amount given. During an interview, on 10/22/24 at 1:15 p.m., the ADON indicated the nurse incorrectly documented the amount given. b. The following entries were documented in the month of September on the narcotic medication count sheet for Oxycodone 5 milligrams: 1. An entry, dated 9/14/24 at 5:20 p.m., indicated one Oxycodone was administered. This administration was not documented in the MAR. 2. An entry, dated 9/18/24 at 10:19 a.m., indicated one Oxycodone was administered and the remaining quantity was one. 3. An entry, dated 9/18/24 at 5:00 p.m., indicated one Oxycodone was administered and the remaining quantity was one. The remaining quantity documented on this entry was incorrect. 4. An entry, dated 9/18/24 at 5:00 p.m., indicated one Oxycodone was administered and the remaining quantity was zero. This entry did not have a nurse signature. During an interview, on 10/22/24 at 3:00 p.m., the Director of Nursing (DON) indicated she was aware the nurses were signing out the medication on the medication count sheet but not documenting the administration in the MAR. c. Review of a narcotic count sheet for a discontinued medication order of Oxycodone 10 milligrams, indicated 28 doses remained and were destroyed on 5/30/24. The documentation indicated LPN 9 signed the disposition of the remaining 28 doses on the narcotic count sheet and failed to obtain a witness signature. During an interview, on 10/22/24 at 11:21 p.m., the ADON indicated when a narcotic medication was destroyed, the unit manager and a nurse would destroy the remaining quantity, and both would sign the disposition sheet. During an interview, on 10/22/24 at 1:14 p.m., the ADON reviewed the disposition of remaining doses on the narcotic count sheet, dated 5/30/24, and indicated she was not sure why the disposition did not have a witness signature. She indicated, as the unit manager, she should have witnessed the destruction of the discontinued medication and signed as the witness. A current policy, titled Medication Administration, dated 1/2/2024 and received by the DON on 10/22/24 at 3:00 p.m., indicated .Sign MAR after administered A current policy, titled Documentation of Mediation Administration, last revised 4/2007 and received by the DON on 10/22/24 at 3:00 p.m., indicated .A Nurse of Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR) .Administration of medication must be documented immediately after (never before) it is given A current policy, titled Controlled Substances, last revised 4/2019 and received by the DON on 10/22/24 at 3:00 p.m., indicated .The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medication .Upon disposition .Medication that are opened and subsequently not given (refused or partly administered) are destroyed. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet This citation relates to Complaint IN00443626. 3.1-25(e)(2) 3.1-25(o) 3.1-25(s)(8)

Based on observation and interview, the facility failed to ensure food was served at a safe and appetizing temperature for 1 of 1 room tray tested for temperatures. (100 hall) Findings include: During an interview, on 10/16/24 at 10:54 a.m., Resident E indicated the food was usually cold, especially for room trays. During an interview, on 10/16/24 at 2:53 p.m., Resident 48 indicated the food was cold a lot. During a resident council meeting, on 10/18/24 at 2:35 p.m., the resident council indicated the food was cold, even when eating in the dining room. During an observation and interview, on 10/16/24 at 12:40 p.m., a lunch tray was chosen to get food temperatures. The ravioli temped at 116 degrees. The dietary manager indicated hot foods should be served at least 120 degrees or above. A facility policy, titled Food: Quality and Palatability, last revised on 2/2023 and received from the Director of Nursing on 10/16/24 at 3:30 p.m., indicated .Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature .Proper (safe and appetizing) temperature. Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns This citation relates to Complaints IN00435618, IN00436796, and IN00439138. 3.1-21(a)(2)

Based on interview and record review, the facility failed to document mood and behaviors in the Electric Health Records (EHR) for 1 of 1 resident with suicidal thoughts. (Residents 81) Finding includes: During an interview, on 10/21/24 at 10:06 a.m., Resident 81 indicated she told a nurse, on 10/19/24, she felt like killing herself and wanted to get help. The resident was very upset. The clinical record for Resident 81 was reviewed on 10/12/24 at 11:25 a.m. The diagnoses included, but were not limited to, major depressive disorder and general anxiety. A physician's order, dated 5/18/24, indicated to give 60 milligrams (mg) of duloxetine delayed release for depression daily. A physician's order, dated 10/2/24, indicated to give 10 mg of buspirone for anxiety three times a day. There was nothing documented in the EHR about the thoughts and feeling Resident 81 was having. During an interview, on 10/21/24 at 11:21 a.m., the Director of Nursing (DON) indicated the staff should document the resident's mood and behavior in the medical records and nothing was charted. A current policy, titled Suicidal Thoughts & Ideations, dated 1/2/24 and received from the Clinical Support Nurse on 10/21/24 at 10:16 a.m., indicated .All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent .Objectively document the resident's mood and behaviors, as well as all actions taken, in the medical records 3.1-50(1)

Based on observation, interview and record review, the facility failed to ensure staff transported soiled linen down the hall correctly and staff wore PPE (personal protective equipment) into an isolation room for 3 of 3 randomly observed staff. (CNA 12, 13 and 14) Findings include 1. During an observation, on 10/18/24 at 11:45 a.m., Certified Nursing Assistant (CNA) 12 was observed dragging a large clear trash bag of dirty linen down the 100 hall and placed the bag into the soiled utility room. During an interview, on 10/18/24 at 11:48 a.m., CNA 12 indicated she should not drag dirty linen down the hall. During an interview, on 10/18/24 at 11:49 a.m., the Director of Nursing (DON) indicated the CNA was not supposed to drag dirty linen down the hall. 2. During an observation, on 10/18/24 at 11:52 a.m., Resident G was in Enhanced Barrier Precautions (EBP). CNA 13 and CNA 14 was in the resident's room transferring the resident from her wheelchair to the bed. The CNAs were not wearing PPE when touching the resident, wheelchair, and bed. Licensed Practical Nurse (LPN) 6 entered the room wearing gloves and saw the CNAs without PPE. LPN 6 handed a gown enclosed in a clear bag to CNA 13 and instructed her to put it on. LPN 6 told CNA 14 she also needed to put on a gown and gloves. CNA 14 put on her gown and did not tie the back of the gown. The CNAs transferred the resident to the bed and removed the mechanical lift pad. CNA 14 took the used mechanical lift pad and returned to the resident's bedside without gloves. CNA 14 started to place a pillow under the resident's head and reposition the resident without wearing gloves. The clinical record for Resident G was reviewed, on 10/18/24 at 10:46 a.m. The diagnoses included, but were not limited to, end stage renal, major depressive disorder, and hypertension. A physician's order, dated 10/18/24, indicated EBP when engaging in high contact resident care activities. During an interview, on 10/18/24 at 12:03 a.m., CNA 14 indicated she was not aware gloves were needed when putting a pillow under the resident's head. During an interview, on 10/18/24 at 12:07 a.m., LPN 6 indicated CNA 14 needed to put gloves on before touching the resident and gowns need to be tied when providing care. A current policy, titled Hand Hygiene, dated 1/2/24 and provided by the Director of Nursing on 10/23/22 at 2:04 p.m., indicated .All staff will perform proper hand hygiene procedures to prevent the spread of infection A current policy, titled Infection Prevention & Control Program, dated 1/2/24 and provided at entrance on 10/16/24, indicated .Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE .Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection .All staff shall demonstrate competence in relevant infection control practices 3.1-18(b) 3.1-18(l)

Based on record review and interview, the facility failed to ensure residents were provided Activities of Daily Living (ADL) care for 4 of 4 residents reviewed for ADLs. (Residents J, K, L, and M) Finding include: 1. An Indiana Department of Health (IDOH) reportable, dated 8/17/2023, indicated Resident J did not receive personal care when she needed to be changed on 8/16/2023. Resident B needed personal care when her ostomy bag leaked in her bed. She indicated CNA 2 did not provide her with care. CNA was terminated when the allegation was substantiated. The record for Resident J was reviewed on 9/12/2023 at 2:15 p.m. Diagnoses included, but were not limited to, hypertension, type 2 diabetes mellitus, bipolar disorder, and hemiplegia. The resident had a Brief Interview for Mental Status (BIMS) of 14. This score indicated the resident was not cognitively impaired. During an interview, on 9/12/2023 at 3:50 p.m., Resident J indicated her ostomy bag had leaked in her bed and she called for assistance. CNA 2 came to assist her. CNA 2 she did not clean her bed or change her linen. She slept in a wet bed all night. She notified the nursing staff, on 8/17/2023, she had not received care on 8/16/2023 when her ostomy bag leaked all over her and her bed. CNA 2 put a clean sheet over her and walked out of the room and never returned. The resident slept and woke up wet and in a wet bed. 2. The record for Resident K was reviewed on 9/12/2023 at 3:10 p.m. Diagnoses included, but were not limited to, chronic respiratory failure, type 2 diabetes mellitus, asthma, and edema. The resident had a BIMS score of 15. This score indicated the resident was not cognitively impaired. During an interview, on 9/12/2023 at 3:57 p.m., Resident K indicated she had been turned on her side by CNA 2. She was in position to have herself cleaned by CNA 2. CNA 2 left her in that position. CNA 2 did not return for 2 hours to complete her care. Resident K did not report her incident until she was questioned by the staff regarding care by CNA 2 during an investigation. Resident K did not recall the date, she indicated CNA 2 left her many times in that position and did not return for a long time. 3. The record for Resident L was reviewed on 9/12/2023 at 3:20 p.m. Diagnoses included, but were not limited to, anxiety and depressive disorders, emphysema, and chronic obstructive pulmonary disease (COPD). The resident had a BIMS score of 15. This score indicated the resident was not cognitively impaired. During an interview, on 9/12/2023 at 4:02 p.m., Resident L indicated care had been started many times by CNA 2 and then she would leave and not come back. She indicated this had happened to her many times. Resident L did not report the incidents until she was questioned by the staff regarding care by CNA 2 during an investigation. Resident L did not recall the date. 4. The record for Resident M was reviewed on 9/12/2023 at 3:30 p.m. Diagnoses included, but were not limited to, COPD and type 2 diabetes mellitus. The resident had a BIMS score of 15. This score indicated the resident was not cognitively impaired. A nursing note, dated 8/17/2023, indicated Resident M reported she was left with her pants and briefs around her knees on the side of her bed by CNA 2. CNA 2 just left the resident and the room and did not return. The resident wanted assistance from staff to complete dressing. During an interview, on 9/12/2023 at 4:40 p.m., the Executive Director (ED) indicated he interviewed CNA 2, and she denied the allegations of neglect of care. The ED suspended CNA 2 during the investigation. After the investigation was completed, the ED terminated CNA 2 due to lack of care to Residents J, K, L, and M and poor customer service. A policy was not received before the date of exit. This Federal tag relates to Complaint IN00416164. 3.1-38(a)(2)(A) 3.1-38(a)(2)(C)

