Every finding on record at Majestic Care of Newburgh

Based on observation, interview, and record review, the facility failed to ensure physicians' orders were followed for 2 of 3 residents reviewed for medications. Medications were observed at a resident's bedside table; the medication was held without a physician's order. ( Resident B, Resident D) Findings include:On 7/30/25 at 9:44 a.m., a medication cup with pills inside was observed sitting on Resident B's bedside table. Resident B indicated she does not take her medications until she eats her breakfast. On 7/30/25 at 10:36 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, hypertensive heart disease and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, Parkinson's disease with dyskinesia, and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated cognition intact.Care plans were reviewed and included, but were not limited to: [Resident B] is at risk for complications related to medical conditions, medications, and treatments. Interventions included, but were not limited to: medications and treatments per physicians' orders, initiated 9/1/25, revised 5/20/25. Physicians' orders for June and July 2025 were reviewed and included but were not limited to:Carvedilol (hypertensive medication) oral tablet 6.25 mg (milligram) tablet by mouth two times a day related to hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, unspecified chronic kidney disease, order date 11/18/24. The Electronic Medication Administration Record (EMAR) for June and July 2025 was reviewed for the above medication. The following dates and times were not signed as given and had code 4 documented. The code list on the EMAR indicated code 4 was for vitals outside of parameters for administration. June 20256/1- 6:30 a.m., no B/P recorded6/5- 6:30 a.m., no B/P recorded6/7- 6:30 a.m., no B/P recorded6/9- 6:30 a.m., B/P 116/486/11- 6:30 a.m., no B/P recorded6/15- 6:30 a.m., no B/P recorded6/16- 6:30 a.m., B/P 95/546/18- 6:30 a.m., no B/P recordedJuly 20257/9-6:30 a.m., no B/P recorded6/11-6:30 a.m., no B/P recorded6/23- 6:30 a.m., no B/P recorded2. On 7/30/25 at 1:30 p.m., resident report of concern forms were reviewed and included but were not limited to: Incident date: 5/30/25Affected Resident: Resident DDescription of Concerns: I woke up at 4 AM, meds on OBT (over bed table), I took them-then the nurse brought my morning meds to me at 6 AM- Too close together. I want to be awaken to take my pills if I'm asleep. Follow-up/Resolution: Corrective Action Taken:Staff educated not to leave meds @ beside Complainant notified on 6-3-25 On 7/31/25 at 8:38 a.m., a medication cup with pills inside was observed sitting on Resident B's bedside table. Resident B indicated that they were her morning medications and she would take them when she was done eating her breakfast. On 7/31/25 at 8:42 a.m., RN 2 indicated that when giving medications to a resident, the staff are supposed to stay in the room until the resident has taken the medications. There is no reason that a medication should be left on the bedside table when staff leave the room. On 7/31/25 at 9:06 a.m., Resident D indicated some nurses leave her medications and leave the room, some nurses stay until she takes them. On 7/31/25 at 9:17 a.m., LPN 2 indicated she did not see any B/P parameters on Resident B's physician's orders to hold the medication; she would have to check with the physician or nurse practitioner. On 7/31/25 at 11:27 a.m., the Administrator provided the current policy for medication administration, with a reviewed date of 12/12/23. The policy included but was not limited to: .8. Obtain and record vital signs, when applicable or per physician's orders. When applicable, hold medications for those vital signs outside the physicians' prescribed parameters .15. Observe resident consumption of medication .23. Unless the resident has been assessed for safe self-administration of medications, medications are not to be left unattended for the resident to consume at a later time .This citation relates to Complaint 2566732.3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the dishwasher was sanitizing dishes properly and staff knew how to properly test for sanitization for 1 of 1 kitchens in the facility. (Kitchen) Finding includes: During an observation on 6/29/25 at 8:15 A.M., the Kitchen Manager ran a dishwasher cycle. The wash cycle reached 155 degrees Fahrenheit (F), the rinse cycle reached 138 degrees F, and the sanitization level on the chlorine test strips read zero parts per million (ppm). The Kitchen Manager indicated the dishwasher was a low temperature dishwasher and the dishwasher sanitization had been testing fine the night before. Kitchen staff continued to put dishes through the dishwasher. During an observation on 6/29/25 at 12:58 P.M., staff members were observed serving lunch on dishes ran through the dishwasher. During an interview on 6/29/25 at 