Based on observation, interview and record review, the facility failed to ensure a residents pressure ulcers were identified prior to being unstageable, to document which treatment was being used, to reassess the effectiveness of the treatment and to follow up on a referral to a wound clinic for 1 of 4 residents reviewed for pressure ulcers (Resident 72). Resident 72's pressure ulcers of the left posterior ischium was discovered unstageable and progressed into one large area. Finding includes: During an interview, on 03/07/19 at 1:57 p.m., Resident 72 indicated she had a wound on her buttock which was getting worse and she had not gone to the wound clinic. The record for Resident 72 was reviewed on 03/10/19 at 10:52 a.m. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 02/18/19, indicated the resident had two stage 3 pressure ulcers which were not present on admission. A care plan, dated 02/01/19, addressed the problem the resident was at risk for pressure ulcers and had an actual pressure ulcer on her left lower buttocks which was a stage 3. Interventions included, but were not limited to, observe the effectiveness and the response of the treatment. A physician's orders [REDACTED]. Apply Santyl (a topical ointment used to help break up and remove dead skin and tissue) to the wound beds until the sloth (sic) was gone. Once the sloth (sic) had been debrided, stop the Santyl ointment and use silver alginate (an antimicrobial dressing) for the [DIAGNOSES REDACTED]. The frequency of the order was daily. A physician's orders [REDACTED]. Apply Santyl to the wound bed only, then apply alginate over the Santyl and cover with a bordered foam for the [DIAGNOSES REDACTED]. The frequency of the order was as needed. A review of the resident's progress notes and medication administration record did not indicate whether santyl or alginate was used when the resident's dressing was changed daily from (MONTH) 2, 2019 to (MONTH) 11, 2019. A review of Resident 72's Weekly Skin Integrity Evaluation sheets on 12/26/18, 01/02/19, 01/10/19, 01/16/19, 01/23/19 and 01/30/19 did not indicate the resident had any skin impairments. A progress note, dated 02/01/19 at 8:25 a.m., indicated a CNA notified the nurse of two open areas on the residents left lower buttocks. A Santyl order form, sent to the pharmacy and dated 02/02/19, indicated the resident had two wounds to her left lower buttocks which were a stage 3. The wounds' edges were even with the wound bed and had zero tunneling (channels which extended from the wound into and through subcutaneous tissue or muscle). Wound one measured 2.5 cm (centimeters) x 2 and wound two measured 1.75 cm x 2 cm. A review of Resident 72's Pressure Ulcer Record for wound one indicated the following: a. On 02/01/19, it was marked the resident had a stage 3, unstageable, facility acquired pressure ulcer to her lower buttock. The form was marked as both a stage 3 and unstageable. It measured 2.5 cm x 2 cm x 0.1 depth. There was no exudate (liquid produced by the body in response to tissue damage). The wound bed had slough (dead tissue, usually cream or yellow in color) with discoloration to the surrounding skin. It indicated the resident refused to lie down between meals. b. On 02/05/19, it was marked the resident had an unstageable pressure ulcer. It measured 2.3 cm x 1.9 cm x 0.1 depth. There was a small amount of purulent exudate (exudate with pus). The wound bed had slough with pink, pale tissue. It indicated the wound had improved and to encourage the resident to lie down between meals and a roho cushion was ordered for her wheelchair. c. On 02/12/19, it was marked the resident had an unstageable, facility acquired pressure ulcer. It measured 2.5 cm x 2.1 cm x 1.0 depth. There was a small amount of purulent exudate. The wound bed had slough. It indicated the wound had deteriorated, the resident refused to lie down and no new orders at this time. A review of Resident 72's Pressure Ulcer Record for wound two indicated the following: a. On 02/01/19, it was marked the resident had a stage 3, unstageable, facility acquired pressure ulcer to her lower buttock. It measured 2 cm x 1.5 cm x 0.5 depth. There was no exudate. The wound bed had slough. b. On 02/05/19, it was marked the resident had an unstageable pressure ulcer. It measured 2 cm x 1.4 cm x 0 depth. There was a small amount of purulent exudate. The wound bed had slough with pink, pale tissue. It indicated the wound had improved and to encourage the resident to lie down between meals and a roho cushion was ordered for her wheelchair. c. On 02/12/19, it was marked the resident had an unstageable, facility acquired pressure ulcer. It measured 2 cm x 1.5 cm x 0.5 depth. There was a small amount of serous, purulent exudate. The wound bed had slough and the surrounding skin was reddened. It indicated the wound had not changed, and the resident would lie down between breakfast and lunch or lunch and dinner but not all 3. A progress note, dated 02/06/19 at 7:47 p.m., indicated for clarification, the resident had two open areas to left lower buttocks and to continue to cleanse both wounds with normal saline and pat dry. Apply Santyl to the wound bed only, then apply alginate over the Santyl and cover with a bordered foam dressing, daily and as needed. A new cushion was ordered for her wheelchair and to encourage the resident to lay down between meals. A progress note, dated 02/18/19 at 10:01 a.m., indicated the resident received a new order for a pommel cushion for her wheelchair. A review of Resident 72's Pressure Ulcer Record indicated the resident's two wound turned into one wound and indicated the following: a. On 02/19/19, it was marked the resident had an unstageable, facility acquired pressure ulcer. It measured 3.4 cm x 2.4 cm x 1.0 depth. There was a small amount of serous, purulent exudate. The wound bed had slough and the surrounding skin had pink, pale tissue and dark pink/red tissue. b. On 02/26/19, it was marked the resident had an unstageable, facility acquired pressure ulcer. It measured 5 cm x 4 cm x 1.2 depth. There was a small amount of purulent exudate. The wound bed had slough and eschar (dead tissue). It indicated the facility was going to obtain a wound clinic referral. c. On 03/05/19, it was marked the resident had an unstageable, facility acquired pressure ulcer. It measured 7 cm x 7 cm x 2 depth. The wound bed had slough and eschar. A review of Resident 72's Weekly Skin Integrity Evaluation sheet, dated 02/27/19, indicated the resident had a pressure ulcer, undermining (occurred when the tissue under the wound edges became eroded, resulting in a pocket beneath the skin at the wound's edge) was present, slough covered 100% of the wound with necrotic (dead) tissue around the wound edges. It measured 5 cm X 1.2 cm with a depth of undermining to be 0.5 cm. A review of Resident 72's medication administration record for (MONTH) did not indicated the resident's dressing was changed on the 8th, 10th, 11th and the 26th. A review of Resident 72's Weekly Skin Integrity Evaluation sheet, dated 03/06/19, indicated the resident had an open area to her left lower buttocks/thigh. It measured 7 cm x 7 cm x 2 cm depth. Slough was present with necrotic areas and the wound bed was visible in the center. The area was painful to touch and movement. A progress note, dated 02/27/19 at 1:51 p.m., indicated the resident had a wound to the upper thigh area, the physician was notified and the facility was awaiting orders to go to the wound clinic. A progress note, dated 03/02/19 at 6:21 a.m., indicated the resident's wound appeared bigger and deeper with no signs of improvement. The wound had a foul odor and the resident was lethargic. A progress note, dated 03/04/19 at 9:08 a.m., indicated the resident was placed on a Stat Guard 2 Air Mattress with a setting of 4-5 (a pressure relieving air mattress). A progress note, dated 03/05/19 at 8:38 a.m., indicated it was a late entry for 02/20/19 and the resident's pommel cushion was discontinued as it could have caused added pressure. A progress note, dated 03/07/19 at 9:26 p.m., indicated the physician was faxed requesting a wound care clinic referral. A progress note, dated 03/08/19 at 1:36 p.m., indicated the physician faxed back with new order for wound care. There was no documentation located in the resident's record of a follow-up on the request for an order to the wound care clinic from 02/27/19 to 03/07/19. A review of Resident 72's food intakes which were documented for (MONTH) indicated the following: a. The resident consumed an average of 85% of her breakfast. b. The resident consumed an average of 87% of her lunch. c. The resident consumed an average of 71% of her dinner. This was a combined average of 81% A review of Resident 72's food intakes which were documented for (MONTH) indicated the following: a. The resident consumed an average of 79% of her breakfast. b. The resident consumed an average of 86% of her lunch. c. The resident consumed an average of 84% of her dinner. This was a combined average of 83% A review of the resident's Braden Risk Scale for predicting pressure sore risk indicated the following: a. On 04/06/18, the resident was not at risk. b. On 07/04/18, the resident was mildly at risk. c. On 10/04/18, the resident was not at risk. d. On 03/11/19, completed during the survey, the resident was moderately at risk. During an interview, on 03/11/19 at 1:29 p.m., the Birchwood Unit Manager (UM) indicated the dressing change order should have been more specific on what to use and if both were listed the nurses should have indicated what they used during the dressing change. On 03/11/19 at 1:44 p.m., Resident 72 indicated her wound hurt around the edge at all times. The UM changed the resident dressing using Santyl. The wound was covered in green slough and necrotic tissue with a strong foul odor. The wound bed could not be seen due to the slough. During an interview, on 03/11/19 at 1:46 p.m., the Director of Nursing (DON) indicated the physician order [REDACTED]. During an interview, on 03/11/19 at 2:39 p.m., the DON indicated the facility did not have a wound nurse. Therapy discontinued the cushion to the wheelchair as it could have caused more damage. During an interview, on 03/11/19 at 3:34 p.m., the DON indicated the resident's pressure ulcer should have been documented on daily in the progress notes which included a description of the wound observed during the dressing change. During an interview, on 03/12/19 at 3:09 p.m., the DON indicated she could not locate weekly skin sheets from 01/31/19 to 02/26/19 for the resident and the second, as needed order, written on the 02/06/19 should have been discontinued and the original order should have been addressed. During an interview, on 03/13/19 at 3:17 p.m., the DON indicated the wound care doctor wanted to put in a [MEDICAL CONDITION], urinary catheter and debride (remove the damaged tissue) the wound under anesthesia. While at the appointment, she discussed what the doctor meant with the resident and what the procedure would contain. The resident decided not to go through with the surgery at this time. A new order was obtained from the wound clinic to pack the wound twice daily. The resident's doctor was going to meet with her the next day to discuss hospice options. A review of Resident 72's medication administration record (MAR) for (MONTH) did not indicated the resident's dressing was changed on the 3rd and the 8th. On 03/13/19 at 2:09 p.m., information related to the missed dressing changes were requested. A document, dated 3/14/19, received from the Executive Director at 3/14/19 at 12:48 p.m., indicated the nursing staff who took care of Resident 72 on 2/8, 2/10, 2/26, 3/3 and 3/8 were contacted and verbally indicated the dressing was changed but not documented they were completed. The nurse working 2/11 could not remember if the treatment was completed. During an interview, on 03/14/19 at 12:48 p.m., the Executive Director indicated there was not any documentation for the missing dressing changes. The nurses should document on the MAR and progress notes when the dressing was changed. A current facility policy, titled Pressure Ulcer (Injury) Daily Monitoring, received from the DON, on 03/11/19 at 3:09 p.m., indicated .Daily evaluation and documentation of the resident's pressure ulcer sites is the standard of care in providing safe, effective and positive outcomes for all residents. Guideline: 1. All residents with a pressure ulcer(s) will have that area evaluated and documented on daily .will include pressure ulcer site (located in the [DIAGNOSES REDACTED]. 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure a resident with complaints of pain, nausea and who became unresponsive was assessed by licensed staff for a change in condition for 1 of 3 residents reviewed for death (Resident B). The Immediate Jeopardy began (MONTH) 19, (YEAR), when the facility failed to assess a resident who had been complaining of nausea, pain and had a fever, and failed to perform an assessment on a resident prior to instructing a Certified Nurse Aide (CNA) not CPR certified to perform CPR on the resident. The Administrator, Director of Nursing, and Nurse Consultant were notified of the Immediate Jeopardy on [DATE] at 5:45 p.m. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Finding includes: A written statement, dated [DATE], from Certified Nurse Aide (CNA) 21 indicated RN 23 was the nurse caring for Resident B during the night shift from 10:00 p.m. to 6:00 a.m. He indicated between 11:15 p.m. and 11:30 p.m., on [DATE], Resident B had complained of general pain in her head and abdomen and she asked for Tylenol to help with her pain. He indicated he notified RN 23 of the resident's concerns at that time. CNA 21 indicated he and CNA 24 got to Resident B's room to assess her, reposition and check her for incontinence at 5:12 a.m., during which time CNA 24 noticed Resident B was unresponsive. RN 23 was immediately notified, CPR (Cardio-pulmonary Resuscitation) was started by CNA 21and continued until EMS (Emergency Medical Services) arrived and took over CPR. EMS applied the AED pads to the resident. During an interview on [DATE] at 1:00 p.m., RN 23 indicated she was in the hallway at approximately 5:12 a.m., when the CNA's yelled for her to come to Resident B's room because they thought she was gone and she did not have a pulse. She told them to start CPR and she went to check the chart to check if the resident was a full code. RN 23 had not physically went into Resident B's room during the night shift to lay eyes on her to actually see her. She looked at her from the hallway. During an interview on [DATE] at 12:33 p.m., RN 12 was in attendance. Housekeeper 29 indicated she cleaned Resident B's room on the evening of [DATE] at approximately 5:30 p.m., and the resident was complaining of pain and not feeling well and was requesting help. Housekeeper 29 went to the nurse's station two times while cleaning the resident's room to request someone come down to help the resident. The time it took her to clean the resident's room was approximately 20 minutes. She was not sure, which staff she had informed because she was from a contract company and she did not know who the facility staff was at the nurses station. She was on that hallway cleaning rooms from 5:30 p.m. to 6:30 p.m., and during that time she did not see a staff member come to the resident's room to check on her. When she got done cleaning the room next to the resident's she went back and asked the resident if anyone had come to check on her and Resident B said No. Resident B's record was reviewed on [DATE] at 3:30 p.m. [DIAGNOSES REDACTED]. The resident had a care plan dated [DATE], which addressed the problem she had an actual potential cardiovascular problem related to hypertension, [MEDICAL CONDITION], history of [MEDICAL CONDITION]. Approaches included, but were not limited to, (1) [DATE]--Observe for and report any: Chest pain/pressure, jaw, neck, shoulder or arm pain, SOB (shortness of breath), Pain/numbness/tingling in extremities, Sweating/pale skin, Restlessness, N/V (Nausea/Vomiting) (2) [DATE]--Monitor V/S (vital/signs) and report to physician any change of condition The resident had a care plan dated [DATE], which addressed the problem she was at risk for increased confusion and disorientation due to history of delusions and moderately impaired cognition. BIMS (Brief Interview Mental Status) was13 on [DATE]. Approaches included, but were not limited to, .(7) Notify MD of significant changes in cognition The resident's EMAR (Electronic Medication Administration Record) dated [DATE] to [DATE], included, but were not limited to, the following orders: [MEDICATION NAME] (a narcotic pain medication) ,[DATE] mg (milligrams) Give one tablet by mouth every four hours as needed for pain. (The last dose of this medication documented as given for complaints of pain was [DATE] at 2:51 a.m.) [MEDICATION NAME] ([MEDICATION NAME]) 325 mg Give two tablets (650 mg) by mouth every six hours as needed for pain (Not to exceed three grams of [MEDICATION NAME] in 24 hours). (There was no doses documented on the EMAR as given for pain for the month of November). Progress notes included, but were not limited to the following: On [DATE] at 6:09 a.m., RN 18 indicated she arrived to the facility at 5:30 a.m. She arrived onto the unit and was told Resident B was actively being coded by EMS/Fire Department. The EMS pronounced the resident deceased at 5:38 a.m. RN 18 notified the family at 5:50 a.m. [DATE] at 10:47 a.m., Family arrived to facility around 8 am. Family in resident room. No needs expressed at this time. Will continue to work with family to provide for needs. [DATE] at 1:55 p.m., Resident body left facility at 1355 (1:55 p.m.). On [DATE] at 1:31 p.m., the employee records were reviewed for appropriate coverage for CPR. A CPR certification for CNA 21, who had performed CPR on Resident B prior to EMS arriving expired in (MONTH) 2014. On [DATE] at 10:54 a.m., the DON provided a current policy, titled, Charting and Documentation, dated [DATE]. The policy indicated, Services provided to the resident, or any change in the resident's medical or mental condition, shall be documented in the resident's medical record .2 Incidents, accidents, or changes in the resident's condition shall be recorded .6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided .c. The assessment data and/or any unusual findings obtained during the procedure/treatment .f. Notification of family, physician or other staff, if indicated . On [DATE] at 5:02 p.m., the Director of Nursing (DON) provided a current policy, titled, Change of Condition, dated [DATE]. The policy indicated, The facility will evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay evaluation information to physician and to document actions to include but not limited to the following: A significant change in the resident's physical mental or psychosocial status, a need to alter treatment, a decision to transfer or discharge the resident from the facility .1. Licensed Nurse or Nurse Practitioner (NP) will evaluate any change in condition through direct observation, physical examination and vital signs at the onset of the change and as ordered by the physician .Complete the Situation, Background, Assessment, Recommendations (SBAR) in the Electronic Medical Record (EMR) to provide the physician with necessary evaluation findings .6. Document in the medical record physician/NP/PA (Physician's Assistant) notification .7. Notify the resident's representative, consistent with his or her authority, of change and follow through completed by the facility, and documented in the medical record .10. Follow up and documentation by the licensed nurse should continue for 72 hours . The immediate jeopardy that began on [DATE], was removed on [DATE], when the facility audited all the residents' records for recent change in condition; and in-serviced staff on change of condition, resident code status, CPR procedure, and conducted practice Code Blue scenarios, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for the more that minimal harm that is not immediate jeopardy because the facility is continuing the in-servicing of staff, and monitoring of change in condition of residents, and staff knowledge of CPR and resident code status. This Federal tag relates to Complaint IN 779. 3XXX,[DATE](a)

Based on interview and record review, the facility failed to perform Cardio-Pulmonary Resuscitation (CPR) according to the resident's code status preference for 1 of 3 residents reviewed for death (Resident D), and failed to follow the CPR procedure for unresponsive residents for 1 of 3 residents reviewed for death (Resident B). The Immediate Jeopardy began (MONTH) 27, (YEAR), when the facility failed to initiate CPR on a resident found unresponsive. The Administrator, Director of Nursing, and Nurse Consultant were notified of the Immediate Jeopardy on [DATE] at 5:45 p.m. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at a lower scope and severity of isolated, no actual harm, with potential for more than minimal harm that was not Immediate Jeopardy. Findings include: 1. On [DATE] at 8:20 a.m., the Administrator (ADM) provided a document titled, Resident Tracking Detail, dated [DATE] - [DATE]. The document indicated Resident D had an unexpected death on [DATE]. Record review for Resident D was completed on [DATE] at 10:50 a.m. The record indicated the resident was admitted on [DATE] and had current [DIAGNOSES REDACTED]. A document titled, Indiana Physician order [REDACTED]. The document indicated, Attempt Resuscitation/CPR, and Full Intervention. Treatment Goal: Full interventions including life support measures in the intensive care unit A document titled, History and Physical, dated [DATE]. The document indicated, Code status: full scope of treatment . Care Plans for Resident D, included but were not limited to, Problem: Resident has advanced directives on record: Full Code. Goal: Resident's Advanced Directives are in effect, and their wishes and directions will be carried out in accordance with their advanced directives on an ongoing basis through next review date. Approach: Resident is capable of making informed consent regarding their health care decisions. Allow resident, if able to discuss feeling regarding their Advanced Directives. Staff to follow Advanced Directives for Full Code . Resident D's nurse's notes, dated [DATE] at 4:25 a.m., indicated, At 2:00 a.m. during rounds resident was taken snack and milk per request. At 4:10 a.m. during rounds resident was found with no respirations, no heart rate, no pulse, cold on the left side but warm toes on right. Daughter notified of status awaiting her arrival. There was no documentation CPR had been initiated. Review of Resident D's nurse's notes, dated [DATE] at 9:52 a.m., (late entry for [DATE] at 9:30 a.m.), indicated, Resident body released to funeral home and escorted out of the building by writer. Review of a document titled, Provisional Notification of Death - Burial Transit Permit, dated [DATE]. The document indicated Resident D expired on [DATE] at 4:10 a.m., and her body was released to the funeral home. Review of a statement, written by Licensed Practical Nurse (LPN) 25, dated [DATE] at 6:30 a.m. The statement indicated, I arrived at work and heard from housekeepers that (Resident D) had passed away at 4:10 a.m. this morning. Writer went to the office and checked code status in (pharmacy name), it stated that she was a full code .I asked if they coded her, and (LPN 17) stated yes .I asked (Registered Nurse (RN) 26) what happened. She stated, we received a critical lab on her last night, her CO2 (carbon [MEDICATION NAME]) was high, the doctor called and stated to put her [MEDICAL CONDITION] (provides variable respiratory and lower expiratory pressure for easier breathing while your sleep) on her. We put her [MEDICAL CONDITION] on her and she was fine. At 1:00 a.m. we checked on her and she was her normal self. Then at 4:10 a.m., they found her dead. I asked (RN 26) if they coded her and she stated yes. I said, ok then the EMT's came and called the doctor to pronounce her dead? (RN 26) stated, no the EMT's did not come, she was not breathing and she was blue, half of her body was cold and half warm, her toe was warm, she was gone. So I stated, so you stopped CPR? (RN 26) stated, no, we never started CPR because she was not breathing. I stated, she was a full code, you always start CPR no matter what if they are a full code. (RN 26) stated, well she was gone and wasn't breathing. I thought they were supposed to change her to a DNR. I stated, did you check the POST form? (RN 26) stated, yes. I asked what it said, (RN 26) stated full code. I asked if she notified the (Director of Nursing name), and she stated, yes about her dying, not about the other . Review of a statement, written by Certified Nursing Aid (CNA) 27, dated [DATE]. The statement indicated, I walked into (Resident D's) room .I noticed her chest wasn't moving so I ran and got both nurses, (LPN 7 and RN 26). Review of a statement written by LPN 7, dated [DATE]. The statement indicated, on Wednesday ,[DATE], CNA 27 had come out of Resident D's room and yelled she needed help. LPN 7 and RN 26 got up from behind the nurses station, hurried down hallway, and when they entered the room, Resident D wasn't responding. (RN 26) used my equipment and tried to take vitals. I was on the right side and noted her leg was warm but upper body cold. (RN 26) removed [MEDICAL CONDITION] (continuous positive airway pressure for people who can't breathe spontaneously). After not being able to take vitals we exited the room and I called the daughter while (RN 26) was retrieving paperwork. Review of a statement written by RN 26, on [DATE]. The statement indicated, On the morning of 27th at 0410 the aide (27) called me into her room, (Resident D's). She was non-responsive with no vital signs, no pulse, no heart rate, no respirations, and no oximetry. Her left side was cold to the touch, her toes on the right were warmer. I left the room called the doctor on call for (physician's name) with orders to release the body. (LPN 7) called the family. Review of a statement written by RN 18, on [DATE] at 1:30 p.m. The statement indicated, Arrived at the facility at 5:40 a.m. and went to unit .I saw Resident D's daughter and granddaughter I asked (LPN 7 and RN 26) why the family was here so early and they both quickly said that (Resident D) had passed away. The comment was made that she had a critical CO2 level the evening before. At this time (LPN 25) called to see if they completed CPR as (Resident D) was a full code. I asked (LPN 7 and RN 26) if they had run a code and they just looked at me with blank stares .I gave the phone to (LPN 7 and RN 26), they told (LPN 25) they did not do a code as (Resident D) was visibly already gone . I asked (RN 26) if she looked in the chart to check the code status and both her and (LPN 7) started saying no because the family had been talking about her switching to DNR when she came back from the hospital. (LPN 7) commented that there was nothing to code at that point because she was already cold and blue and it would take Jesus to bring her back . On [DATE] at 3:25 p.m., the Director of Nursing (DON) indicated resident code statuses were found on the POST form in the chart, there was no other advanced directive form used for this facility. Every resident should have had a POST form in the chart. The nurse should have assessed the resident, then checked for the code status. Upon determining the Resident D was a Full Code, CPR should have been initiated immediately, and delegated for someone to get the crash cart, and whoever was calling 911 should have called a Code Blue, all should have been done simultaneously. The nurse on duty would have been responsible for assuring the resident was provided with CPR per her orders and care plan. 2. On [DATE] at 8:20 a.m., the Administrator provided a document, titled, Resident Tracking Detail, dated [DATE] - [DATE]. The document indicated, Resident B experienced an unexpected death on [DATE]. During an interview on [DATE] at 5:40 a.m., RN 18 indicated she clocked in on [DATE] at 5:34 a.m. On her way into the building she noticed the fire truck and ambulance vehicles outside the building with their lights on. She walked down the main hallway on the Birchwood unit and was informed by LPN 22 Resident B was being coded by Emergency personnel. The EMS (Emergency Medical Service) came out of the resident's room at 5:38 a.m., and pronounced the resident deceased . RN 18 indicated EMS told her they were dispatched at 5:21 a.m. (that was when they were called to come to the facility). She indicated the AED (Automatic External Defrillator) pads were placed on the resident by the EMS personnel. RN 18 told Resident B's family she was found deceased a little after 5:00 a.m., from what she was told by the CNA's. A written statement, dated [DATE], from CNA 21 indicated RN 23 was the nurse caring for Resident B during the night shift from 10:00 p.m. to 6:00 a.m. CNA 21 indicated he and CNA 24 got to Resident B's room to assess her, reposition and check her for incontinence at 5:12 a.m., during which time CNA 24 noticed Resident B was unresponsive. RN 23 was immediately notified, CPR (Cardio-pulmonary Resuscitation) was started by CNA 21 and continued until EMS (Emergency Medical Services) arrived and took over CPR. EMS applied the AED pads to the resident. During [DATE] at 7:32 a.m., RN 19 indicated the crash cart was taken out of Resident B's room this a.m. and she just finished restocking it at this time. There was no code report paper used to indicate what was done for the resident during the code prior to EMS arriving. She indicated the AED was located at the end of the main hallway of the Birchwood unit by the dining room because that was a central location for both units. She had placed a piece of tape across the second drawer with the words Crash Cart hand written on it this morning because the cart did not look like a crash cart and some of the staff did not know what the crash cart looked like because this cart looked like the nurses' treatment carts. During an interview on [DATE] at 10:17 a.m., the DON (Director of Nursing) provided a copy of the Emergency Crash Cart Inventory Check List dated (MONTH) (YEAR), which was blank. She the blanks meant the crash cart was not checked. During an interview [DATE] at 12:41 p.m., CNA 24 indicated she and CNA 21 were working on the Birchwood unit the morning Resident B passed away ([DATE]). She went into the resident's room at 5:12 a.m., with CNA 21 on [DATE], to assist him to check the resident for incontinence and she discovered resident did not have a pulse and her arms were ice cold. She indicated both CNAs immediately notified RN 23 the resident did not have a pulse and was gone. CPR was started on Resident B by CNA 21. During an interview on [DATE] at 1:00 p.m., RN 23 indicated she was in the hallway at approximately 5:12 a.m., when the CNAs yelled for her to come to Resident B's room because they thought she was gone and she did not have a pulse. She told them to start CPR and she went to check the chart to check if the resident was a full code. CNA 21 had started the CPR. She grabbed her stethoscope and went to assess the resident and when she walked into the resident's room she knew she was deceased . The resident's eyes were open and her pupils were fixed and dilated, her torso was warm and her arms were cold. She felt for a pulse and listened for a heartbeat and there was none. She had the CNAs continue with CPR taking turns as needed and she went to get the crash cart because the CNAs did not know where the crash cart was located. She had CNA 24 go to the Cedarwood unit to get LPN 22, who called 911. There was no AED in the crash cart and she did not know where it was located, so she asked LPN 22 if he would get the AED and when he did not bring it, she assumed the facility did not have one. RN 23 indicated the CNAs told her when they found Resident B, she had no pulse, so she told them to start CPR. She had not physically went into the resident's room during the night shift to lay eyes on her to actually see her. She had looked at her from the hallway. On [DATE] at 1:31 p.m., the employee records were reviewed for appropriate coverage for CPR. A CPR certification for CNA 21, who had performed CPR on Resident B prior to EMS arriving expired in (MONTH) 2014. Resident B's record was reviewed on [DATE] at 3:30 p.m. [DIAGNOSES REDACTED]. A document titled Indiana Physician order [REDACTED]. The resident had a care plan, dated [DATE], which addressed the problem she had an Advance Directive on record indicating she was a Full Code. Approaches included, but were not limited to, XXX[DATE]-Staff to follow Advance Directives for Full code The resident's Physician orders, dated [DATE], included, but were not limited to, the following: [DATE]-Full Code. Progress notes included, but were not limited to the following: On [DATE] at 6:09 a.m., RN 18 indicated she arrived to the facility at 5:30 a.m. She arrived onto the unit and was told Resident B was actively being coded by EMS/Fire Department. The EMS pronounced the resident deceased at 5:38 a.m. RN 18 notified the family at 5:50 a.m. On [DATE] at 10:47 a.m., Family arrived to facility around 8 am. Family in resident room. No needs expressed at this time. Will continue to work with family to provide for needs. On [DATE] at 1:55 p.m., Resident body left facility at 1355 (1:55 p.m.). A tour of the facility with the RVP (Regional Vice President) in attendance started on [DATE] at 11:30 a.m. During that time the RVP was informed the crash cart from this unit (Birchwood) was not taken out of Resident B's room to be restocked until [DATE], after the complaint survey was started and the resident passed away on [DATE] at 5:38 a.m. He was informed the resident's door was closed with the crash cart in the room and the other crash cart was on the Cedarwood unit. The RVP indicated the crash cart should have been restocked immediately following the code and the crash cart on Cedarwood was too far away for staff to run to get it in an emergency. During an interview on [DATE] at 3:25 p.m., the DON (Director of Nursing) indicated the resident code statuses were found on the POST form in the chart, there was no other advanced directive form used for this facility. The nurse should have assessed the resident, then checked for the code status. Upon determining the resident was a Full Code, CPR should have been initiated immediately, and delegated for someone to get the crash cart, and whoever was calling 911 should have called a Code Blue, all should have been done simultaneously. During an interview on [DATE] at 3:35 p.m., the DON indicated in one part in the CPR policy it indicated any certified staff member can start CPR and in another part it indicated a licensed staff member had to start CPR, so they were looking into the discrepancy right now. RN 19 had just put a piece of tape on the two crash carts on [DATE], to distinguish them as crash carts, but they ordered three red carts, one for each unit and one for the main dining room, so staff could identify them as crash carts. The reason RN 23 did not stay with the resident during the time CPR was first started on the resident was because both CNA's indicated they did not know where the crash cart was, so she went to get it. The DON indicated every nursing staff member should know where the crash carts were located. On [DATE] at 8:21 a.m., the Director of Nursing (DON) provided a current policy, titled, Cardiopulmonary Resuscitation, dated [DATE]. The policy indicated, The initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION] will be initiated by staff certified I CPR/BLS. 1. Cardiopulmonary resuscitation (CPR) will be attempted for any resident who is found to have no palpable pulse and/or no discernible respirations, unless there is a written physician order [REDACTED].Upon identifying a resident with change of condition which presents as an unresponsive condition: a. Assess for safety of environment. b. Activate the facility emergency response process .c. Assess resident for status of breathing and check pulse. d. Check the medical record for advance directive status. e. Retrieve emergency cart and Automated External Defibrillator (AED) if available. f. If resident record indicates CPR is to be instituted, then initiate Basic Life Support if a pulse and/or respirations are undetectable .3. If a resident is found unresponsive and without respirations, a licensed staff member who is certified in CPR/BLS shall promptly initiate CPR for residents: a. Who have requested CPR in their advance directives, b. Who have not formulated an advanced directive, or c. Who do not have a valid Do Not Resuscitate (DNR) order .8. EMS/911 will be contacted immediately when the code blue is called. CPR will be continued by facility staff until EMS arrives to assume responsibility for providing CPR. 10. The facility will contact the resident's legal representative and/or emergency contact, and the resident's physician, as soon as possible after contacting 911 .11. The facility will have a licensed staff member who is certified in CPR/BLS available at all times. The CPR/BLS training shall include hands-on practice and in-person skills assessment, and shall not be online training only. 12. Facility staff should utilize the emergency code documentation form to document the event. This documentation should be placed in the resident's medical record . On [DATE] at 10:17 a.m., the DON provided a current policy, titled, Automated External Defibrillator, dated [DATE]. The policy indicated, An Automated External Defibrillator (AED) is used to treat victims who experience sudden [MEDICAL CONDITION]. The AED must only be applied to victims who are unconscious, without a pulse, and not breathing .An AED will be used in conjunction with Cardio-Pulmonary Resuscitation (CPR) in cases of sudden [MEDICAL CONDITION] at the facility, in accordance with accepted protocols, including those developed by the American Red Cross and American Heart Association. Use of the AED and CPR will continue as appropriate during the course of emergency care, until the patient resumes pulse and respirations, and/or local Emergency Medical Services (EMS) arrive at the scene, and assume responsibility for emergency care of the patient. 1. Assess the scene for safety. 2. Determine the victims' unresponsiveness. 3. Activate the emergency response system (Dial 911). 4. Open airway. 5. Check for breathing. 6. Check for pulse and/or signs of circulation such as normal breathing, coughing, or movement. 7. If no pulse and/or signs of circulation, apply AED immediately. If AED is not immediately available, perform CPR until the AED arrives on the scene On [DATE] at 10:17 a.m., the DON provided a current policy, titled, Emergency Carts, dated [DATE]. The policy indicated, The facility will ensure that emergency equipment is readily available to trained personnel for those residents who desire resuscitation measures .a. The Central Supply clerk, or designee, will maintain 1 emergency cart ready at all times. The emergency cart supply checklist will be utilized to maintain items as listed above. b. The nursing supervisor or designee will be responsible for immediately restocking the cart after each use. 4. Nurses assigned will audit emergency cart(s) and the emergency cart checklist on a daily basis and restock as indicated. On [DATE] at 5:02 p.m., the DON provided a current policy, titled, Death of Resident, Documenting, dated [DATE]. The policy indicated, Appropriate documentation shall be made in the clinical record concerning the death of a resident. 1. A resident may be declared dead by a Licensed Physician or Registered Nurse with physician authorization in accordance with state law. 2. Information pertaining to a resident's death (i.e., dated, time of death, the name and title of individual pronouncing the resident death, etc.) shall be recorded on the nurse's notes . The immediate jeopardy that began on [DATE], was removed on [DATE], when the facility in-serviced staff on resident code status, CPR procedure, and conducted practice Code Blue scenarios, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for the more that minimal harm that is not immediate jeopardy because the facility is continuing the in-servicing of staff, and monitoring of staff knowledge of CPR and resident code status. This Federal tag relates to Complaint IN 779.