2:15 P.M., the Administrator indicated when the dishwasher was not working properly, staff should be hand washing dishes in the three-compartment sink or using disposable dishes to serve meals on. During an observation on 6/29/25 at 2:26 P.M., the Kitchen Manager indicated kitchen staff were now using the three-compartment sink to wash dishes. During an observation on 6/30/25 at 10:27 A.M., the Kitchen Manager showed a chlorine test strip that read between 50-100 ppm. The Kitchen Manager provided a Service Request that indicated the dishwasher sanitization pump was fixed and the dishwasher was in working order again. During an observation on 7/2/25 at 10:18 A.M., kitchen staff indicated it was hard to test the dishwasher sanitization. Staff had to put their hand under the running hot water inside the dishwasher to test for sanitization. The chlorine test strip read zero ppm. The Kitchen Manager asked the Dietitian for suggestions on how to test the water without burning her hand and the Dietitian indicated she was unfamiliar with how that dishwasher worked. During an observation on 7/2/25 at 2:03 P.M., staff were observed serving lunch on dishes washed through the dishwasher that morning. During an observation on 7/3/25 at 8:37 A.M., the dishwasher manufacturer representative was in the facility and indicated the dishwasher was in working order again and that the sanitization was reading 50-100 ppm. The Kitchen Manager indicated the dishwasher manufacturer representative showed staff how to properly test if the dishwasher sanitization was working. On 6/29/25 at 2:15 P.M., the Administrator provided a policy titled Sanitization, dated 10/08, that indicated Dishwashing machines must be operated using the following specifications: Low Temperature Dishwasher (Chemical Sanitization) a. Wash Temperature 120 degrees F, b. Final rise with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure residents dependent on staff for assistance with activities of daily living (ADL) tasks were provided showers or baths for 4 of 5 residents reviewed for ADL care. (Resident 27, Resident 97, Resident 11, and Resident 36) Findings include: 1. During an interview on 6/29/25 at 9:37 A.M., Resident 27 indicated he hadn't had any baths lately. Resident 27 had a strong, pungent smell surrounding him. On 6/30/25 at 10:06 A.M., Resident 27's clinical record was reviewed. Resident 27 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus. The most recent Annual Minimum Data Set (MDS) Assessment, dated 5/28/25, indicated Resident 27 was cognitively intact and dependent on staff for toileting, bathing, and transfers. The Point of Care (a charting system for Certified Nurse Aides) Task Response indicated Resident 27's scheduled shower days were Tuesday and Friday. The Point of Care ADL report and written shower sheets indicated Resident 27 had not received or refused a shower or complete bed bath on the following days during June 2025: 6/3/25 6/10/25 2. On 6/30/25 at 8:41 A.M., Resident 97's clinical record was reviewed. Resident 97 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus. The most recent admission Minimum Data Set (MDS) Assessment, dated 6/12/25, indicated Resident 97 was cognitively intact and required substantial assistance (staff does at least half of the effort) from staff for toileting and bathing. The Point of Care (a charting system for Certified Nurse Aides) Task Response indicated Resident 97's scheduled shower days were Sunday and Thursday. The Point of Care ADL report and written shower sheets indicated Resident 97 had not received or refused a shower or complete bed bath on the following days during June 2025: 6/8/25 3. During an interview on 6/29/25 at 12:52 P.M., Resident 11 indicated she was supposed to get her showers in the morning on Mondays and Thursdays. She indicated that she preferred her showers in the mornings due to seizures that often occurred in the afternoon. She indicated that she didn't always get showers twice a week. On 6/30/25 at 1:38 P.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, epilepsy. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 4/9/25, indicated Resident 11 was cognitively intact and required partial to moderate assistance of staff (staff does less than half of the effort) for bathing. An Activity Preferences Interview, dated 9/18/24, indicated that it was very important for Resident 11 to choose between a shower and a bed bath. A care plan conference was conducted on 6/12/25. Care plans were reviewed. Current care plans included, but were not limited to: Resident 11 needs assistance with activities of daily living related to cognitive impairment, seizure disorder, chronic pain, dated 9/13/23 The Point of Care (a charting system for Certified Nurse Aides) Task Response for Showering indicated Resident 11 received showers on Mondays and Thursdays during the day. The Point of Care ADL report and written shower