Based on interview and record review, the facility failed to ensure a residents pain was reassessed and managed effectively for a resident receiving comfort care for 1 of 2 residents reviewed for pain (Resident 90). Resident 90 cried out in pain for several days before her death without additional intervention. Finding includes: The record for Resident 90 was reviewed on 01/11/18 at 10:20 a.m. [DIAGNOSES REDACTED]. A Significant Change in Status Minimum Data Set (MDS) assessment, dated 10/09/17, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10. Section J- Health Conditions was marked as the resident had frequent pain with a pain rating of an eight on a ten point scale. Resident 90's care plan addressed the problem the resident and family elected comfort measures. Approaches included, but were not limited to, .10/09/17 - Notify family of changes, Notify MD of changes, Assess for pain/discomfort and manage as appropriate Resident 90's care plan addressed the problem the resident was at risk for pain related to health decline/comfort measures. Approaches included, but were not limited to, .Report changes in pain location/type, Monitor for any changes in overall function and report to MD A Progress Note, dated 10/06/17 at 5:31 p.m., indicated the Nurse Practitioner wrote orders per family request for comfort measures and do not transfer to hospital and also wrote orders for [MEDICATION NAME] (a pain medication), [MEDICATION NAME] (an antianxiety medication) and [MEDICATION NAME] drops (used for excessive secretions) as needed. A physician's orders [REDACTED]. A Progress Note, dated 10/15/17 at 9:00 p.m., indicated .Moaning and yelling out most of eve (evening) although I have given her Mso4 0.25 or 5 mg (milligrams) po (by mouth) q (every) hr (hour) and [MEDICATION NAME] 1 mg po still moaning slept very little this noc (night) so far A Progress Note, dated 10/16/17 at 2:46 a.m., indicated .Moved resident's roommate to another room so she could sleep resident still moaning and calling out despite amount of medication given will continue to observe A Progress Note, dated 10/15/17 at 2:00 p.m., indicated .Resident continues to call out in pain prn [MEDICATION NAME] given A Progress Note, dated 10/16/17 at 2:25 p.m., indicated .Resident moaning in pain several times today gave prn [MEDICATION NAME], with short term effectiveness .Respirations ceased at 1010 hours . MD (medical doctor) and management notified There was no documentation in the record to indicate the Physician was contacted when the residents pain medication was no longer effective and she was crying out in pain. There was no Situation Background Assessment Recommendation (SBAR) in the record to indicate the residents lack of pain medication effectiveness was assessed for further intervention. During an interview, on 01/12/18 at 11:33 a.m., the Director of Nursing (DON) indicated she could not location any faxes sent to the MD in the month of (MONTH) besides the one on 10/12/17. During an interview, on 01/12/18 at 11:50 a.m., the Birchwood Unit Manager (UM) indicated if a resident was at the end stage of life and their pain was not being controlled the staff should have notified the MD or Hospice if the resident was on Hospice. During an interview, on 01/16/18 at 1:58 p.m., the Birchwood UM indicated a SBAR should have been completed and the MD called related to the residents pain. A facility policy titled Pain Management dated as revised 11/28/17, received from the Executive Director on 01/12/18 at 10:30 a.m., indicated .Each resident identified with pain will have ongoing assessments, a monitoring system, and a comprehensive person-centered plan of care to address pain management to include the resident's goal .If the pain medication is ineffective the pain will be evaluated and the SBAR will be completed prior to calling the physician for notification of unrelieved pain . A pain evaluation is completed on each shift on all residents and documented in EzMAR. Whenever the results of pain assessments reveal that the resident's pain is not under control, the attending MD/NP/PA should be notified .If pain is identified, assess the resident utilizing the SBAR to notify the physician 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a pressure ulcer was identified, assessed and monitored, and failed to follow prevention interventions for 1 of 1 residents reviewed for pressure ulcers (Resident 14). Resident 14's pressure ulcer to the sacral region was discovered after admission and then deteriorated to a Stage 3, and became infected. Findings include: On 01/09/18 at 9:20 a.m., Resident 14 was observed to be sitting in her Broda chair at the nurses station. A pressure relief cushion was not located in her Broda chair. On 01/17/18 at 1:23 p.m., RN 5 and QMA 10 were observed to transfer Resident 14 from her Broda chair to her bed. A pressure relief cushion was not located in her Broda chair. The record for Resident 14 was reviewed on 01/17/18 at 6:10 a.m. [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE], indicated Section G- Functional Status was marked as extensive assist of two staff members for bed mobility and transfers. Section M- Skin Conditions indicated the resident had one Stage 3 pressure ulcer which measured 9 x 3 x 1.8 cm (centimeter). Resident 14's care plan dated 10/27/14, addressed the problem she was at risk for developing skin breakdown related to incontinence, decreased mobility and gout. The goal dated 08/31/17, indicated the pressure ulcer will be free of infection and show signs of healing. The approaches included, but were not limited to, .07/30/14- Refer to wound nurse as needed, refer to MD as needed . 07/24/17- Provide pressure relieving or reduction chair cushion . 10/20/17- Do wound care as ordered for Stage 3 pressure ulcer, see current treatment record and physicians orders, observe effectiveness of response to treatment, observe for s/s (signs/symptoms) infection or delayed healing and report to MD: redness/[DIAGNOSES REDACTED], drainage/purulent or bloody drainage A physician's orders [REDACTED]. A physician's orders [REDACTED]. Nursing to check placement every shift. A Progress Note, dated 08/27/17 at 5:47 p.m., indicated .CNA reported res (resident) coccyx needed to be seen. Writer last saw area 8/24 site was 1/2 in (inch) abraised area on tip of coccyx, no redness or dung (drainage). Today noted large 6 cm round deep purple bruise with same 1/2 in abraised area with old crusted dung .Hospice aware .MD office aware A Weekly Skin Sheet, dated 08/30/17, indicated Resident 14 had a bruise to her coccyx which was not present on admission. A physician's orders [REDACTED]. The order was discontinued on 12/20/17. A Progress Note, dated 09/01/17 at 1:50 p.m., indicated .Buttocks reddened, bruise remains A Progress Note, dated 09/01/17 at 5:38 p.m., indicated .buttocks more reddened A Progress Note, dated 09/05/17 at 9:51 a.m., indicated .x2 macerated scabbed areas on sacrum. slight odor, covered with [MEDICATION NAME] padding, no bruising noted in sacral area A Weekly Skin Sheet, dated 09/07/17, indicated the resident had a pressure ulcer to her coccyx which was not present on admission. No measurements or Stage was listed. A Progress Note, dated 09/07/17 at 1:18 p.m., indicated .x2 pressure site on res sacrum show no change A Progress Note, dated 09/09/17 at 10:48 a.m., indicated .wound on sacrum padded, black eschar covering site, has spread into horseshoe shape on sacrum A Progress Note, dated 09/09/17 at 5:30 p.m., indicated .Open area remains on coccyx A Progress Note, dated 09/10/17 at 1:25 p.m., indicated .wound at sacrum malodorous, eschar base et (and) horseshoe shape, padding in place A Progress Note, dated 09/12/17 at 12:30 p.m., indicated .sacral wound shows no improvement, padded for comfort, malodorous wound A Progress Note, dated 09/14/17 at 11:57 a.m., indicated .states sacrum painful .new dsg (dressing) to sacrum, site greatly malodorous, brown serous dung (drainage) on old pad, wound base black et cont (continues) to expand at sacrum A Weekly Skin Sheet, dated 09/15/17, indicated the resident had a pressure ulcer to her coccyx which was not present on admission. No measurements or Stage was listed. A Progress Note, dated 09/15/17 at 2:51 p.m., indicated .dsg changed to sacral wound, malodorous with mod (moderate) amt (amount) dung A Progress Note, dated 09/15/17 at 3:57 p.m., indicated .sacral wound malodorous et cont to drain A Progress Note, dated 09/16/17 at 10:43 a.m., indicated .sacral wound malodorous with slough. Covered with dressing A Progress Note, dated 09/17/17 at 5:18 p.m., indicated .dressing to coccyx. Mod amt dk (dark) red drainage on old dressing A Progress Note, dated 09/18/17 at 5:23 a.m., indicated .dressing changed to coccyx some foul odor noted cleansed area well A Progress Note, dated 09/18/17 at 1:42 p.m., indicated .wound to sacral area malodorous, no improvement There was no documentation in the record to indicate the Physician was notified of the worsening of the wound from 08/27/17 until 09/18/17 for treatment intervention. A Progress Note, dated 09/18/17 at 6:36 p.m., indicated .Hospice nurse did wound dressing this shift .new orders put in for [MEDICATION NAME] to wound bed A physician's orders [REDACTED]. A Progress Note, dated 09/19/17 at 1:48 p.m., indicated .tx (treatment to sacral wound, added [MEDICATION NAME] granules to wound for odor control, wound shows no improvement, appears deeper, mod dung on old pad A Weekly Skin Sheet, dated 09/21/17, indicated the resident had a pressure ulcer to her coccyx which was not present on admission. No measurements or Stage was listed. A Progress Note, dated 09/22/17 at 6:37 p.m., indicated .wound continues with purulent and odorous drainage A Weekly Wound Sheet, dated 09/26/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 9 x 3 x 1.8 cm and was a Stage 3. A Weekly Skin Sheet, dated 10/05/17, indicated the resident had a pressure ulcer to her coccyx which was not present on admission. No measurements or Stage was listed. A Progress Note, dated 10/12/17 at 12:44 p.m., indicated .c/o (complaint of) sacral discomfort, Roxinal given with comfort A Weekly Skin Sheet, dated 10/13/17, indicated the resident had a pressure ulcer to her coccyx which was not present on admission. No measurements or Stage was listed. A Progress Note, dated 10/14/17 at 5:40 a.m., indicated .Dressing to coccyx changed. Greenish discharge from wound, with foul odor A Progress Note, dated 10/17/17 at 12:31 a.m., indicated .Sacral wound with greenish colored drainage. Foul odor present A Weekly Skin Sheet, dated 10/19/17, indicated the resident had a pressure ulcer to her coccyx which was not present on admission. No measurements or Stage was listed. A Weekly Wound Sheet, dated 10/20/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 8 x 3 x 0.3 cm and was a Stage 3. A Progress Note, dated 10/23/17 at 10:38 a.m., indicated .wound to coccyx cleaned .Slight odor and moderate drainage noted A Weekly Wound Sheet, dated 10/26/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 8 x 3 x 0.3 cm and was a Stage 3. A Progress Note, dated 10/27/17 at 1:28 p.m., indicated .Hospice nurse here, changed tx to coccyx with Alginate packing et [MEDICATION NAME] dsg daily et PRN (as needed) soilage A physician's orders [REDACTED]. There was no documentation in the record to indicate the Physician was notified of the wounds response to the treatment from 09/18/17 to 10/27/17 for treatment intervention. A Weekly Wound Sheet, dated 11/16/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 7.5 x 3 x 0.3 cm and was a Stage 3. The next Weekly Wound Sheet, 3 weeks later,dated 12/07/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 6.5 x 3 x 0.2 cm and was a Stage 3. A Weekly Wound Sheet, dated 12/12/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 6.5 x 3 x 0.2 cm and was a Stage 3. The next Weekly Wound Sheet, 17 days later, dated 12/30/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 6.5 x 3 x 0.2 cm and was a Stage 3. During an interview, on 01/09/18 at 2:21 p.m., the Cedarwood Unit Manager indicated Resident 14 had a Stage 3 pressure ulcer on her coccyx which was acquired in the facility. On 08/30/17, it was noted as a bruise which measured 8 x 5 cm with