sheets indicated Resident 11 had not received or refused a shower or complete bed bath on the following days during June 2025: 6/5/25 6/9/25 6/12/25 4. During an interview on 6/29/25 at 10:24 A.M., Resident 36 indicated she preferred bed baths. She indicated she was not sure what days she was supposed to get them but was often told by staff that they would get to her if they had time. She indicated she did not receive a bed bath twice a week. At that time, Resident 36's hair looked oily. On 6/30/25 at 2:23 P.M., Resident 36's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease (ESRD). The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 4/22/25, indicated that Resident 36 was cognitively intact and required substantial to maximal assistance of staff (staff does more than half of the effort) for bathing. An Activity Preferences Interview, dated 7/18/24, indicated that it was very important for Resident 36 to choose between a shower and a bed bath. A care plan conference was conducted on 5/1/25. Care plans were reviewed. Current care plans, included, but were not limited to: Resident 36 needs assistance with activities of daily living related to asthma, ESRD with hemodialysis, diabetes, dated 7/12/24 The Point of Care (a charting system for Certified Nurse Aides) Task Response for Showering indicated Resident 36 received bed baths on Sundays and Thursdays during the day. The Point of Care ADL report and written shower sheets indicated Resident 36 had not received or refused a shower or complete bed bath on the following days during June 2025: 6/12/25 6/29/25 During an interview on 7/2/25 at 8:53 A.M., Certified Nurse Aide (CNA) 11 indicated that residents got showers twice a week. If they refused, the aide asked twice and then the nurse would ask a third time. All showers, bed baths, and refusals got documented on a shower sheet and in Point of Care. On 7/3/25 at 10:04 A.M., the Administrator provided a Showers policy, dated 1/2/24, that indicated It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice . Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedules as per facility policy. 3.1-38(a)(2)(A) 3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and labeled for 4 of 5 medication carts reviewed and 1 treatment cart reviewed. (100 Hall Cart 1, 100 Hall Cart 2, 200 Hall Cart 1, 200 Hall Cart 2, 100 Hall Treatment Cart) Findings include: 1. On 6/29/25 at 8:00 A.M., the following loose pills and liquid medications were observed in 100 Hall Cart 1: 1 oblong white pill with numbers 1222 1 round white pill with the letter AM and numbers 520 1 blue oblong pill with letter ARI and number 5 1 small round peach pill 1 small round white pills with the number 15 1 large brown capsule 1 round white pill with the number 745 1 oval white pill with the number 22 1 small round white pill 1/2 small round white pill 1 small round peach pill 1 large white pill- Potassium 1 small white pill with letter A 1/2 oblong lavender pill 1 small white pill with the number 122 1 blue-green oblong with the number 54 1 large white pill 3 containers of Clearlax with no open date 1 container of Milk of Magnesia with a large number of dried drippings 1 drawer with numerous spots of sticky red colored fluid on the bottom 2. On 6/29/25 at 8:31 A.M., the following loose pills were observed in 100 Hall Cart 2: 1 large round white pill with letters TCL and numbers 34 1 large round white pill with letters ATY and numbers 40 1 medication cup with 10 loose pills with no name or room number on the cup 1 small oval white with the letter LS and number 1 1 white capsule 1 peach oval pill with the letters LUPT with Numbers 30 1 small white pill 1 blue oval with letters [NAME] and numbers 571 1 large oblong white with numbers 16 1 small white oval with numbers 124 1 blue oblong pill with letters CL and numbers 29 1 large round white pill with the letters AL 1 large round white pill with the letters TLL and numbers 340 1 large orange capsule 3. On 6/29/25 at 8:45 A.M., the following liquid medications were observed in the 200 Hall Cart 1: 1 bottle of Milk of Magnesia with no open date 1 bottle of Milk of Magnesia with an expiration date of 2/25/25 4. On 6/29/25 at 9: A.M., the following loose pills and liquid medication were observed in the 200 Hall Cart 2: 1 large round oval with numbers 0005 1 bottle of chest congestion liquid with no open date 5. On 6/30/25 at 6:30 P.M., the following undated creams were observed in the Treatment Cart of the 100 Hall: House moisture cream with no label or open date Diflucan (Antifungal Cream) 1 Percent (%) with no open date During an interview on 6/29/25 at 8:15 A.M., Licensed Practical Nurse (LPN) 27 was not aware of how often to check the carts. She had never been shown how to do it. During an interview on 6/29/25 at 8:30 A.M., Qualified Medication Aide (QMA) 21 indicated there should be open dates on medications when opened. QMA 21 indicated she