no depth then it started to get worse and was changed to a pressure ulcer. On 09/26/17, it measured 9. x 3 x 1.8 cm and was a Stage 3. She indicated she could not locate any measurements for the area from 08/30/17 to 09/26/17 and the facility did not have a wound nurse. During an interview, on 01/17/18 at 9:56 a.m., the Birchwood Unit Manager indicated she could not find any other measurements besides what was already provided. During an interview, on 01/17/18 at 1:33 p.m., RN 5 indicated all wounds should have been measured weekly and documented in wound sense. If the wound was found on a Wednesday then it should have been measured every Wednesday. During an interview, on 01/17/18 at 2:51 p.m., the Medical Records staff indicated she could not locate a pressure relieving cushion for Resident 14's wheelchair any where in her room and would check into it. During an interview, on 01/17/18 at 3:26 p.m., the Birchwood Unit Manager indicated the seat of the Broda chair had padding, the facility was not currently adding an extra cushion and the physician's orders [REDACTED]. A facility policy titled Pressure Ulcer Daily Monitoring dated as revised 06/01/15, received from the Director of Nursing on 01/17/18 at 11:05 a.m., indicated .Daily evaluation and documentation of the resident's pressure ulcer sites is the standard of care in providing safe, effective and positive outcomes for all residents 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to recognize a significant change in condition, failed to notify the Medical Doctor (MD), and failed to ensure medical services were provided timely for 1 of 1 residents reviewed for hospitalization (Resident 91). Resident 91 had multiple health complaints several days without physician intervention and nursing assessment. The resident admitted to the hospital for [MEDICAL CONDITION]. Finding includes: The record for Resident 91 was reviewed on 01/11/18 at 11:16 a.m. [DIAGNOSES REDACTED]. A Progress note, dated 11/12/17 at 3:18 p.m., indicated .Complaints of general 'not feeling' well .with no specificity A Progress note, dated 11/18/17 at 1:47 p.m., indicated .Complain of not feeling well, states upset stomach A Progress note, dated 11/19/17 at 10:56 a.m., indicated .Resident states she was not feeling very well yesterday but does report feeling better today. Loose stools noted A Progress note, dated 11/20/17 at 7:29 p.m., indicated .C/O (complaint of) not feeling well and being weak. Ask for bed pan instead of going to the bathroom, too weak. [MEDICATION NAME] d/cd (discontinued) 11/9 and started on [MEDICATION NAME]. Could be adverse reaction, will ask AM shift to notify MD A Progress note, dated 11/21/17 at 12:37 p.m., .Resident states she doesn't feel well and is encouraged to take meds and eat and was effective A Progress note, dated 11/21/17 at 2:29 p.m., indicated .Resident continues to complain of not feeling well .MD notified A fax to the Physician, dated 11/21/17, indicated .has had increase c/o not feeling well/nauseous since the d/c (discontinue) of [MEDICATION NAME] (an antidepressant medication) may we reinstate order The Physician response was .d/c it A Progress note, dated 11/21/17 at 9:48 p.m., indicated .does state that doesn't feel well A Progress note, dated 11/22/17 at 10:21 a.m., indicated .Resident continues to appear tired no complaints of not feeling good thus far this shift will continue to monitor A Progress note, dated 11/22/17 at 9:43 p.m., indicated .Continues to feel weak and unable to get up with help to the bathroom A Progress note, dated 11/23/17 at 10:12 a.m, indicated .Resident continues to complain about feeling weak, writer encouraged resident to eat morning meal and take all meds. Meds taken and resident began eating her am meal will cont to monitor A Progress note, dated 11/24/17 at 9:33 p.m., indicated .Resident c/o not feeling well, states she is nauseous but no emesis. Appetite poor, fluid intake poor. Fluids encouraged. Refused meds at hs (bedtime), writer convinced resident to at least take her [MEDICATION NAME] because B/P (blood pressure) elevated. After [MEDICATION NAME] B/P went down a little .Will cont to monitor A Progress note, dated 11/25/17 at 1:00 a.m., indicated .Continues to c/o nausea. No emesis noted A Progress note, dated 11/25/17 at 4:19 a.m., indicated .After being toileted as CNA was about to assist resident back to bed. Resident appeared to have [MEDICAL CONDITION] which had two minute duration. During that time unable to respond verbally. VS (Vital Signs) after [MEDICAL CONDITION] activity 98.8--84--20--152/80. Stated did not feel well. Wanted to sit up in chair. After a few minutes asked to get back into bed. Assisted by staff into bed. Resting quietly at this time. (Name of Physician) notified via fax A Progress note, dated 11/25/17 at 10:12 a.m., indicated .Resident appeared slightly confused this morning A Progress note, dated 11/25/17 at 8:21 p.m., indicated .Resident has spent the majority of the shift in bed sleeping. General feeling of unwellness coming from resident but no specifics A Progress note, dated 11/26/17 at 6:08 p.m., .Resident flat affect. States she does not feel good although cannot specifically describe how she does not feel good. Complains of nausea but no presence of vomiting. Will contact MD to request orders. Will cont to monitor A Progress note, dated 11/27/17 at 10:42 a.m., .Resident with more decline in status, mentally and physically, daughter at bedside wishes to have resident sent to hospital, (Physician's name) notified and resident sent to (name of hospital) Review of the vital report in the Electronic Medical Administration Record (EMAR) indicated Resident 91 had her vitals signs obtained on 11/13/17 and 11/25/17. No other documented vitals were located in Resident 91's record for November. Resident 91 was only weighed one time in (MONTH) on 11/03/17. There was no other fax communications to the Physician located in Resident 91's record. A Situation Background Assessment Recommendation form (SBAR), dated 11/27/17, indicated the resident had altered mental status, was very weak, talked in a whisper when speaking or just stared. Daughter was at the bedside and requested mother be sent to the hospital. There was no other SBAR forms were located in Resident 91's record. Emergency Department (ED) notes, dated 11/27/17, indicated the resident did not have a history of [MEDICAL CONDITION] and presented in the ED for evaluation of increased confusion over the course of 1 week and .they report '[MEDICAL CONDITION] activity' over the last 2 days Resident 91 was admitted to the hospital for [MEDICAL CONDITIONS] exacerbation. During an interview, on 01/11/18 at 2:57 p.m., the Director of Nursing (DON) indicated she could not locate any lab work or MD notes for November. During an interview, on 01/11/18 at 4:00 p.m., the DON indicated she could not locate the fax to the MD on 11/25/17 only the nursing note which indicated he was faxed. During an interview, on 01/12/18 at 11:48 a.m., the Birchwood Unit Manager (UM) indicated if a resident had a change of condition the staff should have notified the doctor on call and obtained an order to be sent out to be evaluated. During an interview, on 01/16/18 at 1:59 p.m., the Birchwood UM indicated she could not locate SBAR related to Resident 91's [MEDICAL CONDITION]. Resident 91 did not have a [DIAGNOSES REDACTED]. A current facility policy titled Change of Condition dated 05/03/17, received from the Executive Director on 01/12/18 at 10:30 a.m., indicated .Examples of conditions identified that would indicate a Change of Condition and utilization of SBAR and MD/NP notification .[MEDICAL CONDITION]-Altered Mental Status/Sleeplessness .When to use? Issues that require physician notification .Decline from resident's baseline .Conditions that may require a possible transfer to hospital .Process .Completes the SBAR Communication form in EMR. Contact physician .Change of Condition .If message is left with the physicians office and a timely response is not given, follow up with another message .Document in the medical record physician notification 3.1-32(a)

Based on interview and record review, the facility failed to ensure the Medical Doctor (MD) was notified timely when residents had a significant change of condition for 3 of 3 residents reviewed for a change of condition (Resident 90, 91 and 14). Resident 90 cried out in pain for several days before her death without physician intervention, Resident 91 had multiple days of health complaints without physician intevention and was sent to hospital and admitted with [MEDICAL CONDITION] and Resident 14 had a pressure that worsened and became infected without physician intervention. Findings include: 1. The record for Resident 90 was reviewed on 01/11/18 at 10:20 a.m. [DIAGNOSES REDACTED]. A Progress Note, dated 10/06/17 at 5:31 p.m., indicated the Nurse Practitioner wrote orders per family request for comfort measures and to not transfer to the hospital and also wrote orders for [MEDICATION NAME] (a pain medication), [MEDICATION NAME] (an antianxiety medication) and [MEDICATION NAME] drops (used for excessive secretions) as needed. A physician's orders [REDACTED]. A Progress Note, dated 10/14/17 at 2:31 p.m., indicated .Resident in visible pain moaning, [MEDICATION NAME] 0.25 given per orders and helpful A Progress Note, dated 10/14/17 at 9:00 p.m., indicated .has had a change in condition weaker and in more pain prn (as needed) MSO4 ([MEDICATION NAME]) given twice and and effective A Progress Note, dated on 10/15/17 at 2:05 a.m., indicated .has had a change in condition is weaker and has more pain prn MSO4 is effective A Progress Note, dated on 10/15/17 at 9:00 p.m., indicated .Moaning and yelling out most of eve (evening) although I have given her Mso4 0.25 or 5 mg (milligrams) po (by mouth) q (every) hr (hour) and [MEDICATION NAME] 1 mg po still moaning slept very little this noc (night) so far A Progress Note, dated 10/16/17 at 2:46 a.m., indicated .Moved resident's roommate to another room so she could sleep resident still moaning and calling out despite amount of medication given will continue to observe A Progress Note, dated 10/15/17 at 2:00 p.m., indicated .Resident continues to call out in pain prn [MEDICATION NAME] given A Progress Note, dated 10/15/17 at 6:00 p.m., indicated .Resident continues to cry out in pain, prn pain med given and effective A Progress Note, dated as 10/16/17 at 2:25 p.m., indicated .Resident moaning in pain several times today gave prn [MEDICATION NAME], with short term effectiveness .Respirations ceased at 1010 hours . MD (medical doctor) and management notified There was no documentation the Physician was notified of the continued pain. There was no documentation of a Situation Background Assessment Recommendation (SBAR) form located indicating the continued pain was assessed or notified to the physician. Resident 90's care plan addressed the problem the resident was at risk for pain related to health decline/comfort measures. Approaches included, but were not limited to, .Report changes in pain location/type, Monitor for any changes in overall function and report to MD During an interview, on 01/12/18 at 11:33 a.m., the Director of Nursing (DON) indicated she could not locate any faxes sent to the MD in the month of (MONTH) other than the one on 10/12/17. During an interview, on 01/12/18 at 11:50 a.m., the Birchwood Unit Manager (UM) indicated if a resident was at the end stage of life and their pain was not being controlled the staff should have notified the MD or Hospice if the resident was on Hospice. During an interview, on 01/16/18 at 1:58 p.m., the Birchwood UM indicated a SBAR should have been completed and the MD called related to the resident's pain. A facility policy titled Pain Management dated as revised 11/28/17, received from the Executive Director on 01/12/18 at 10:30 a.m., indicated .If the pain medication is ineffective the pain will be evaluated and the SBAR will be completed prior to calling the physician for notification of unrelieved pain .Whenever the results of pain assessments reveal that the resident's pain is not under control, the attending MD/NP/PA should be notified 2. The record for Resident 91 was reviewed on 01/11/18 at 11:16 a.m. [DIAGNOSES REDACTED]. A Progress note, dated 11/12/17 at 3:18 p.m., indicated .Complaints of general 'not feeling' well .with no specificity A Progress note, dated 11/18/17 at 1:47 p.m., indicated .Complain of not feeling well, states upset stomach A Progress note, dated 11/19/17 at 10:56 a.m., indicated .Resident states she was not feeling very well yesterday but does report feeling better today. Loose stools noted A Progress note, dated 11/20/17 at 7:29 p.m., indicated .C/O (complaint of) not feeling well and being weak. Ask for bed pan instead of going to the bathroom, too weak. [MEDICATION NAME] d/cd (discontinued) 11/9 and started on [MEDICATION NAME]. Could be adverse reaction, will ask AM shift to notify MD A Progress note, dated 11/21/17 at 12:37 p.m., .Resident states she doesn't feel well and is encouraged to take meds and eat and was effective A Progress note, dated 11/21/17 at 2:29 p.m., indicated .Resident continues to complain of not feeling well .MD notified A fax to the Physician, dated 11/21/17, indicated .has had increase c/o not feeling well/nauseous since the d/c (discontinue) of [MEDICATION NAME] (an antidepressant medication) may we reinstate order The Physician response was .d/c it A Progress note, dated 11/21/17 at 9:48 p.m., indicated .does state that doesn't feel well A Progress note, dated 11/22/17 at 10:21 a.m., indicated .Resident continues to appear tired no complaints of not feeling good thus far this shift will continue to monitor A Progress note, dated 11/22/17 at 9:43 p.m., indicated .Continues to feel weak and unable to get up with help to the bathroom A Progress note, dated 11/23/17 at 10:12 a.m., indicated .Resident continues to complain about feeling weak, writer encouraged resident to eat morning meal and take all meds. Meds taken and resident began eating her am meal will cont to monitor A Progress note, dated 11/24/17 at 9:33 p.m., indicated .Resident c/o not feeling well, states she is nauseous but no emesis. Appetite poor, fluid intake poor. Fluids encouraged. Refused meds at hs (bedtime), writer convinced resident to at least take her [MEDICATION NAME] because B/P (blood pressure) elevated. After [MEDICATION NAME] B/P went down a little .Will cont to monitor A Progress note, dated 11/25/17 at 1:00 a.m., indicated .Continues to c/o nausea. No emesis noted A Progress note, dated 11/25/17 at 4:19 a.m., indicated .After being toileted as CNA was about to assist resident back to bed. Resident appeared to have [MEDICAL CONDITION] which had two minute duration. During that time unable to respond verbally. VS (Vital Signs) after [MEDICAL CONDITION] activity 98.8--84--20--152/80. Stated did not feel well. Wanted to sit up in chair. After a few minutes asked to get back into bed. Assisted by staff into bed. Resting quietly at this time. (Name of Physician) notified via fax A Progress note, dated 11/25/17 at 10:12 a.m., indicated .Resident appeared slightly confused this morning A Progress note, dated 11/25/17 at 8:21 p.m., indicated .Resident has spent the majority of the shift in bed sleeping. General feeling of unwellness coming from resident but no specifics A Progress note, dated 11/26/17 at 6:08 p.m., .Resident flat affect. States she does not feel good although cannot specifically describe how she does not feel good. Complains of nausea but no presence of vomiting. Will contact MD to request orders. Will cont (continue) to monitor A Progress note, dated 11/27/17 at 10:42 a.m., .Resident with more decline in status, mentally and physically, daughter at bedside wishes to have resident sent to hospital, (Physician's name) notified and resident sent to (name of hospital) There was no other fax communications to the Physician located in the record related to the resident's change in condition. A Situation Background Assessment Recommendation form (SBAR) dated 11/27/17, indicated the resident had altered mental status, was very weak, talked in a whisper when speaking or just stares. Daughter was at the bedside and requested mother be sent to the hospital. This was the only SBAR related to the change in condition located in the record. Emergency Department (ED) notes, dated 11/27/17, indicated the resident did not have a history of [MEDICAL CONDITION] and presented in the ED for evaluation of increased confusion over the course of 1 week and .they report '[MEDICAL CONDITION] activity' over the last 2 days Resident 91 was admitted to the hospital for [MEDICAL CONDITIONS] exacerbation. During an interview, on 01/11/18 at 2:57 p.m., the Director of Nursing (DON) indicated she could not locate any lab work or MD notes for November. During an interview, on 01/11/18 at 4:00 p.m., the DON indicated she could not locate the fax to the MD on 11/25/17 only the nursing note which indicated he was faxed. 3. The record for Resident 14 was reviewed on 01/17/18 at 6:10 a.m. [DIAGNOSES REDACTED]. Resident 14's care plan dated 10/27/14, addressed the problem she was at risk for developing skin breakdown related to incontinence, decreased mobility and gout. The approaches included, but were not limited to, .07/30/14- Refer to wound nurse as needed, refer to MD as needed .10/20/17- Do wound care as ordered for Stage 3 pressure ulcer, see current treatment record and physicians orders, observe effectiveness of response to treatment, observe for s/s (signs/symptoms) infection or delayed healing and report to MD: redness/[DIAGNOSES REDACTED], drainage/purulent or bloody drainage A Progress Note, dated 08/27/17 at 5:47 p.m., indicated .CNA reported res (resident) coccyx needed to be seen. Writer last saw area 8/24 site was 1/2 in (inch) abraised area on tip of coccyx, no redness or dung (drainage). Today noted large 6 cm round deep purple bruise with same 1/2 in abraised area with old crusted dung .Hospice aware .MD office aware A physician's orders [REDACTED]. The order was discontinued on 12/20/17. A Progress Note, dated 09/01/17 at 1:50 p.m., indicated .Buttocks reddened, bruise remains A Progress Note, dated 09/01/17 at 5:38 p.m., indicated .buttocks more reddened A Progress Note, dated 09/05/17 at 9:51 a.m., indicated .x2 macerated scabbed areas on sacrum. slight odor, covered with [MEDICATION NAME] padding, no bruising noted in sacral area A Progress Note, dated 09/07/17 at 1:18 p.m., indicated .x2 pressure site on res sacrum show no change A Progress Note, dated 09/09/17 at 10:48 a.m., indicated .wound on sacrum padded, black eschar covering site, has spread into horseshoe shape on sacrum A Progress Note, dated 09/09/17 at 5:30 p.m., indicated .Open area remains on coccyx A Progress Note, dated 09/10/17 at 1:25 p.m., indicated .wound at sacrum malodorous, eschar base et (and) horseshoe shape, padding in place A Progress Note, dated 09/12/17 at 12:30 p.m., indicated .sacral wound shows no improvement, padded for comfort, malodorous wound A Progress Note, dated 09/14/17 at 11:57 a.m., indicated .states sacrum painful .new dsg (dressing) to sacrum, site greatly malodorous, brown serous dung on old pad, wound base black et cont (continues) to expand at sacrum A Progress Note, dated 09/15/17 at 2:51 p.m., indicated .dsg changed to sacral wound, malodorous with mod (moderate) amt (amount) dung A Progress Note, dated 09/15/17 at 3:57 p.m., indicated .sacral wound malodorous et cont to drain A Progress Note, dated 09/16/17 at 10:43 a.m., indicated .sacral wound malodorous with slough. Covered with dressing A Progress Note, dated 09/16/17 at 5:18 p.m., indicated .dressing to coccyx. Mod amt dk (dark) red drainage on old dressing A Progress Note, dated 09/16/17 at 5:23 a.m., indicated .dressing changed to coccyx some foul odor noted cleansed area well A Progress Note, dated 09/18/17 at 1:42 p.m., indicated .wound to sacral area malodorous, no improvement There was no documentation in the record to indicate the Physician was notified of the worsening of the wound from/27/17 until 09/18/17. A Progress Note, dated 09/18/17 at 6:36 p.m., indicated .Hospice nurse did wound dressing this shift .new orders put in for [MEDICATION NAME] to wound bed A physician's orders [REDACTED]. The order was discontinued 10/27/17. A Progress Note, dated 09/19/17 at 1:48 p.m., indicated .tx (treatment to sacral wound, added [MEDICATION NAME] granules to wound for odor control, wound shows no improvement, appears deeper, mod dung on old pad A Progress Note, dated 09/22/17 at 6:37 p.m., indicated .wound continues with purulent and odorous drainage A Weekly Wound Sheet dated 09/26/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 9 x 3 x 1.8 cm and was a Stage 3. A Progress Noted dated 10/12/17 at 12:44 p.m., indicated .c/o (complaint of) sacral discomfort, Roxinal given with comfort A Progress Noted dated 10/14/17 at 5:40 a.m., indicated .Dressing to coccyx changed. Greenish discharge from wound, with foul odor A Progress Noted dated 10/17/17 at 12:31 a.m., indicated .Sacral wound with greenish colored drainage. Foul odor present A Weekly Wound Sheet dated 10/20/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 8 x 3 x 0.3 cm and was a Stage 3. A Progress Noted dated 10/23/17 at 10:38 a.m., indicated .wound to coccyx cleaned .Slight odor and moderate drainage noted . A Weekly Wound Sheet dated 10/26/17, indicated Resident 14 had a pressure ulcer to her coccyx not present on admission which measured 8 x 3 x 0.3 cm and was a Stage 3. A Progress Noted dated 10/27/17 at 1:28 p.m., indicated .Hospice nurse here, changed tx to coccyx with Alginate packing et [MEDICATION NAME] dsg daily et PRN (as needed) soilage A physician's orders [REDACTED]. There was no documentation in the record to indicate the Physician was notified of the wounds response to the treatment from 09/18/17 to 10/27/17. During an interview on 01/12/18 at 11:48 a.m., the Birchwood Unit Manager (UM) indicated if a resident had a change of condition the staff should have notified the doctor on call and obtained orders. A current facility policy titled Change of Condition dated 05/03/17, received from the Executive Director on 01/12/18 at 10:30 a.m., indicated .Examples of conditions identified that would indicate a Change of Condition and utilization of SBAR and MD/NP notification .[MEDICAL CONDITION]-Altered Mental Status/Sleeplessness .When to use? Issues that require physician notification .Decline from resident's baseline .Conditions that may require a possible transfer to hospital .Process .Completes the SBAR Communication form in EMR (Electronic Medical Record). Contact physician .Change of Condition .If message is left with the physicians office and a timely response is not given, follow up with another message .Document in the medical record physician notification 3.1-5(a)(2) 3.1-5(a)(3)