was not aware what the pills where in the medication cup or who they belonged to. She indicated that she would have to contact her charge nurse. During an interview on 6/29/25 at 8:46 A.M., LPN 23 indicated expired medications should be thrown away. During an interview on 6/30/25 at 6:35 P.M., QMA 21 indicated that house stock should have a resident name and open date on it. On 7/3/25 at 10:04 A.M., the Administrator provided a current Labeling of Medication policy, dated 2/22/22, that indicated .medications should be labeled with open date .medications will have a small auxiliary label attached . On 7/3/25 at 10:04 A.M., the Administrator provided a current Expiration Dating policy, dated 2/22/22, that indicated .medication must be checked by the facility regularly for expiration dates and deterioration .expired medication will be removed from use and destroyed per facility policy and procedures . On 7/3/25 at 10:04 A.M., the Administrator provided a current Medication Administration policy, dated 1/2/24, that indicated .medications are administrated by licensed nurses, or other staff authorized .as ordered by the physician and in accordance with professional standards of practice .observe resident consumption of medication . medications are not left unattended . 3.1-25(b)(4) 3.1-25(k) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were implemented during laundry services during 1 of 1 observations of laundry services. (Laundry Room) Finding includes: During an observation on 7/1/25 at 11:12 A.M., the Corporate Manager emptied the washer without wearing an apron and items in the washer were placed against her shirt and top of pants as well as her arms. During an interview on 7/3/25 at 9:22 A.M., the Director of Nursing indicated that when staff transferred clean laundry they should ensure laundry was not touching their uniforms. On 7/3/25 at 10:04 A.M., the Administrator provided a policy titled Personal Laundry Handling and Processing, dated 1/25, that indicated Items should be moved from the washer to the dryer as promptly as is practicable in a manner that minimized the risk of contamination and/or re-soiling. 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure as needed (PRN) medications administered by a Qualified Medication Aide (QMA) were preauthorized by a licensed nurse for 2 of 5 resident reviewed for unnecessary medications. (Resident 66 and Resident 87) Findings include: 1. On 6/30/25 at 11:09 A.M., Resident 66's clinical record was reviewed. Diagnoses included, but were not limited to, gastroesophageal reflux disease (GERD). The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 5/15/25, indicated Resident 66 was cognitively intact and required setup assistance for eating. Current physician orders included, but were not limited to: ondansetron (an antinausea medication) 4 milligrams (mg) - Give one tablet by mouth every six hours as needed (PRN) for nausea and vomiting, dated 2/19/25 Resident 66's Medication Administration Record (MAR) from 5/1/25 through 6/30/25 included, but was not limited to, the following dates that ondansetron 4 mg PRN was administered by a QMA without authorization from a licensed nurse: 5/10/25 at 11:33 A.M. given by QMA 15 6/9/25 at 11:54 A.M. given by QMA 3 2. On 6/30/25 at 8:45 A.M., Resident 87's clinical record was reviewed. Diagnoses included, but were not limited to, generalized anxiety disorder and osteoarthritis. The most recent Annual Minimum Data Set (MDS) Assessment, dated 5/9/25, indicated Resident 87 had severe cognitive impairment, required setup assistance for eating, and received an antianxiety medication during the 7-day look back period. Physician orders included, but were not limited to: lorazepam (an antianxiety medication) - Give 0.5 milligrams (mg) by mouth every 24 hours as needed (PRN) for generalized anxiety disorder, dated 4/28/25 with a stop date of 5/5/25 Tylenol Arthritis Pain Extended Release (a pain reliever) - Give 650 mg by mouth every 24 hours PRN for arthritis pain, dated 4/23/25 Resident 87's Medication Administration Record (MAR) from 5/1/25 through 6/30/25 included, but was not limited to, the following dates that lorazepam 0.5 mg PRN was administered by a QMA without authorization from a licensed nurse: 5/1/25 at 12:17 P.M. given by QMA 3 5/4/25 at 5:17 P.M. given by QMA 5 Resident 87's Medication Administration Record (MAR) from 5/1/25 through 6/30/25 included, but was not limited to, the following dates that Tylenol 650 mg PRN was administered by a QMA without authorization from a licensed nurse: 5/13/25 at 12:17 P.M. given by QMA 7 6/13/25 at 8:04 A.M. given by QMA 9 During an interview on 7/2/25 at 8:51 A.M., QMA 5 indicated that a QMA must have nurse authorization before administering a PRN medication and that authorization was documented in a progress note. On 7/3/25 at 10:04 A.M., the Administrator provided a Qualified Medication Aide Job Description, dated March 2025, that indicated Administer PRN drugs, as allowed, when authorized by a licensed nurse . Keep medical records current by charting pertinent resident conditions timely and routine charting as scheduled, with co-signature by a licensed nurse. On 7/3/25 at 10:04 A.M., the Administrator provided an undated Qualified Medication Aide Scope of Practice that indicated Administer previously ordered pro re nata (PRN) medication only if authorization is obtained from the facility's licensed nurse on duty or on call. If authorization is obtained, the QMA must do the following: . Document in the resident record that the facility's licensed nurse was contacted, symptoms were described, and permission was granted to administer the medication, including the time of contact . 3.1-35(g)(2)

Based on observation, record review, and interview, the facility failed to ensure care according to professional standards of a gastro/jejunal feeding tube (G-Tube) in 1 of 1 residents reviewed for tube feeding. The resident was not checked for residual as ordered prior to feedings. (Resident 44) Finding includes: On 6/30/25 at 11:15 A.M., Licensed Practical Nurse (LPN) 17 was observed administering a feeding to Resident 44 via his G-Tube. LPN 17 did not check for residual prior to the administration. On 6/30/25 at 10:00 A.M., Resident 44's clinical record was reviewed. Diagnoses included, but were not limited to, tracheostomy, neoplasm of larynx, and dysphagia, oropharyngeal phase. The current Quarterly Minimum Data Set (MDS) Assessment, dated 5/12/25, indicated Resident 44 was cognitively intact. The resident had a feeding tube, and needed supervision of staff for hygiene, dressing, and transferring Current physician orders included, but were not limited to: Enteral feed, five times a day, administer 250 milliliters (ml), TwoCal HN 2.0 (a nutritionally complete, high-calorie formula) by gravity. Check placement of G-Tube prior to administration of medication and tube feeding, hold feeding for residual greater than 150 ml, dated 5/19/25. A risk for complications of tube feeding care plan, dated 2/6/25, included, but were not limited to, the following interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record, dated 2/6/25. Tube feeding and water flushes as per physician orders, dated 2/6/25 During an interview on 6/30/25 at 11:15 A.M., LPN 17 indicated she did not always check residuals before the feedings. During an interview on 06/30/25 5:40 P.M., a family member indicated that staff did not always check residuals prior to administering feedings and medications. During an interview on 7/1/25 at 10:00 A.M., the Director of Nursing (DON) indicated that staff should check residuals prior to each feeding. On 7/3/25 at 10:04 A.M., the Administrator provided a current Enteral Feeding policy, dated 1/2/24, that indicated .in accordance with the facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location, tube placement will be verified before beginning a feeding and before administrating medications . 3.1-47(a)(2)

Based on observation, record review, and interview, the facility failed to ensure proper airway management for 1 of 1 residents reviewed with a laryngectomy. A self-assessment for care was not performed, documentation was not accurate, and the facility did not have the correct parts for the laryngectomy tube ([NAME] Tube). (Resident 44) Finding includes: On 6/29/29/25 at 11:00 A.M., Resident 44's [NAME] Tube was observed laying on the resident's bed. The resident realized it was out and the resident placed it back into the laryngectomy stoma (surgical incision and removal of the larynx). On 6/30/25 at 10:00 A.M., Resident 44's clinical record was reviewed. Diagnoses included, but were not limited to, tracheostomy, neoplasm of the larynx, esophageal fistula post tracheostomy, and absence of the larynx. The current Quarterly Minimum Data Set (MDS) Assessment, dated 5/12/25, indicated Resident 44 was cognitively impaired. Resident 44 had a laryngectomy, had a g-tube for tube feeding, and needed supervision with hygiene, transferring, and dressing. Current Physicians orders: If [NAME] tube TPE (tracheoesophageal Puncture) outer part of [NAME] tube comes out place red rubber catheter in place and send to ER every day and night shift ordered 2/10/2025 [NAME] tube monitoring: monitor for placement and function of [NAME] tube every shift every shift ordered 2/11/2025 Monitor [NAME] site for s/sx (signs and symptoms) of infection every shift every shift ordered 2/11/2025 stoma site to be cleansed with normal saline around TPE; remove [NAME] tube and cleanse with NS (Normal Saline) and reinsert every day and night shift ordered 2/25/2025 ENHANCED BARRIER PRECAUTIONS: Gloves and gown prior to the high-contact care activity. Face protection when performing activity with risk of splash or spray. (Change PPE [Personal Protective Equipment] and complete hand hygiene