Based on interview and record review, the facility failed to follow facility policy for elopement of a resident who eloped and was outside the facility for greater than 20 minutes with whereabouts unknown for 1 of 1 residents reviewed for elopement (Resident B). The facility also failed to ensure all door alarms were functional for 1 of ??doors observed and failed to ensure the facility elopement book had current information for residents deemed an elopement risk for 2 of 5 resident reviewed for elopement. (Resident E and C) The Immediate Jeopardy began on 1/27/2017 when the facility failed to follow their elopement policy to thoroughly check resident whereabouts when a door alarm sounded. The resident exited the building through the front door and was not identified as having eloped for greater than 20 minutes. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 2/9/2017 at 3:30 p.m. The Immediate Jeopardy was removed on 2/10/2017, but noncompliance remained at a lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During an interview on 2/7/2016 at 7:00 a.m., with the Director of Nursing, she indicated she was aware of elopement on 1/27/2017 of Resident B. She indicated the resident search had not been done per procedure when the door alarm sounded at 4:00 a.m. She indicated the resident's wanderguard was not in place and had been located under the residents bed when she was returned to the facility by a staff member. She indicated the front door alarm had sounded and the staff had looked at the video feed for the front door and staff had looked outside of the facility bear the front door but then staff turned off alarm and did nothing else until the resident was returned to facility by a staff member at 4:22 a.m., on 1/27/2017. The staff then conducted the resident search per protocol for a missing resident. The DON indicated when a door alarm sounded, staff should notify a supervisor, look at the video feed for exit door that alarmed, look outside the facility of door that alarmed for residents and then check that all residents are present in facility. The clinical record of Resident B was reviewed on 2/9/2017 at 12:15 p.m. [DIAGNOSES REDACTED]., hypertension and restless leg syndrome. The resident had moderate cognitive impairment and a BIMS (Brief Interview of Mental Status) of 9 per Minimum Data Set (MDS) assessment on 1/17/2017. Resident B resided on the Birchwood Unit. The resident care plan dated 1/29/2016 indicated Resident B was at risk for impaired cognitive skills due to Parkinson's, Alzheimer's and dementia, and she had a wanderguard. Nursing progress note dated 1/27/2017 at 4:30 a.m., indicated resident was returned to the facility, head to toe assessment was completed, resident had a 2.0 centimeter (cm) slit to right side of the nose and a 2.3 cm slit right above the eye areas. The areas were cleansed with normal saline and the resident had small bruise to her right hand, 2.6 cm x 4 cm and purple in color. The resident's hands were cool, but torso and extremities were warm to touch, no signs of exposure on the resident. A nursing assessment report for Resident B, dated 1/27/2017 at 4:15 a.m., indicated Resident B was found on the road approximately .324 miles (1,710 feet) from the facility by the Unit Manager #12 on her way to work at 4:15 a.m. Resident B was found on the side of road with her rolling walker on the side of road with the resident. Resident B was assisted to Unit Manager #12 car by passing police officer. Resident B was returned to the facility and assessed. Resident had lacerations and bruising which were addressed by the staff. Doctor and Family were notified. The resident vital signs included blood pressure 111/53, pulse 64, respirations 18, oxygen saturation 99% and temperature was 97.9 degrees. Resident was not taken to the hospital/emergency room . Patient examination indicated contusion on right forehead, abrasion to right lower eyelid, bruising right lower eyelid, abrasion right lower extremity and head trauma. During an interview on 2/7/2017 at 8:00 a.m., with Unit Manager #12, she indicated she was traveling to work and saw the resident on the side of the road near the facility and assisted the resident to the facility. When resident B was returned to the facility a resident missing person protocol was initiated. All residents were in facility. Resident B was assessed for bruising and lacerations. Resident B was wearing socks and shoes, sweater, long sleeve dress and sweat pants. Unit Manager #12 indicated the outside temperature when she found Resident B was 29 degrees, and the resident's hands were cool to touch but her body was warm. Resident temperature was 97.7 degrees when taken upon return to the facility. Resident B was alert and responsive and did not complain of pain. During an observation with the Executive Director (ED) on 2/9/17 at 11:30 a.m., at the Cedarwood Unit Nursing station, the front door alarm was triggered to go off and the alarm panel was observed to light up as front door. The video monitor also showed the individual who triggered the alarm pushing on the door for 15 seconds then the door released and the individual was able to walk outside. At this time during interview, he indicated if staff were not at the nursing station, there could be a time lapse in response to the alarm. He indicated if a door alarm sounded, the staff would check the video feed, go to the door activated, check outside and then do a head count. He indicated when Resident B eloped, the staff did not follow the elopement policy. During an interview with the DON on 2/9/17 at 11:50 a.m., she indicated the policy was not followed with Resident B eloped. She indicated some residents went outside independently and the alarms would sound and the staff had gotten used to hearing the alarms. During an interview with LPN # 8 on 2/9/17 at 12 p.m., she indicated she was working on Birchwood Unit the night Resident B eloped from the facility. She indicated there were 2 nurses and 2 CNA's on the unit working. Resident B was visualized around 3:45 a.m., ambulating in the hallway with her rollator walker. The walker had stuff packed on top of the seat and this was the resident normal routine to be up through the night and pack her items. She indicated she walked very rapidly and was difficult to keep up with. LPN # 8 indicated Birchwood unit did not have an alarm panel to hear if a door alarm was sounding in the building. She indicated there was a wander guard alarm panel to alert if a resident with a wander guard came close to the doors. There were 4 resident's on Birchwood that wandered. The night Resident B eloped, she was unaware the door alarm had sounded until she was walking to the Cedarwood Unit to relieve the nurse on duty for a break. As she was walking there, she heard the Cedarwood Unit nurse, LPN # 10 yell to go to the front door because an incoming staff member was bringing Resident B back into the facility. During an telephone interview with CNA #9 on 2/9/17 at 2 p.m., she indicated she was working Cedarwood Unit with LPN# 10 the night Resident B eloped. This was not the usual staffing, and there were usually 2 nurses and 1-2 CNA's on the unit during the night. She was coming out of a resident's room, when she heard the alarm and LPN # 10 told her to go turn the alarm off at the front door. She went to the front door, stepped a few steps out the front door, came back inside and turned off the alarm, then returned to the unit. She indicated Cedarwood did not have anyone up or wandering at that time. She continued her normal duties on and she not instructed by LPN # 10 to do anything else. During a telephone interview with LPN # 10 on 2/9/17 at 2:10 p.m., she indicated she was working with CNA # 9 on the Cedarwood unit on the night Resident B eloped. She indicated there were usually 2 nurses and 1-2 CNA's working on the unit,but this night there were only one nurse and one CNA. The alarm sounded at 4 a.m., for the front door, she checked the video and did not see anyone at the door, and sent the CNA to turn off the alarm. The CNA returned and indicated she did not see anyone. There were no residents up or wandering on the unit and she had no idea if any residents were up and wandering on the Birchwood Unit. She did not notify the Birchwood unit the alarm had sounded. She indicated there was a resident that went in and out on the front door during the night and the alarm sounding was normal. The policy was to do a head count and she did not do that. During an observation and interview with the Executive Director on 2/9/17 at 2:15 p.m., the front door alarm was triggered the facility staff and the Birchwood Unit alarm panel was observed. The light for the front door lit up red, but there was no audible alarm and no video feed of the front door. The ED indicated the staff were trained at Cedarwood to check the video and alarm at the Cedarwood Unit. There was no system to alert the Birchwood staff a door alarm was sounding except for the 3 exit doors on that unit. When queried if Cedarwood communicated with Birchwood when a door alarm sounded, he indicated there was no communication between the units when the alarm sounded. He indicated the nurse did not follow the policy. 2. During an interview and observation on 2/7/2017 at 11:20 a.m., with the Plant Operations Director, the exit door to the therapy room/backdoor entrance to the facility did not alarm. The door alarm to the outside area of the facility located in the dining area was too weak to hear past the dining room area. 3. During a record review on 2/7/2017 at 2:30 p.m., of the Elopement Protocol Books located at the Front Desk, Birchwood and Cedarwood Nursing Desks, two of the five profiles for the facility five residents who were elopement risks and utilized wanderguards were incorrect. a. Resident E was located on 2/9/2017 to be in room 135 on the Birchwood unit and the elopement book profile indicated he was in room 213. The clinical record of Resident E was reviewed on 2/10/2017 at 10:15 a.m. [DIAGNOSES REDACTED]. The resident had moderate cognitive impairment and a BIMS of 11 per MDS assessment on 12/29/2016. The resident care plan dated 9/22/2016 indicated Resident E was at risk for moderately impaired cognitive skills due to Parkinson's, and dementia, and he had a wanderguard. b. Resident C was located on 2/9/2017 to be in room 131 on the Birchwood unit and the elopement book profile indicated she was in room 230. The clinical record of Resident C was reviewed on 2/10/2017 at 9:45 a.m. [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and a BIMS of 4 per MDS assessment on 12/15/2016. The resident care plan dated 10/25/2016 indicated Resident C was at risk for severely impaired cognitive skills due to dementia, and she had a wanderguard. During an interview on 2/9/2017 at 3:10 p.m., with the Social Services #6 staff member, she indicated she had completed a review of the five resident profiles who were elopement risks on 2/7/2017 and had updated their records. She indicated she had not thought to change there room assignments on the profiles when they changed rooms. A policy titled Missing Resident dated 07/13/2016 was provided by the DON on 2/9/2017 at 1:30 p.m., and deemed as current. She indicated at this time, if an alarm sounded the staff should think of a missing resident and follow the policy. The policy indicated: .7. An exhausted search of the facility will be conducted to include the following: 1. Check all resident rooms including vacant rooms .5. Outside the facility shall be searched, to include the parking lots, and all the grounds surrounding the facility The Immediate Jeopardy began on 1/27/2017. The Immediate Jeopardy was removed on 2/10/2017 but the noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the need for ongoing staff training. and implementation practices and secuity monitor installement on Birchwood unit. The surveyor confirmed the following by observation, interview and record review: 1. 1/27/2017: The resident was assessed by physician and placed on 24 hour 1 to observation. Wanderguard was replaced and checked and working appropriately and resident was then transferred to a closed facility on 1/27/2017. 2. 1/27/2017 All door and alarms were checked by the Plant Operations Director (POD). All wanderguards were checked by Unit Manager #12. All doors, alarms and wanderguards were functioning properly. 3. 1/27/2017-2/3/2017 All staff inservicing was completed related to elopement policy and procedure prior to reporting for shift. 4. 1/27/2017 All door codes were changed and will continue to be changed monthly by the POD. 5. 1/27/2017 thru 1/30/2017 elopement drills were conducted every shift and are ongoing randomly during the month of February. Then the elopement drill will be conducted with fire drills on a monthly schedule. 6. 1/27/2017 Elopement risk re-assessments completed for all residents. 7. 2/10/2017 All elopement books were reviewed and updated. Elopement books were located at each nursing station and the front desk. 8. 2/9/2017 thru 2/17/2017 Staff were assigned to observe video and audio monitor on Cedarwood Unit for exits from the facility from 5:00 p.m., until 8:00 a.m. each day. 9. 2/10/2017 (Name of Alarm Company) were at facility to check all alarms and install an alarm sounding device on the Birchwood Unit of the facility. Through record review and interview, nursing, dietary, activity, therapy, laundry and housekeeping staff were able to identify the steps to take, in the event of sounding door alarms, missing resident and indicated they had participated in inservicing and facility elopement drills. On 2/10/2017 at 1:03 p.m. an observation of an elopement drill indicated all staff participating were following facility elopement procedures. This Federal tag related to complaints IN 115 and IN 250 . 3.1-45(a)(2)