prior to caring for another resident). every shift for PEG, [NAME]-tube ordered 3/5/25 The clinical record lacked physician orders for the resident to perform his own stoma care. The care plans were reviewed in a care plan conference on 5/5/25. The care plan lacked an intervention that indicated the resident was capable of performing his own stoma care. A [name of hospital] Speech Pathologist progress note, dated 2/4/25, indicated that the resident was educated on laryngectomy care, voice prosthesis insertion, and other products. The note indicated that the patient and a family member would keep the integrity of the fistula and would keep it clean. The Speech Pathologist indicated that the resident was not independent with care and was interested in placement in a Skilled Nursing Facility due to the amount of care that the resident needed. There was no documentation that noted the resident was assessed or observed the resident skills for caring for the stoma. The resident was admitted to the facility on [DATE]. A nursing admission note, dated 2/5/25, indicated that the resident had a tracheostomy and not a laryngectomy. The note lacked measurement and assessment of the stoma. A [name of hospital] Speech Pathologist progress note, dated 2/11/25, indicated that the resident had thick secretions and developed an abscess in the stoma which was irritated by the [NAME] Tube. The [NAME] Tube was removed by the therapist and instructed the resident not to use the [NAME] Tube and the housing. The progress notes indicated that there would be a referral sent to an Ear, Nose and Throat (ENT) physician regarding the status of the stoma. It was also noted that the therapist instructed the former Director of Nursing (DON) on the care of the laryngectomy stoma that was first thought to be a tracheostomy. Instructions included the daily care of the stoma, when to contact the therapist, and to place a 20 French red rubber catheter if the prosthesis fell out and then send the resident to the emergency room (ER). A nursing progress note, dated 6/7/25 at 5:48 P.M., indicated that the staff sent the resident to the hospital because the [NAME] Tube had a missing piece that needed to be replaced. ER documentation, dated 6/7/25, indicated the resident was evaluated. The ER did not have the equipment needed to replace the part that was missing and it needed to be ordered. The physician indicated that the fistula was stable and could be left open, so the resident was to be sent back to the facility with orders to be sent to the ENT clinic that week. The June Medication Administration Record / Treatment Administration Record (MAR/TAR) indicated that staff performed all stoma care and the resident did not perform any of his own stoma care. The clinical record lacked an assessment of the resident's skills for laryngectomy care and tube. During an interview on 6/30/25 at 11:20 A.M., Resident 44 indicated the staff did not clean his stoma and he was supposed to have it cleaned two to three times a day. The resident was very upset about that not being done. At that time, he was observed lying in bed with his [NAME] tube placed beside him in the bed. During an interview on 6/30/25 at 2:15 P.M., Licensed Practical Nurse (LPN) 17 indicated that the resident wanted to do the stoma care himself most of the time. She indicated that she documented that she did it even when the resident did it. During an interview on 6/30/25 at 3:15 P.M., LPN 23 indicated the [NAME] Tube should be in all the time and that the resident was non-compliant with care. She indicated that the nursing staff had an in-service training for trach care. During an interview on 6/30/25 at 5:40 P.M., a family member indicated that she had performed stoma care for the resident several times and that the facility did not have the right equipment for the [NAME] Tube. The family indicated that they had been dealing with that problem since the resident had been admitted to the facility. The family member also indicated that the facility was supposed to order the equipment needed for the [NAME] Tube. The staff treated the stoma as a trach on admission. During an interview on 7/1/25 at 9:15 A.M., the DON indicated that the resident had a [NAME] Tube. Nursing staff was to clean the stoma and the outer part of the device every shift with saline. She indicated that the resident sometimes wanted to do the care himself, and there should be documentation in the progress notes when that happened. She indicated that the resident went to the ER on [DATE] and a red catheter was placed. She indicated that during that visit the ENT on call did not have a part for the tube and it would have to be ordered. She also indicated that there should be an order for the resident to do his own care. On 7/1/25 at 1:30 P.M., the DON provided a staff skills evaluation, dated 2/10/25, for tracheostomy care and gastro feeding tube care. During an interview on 7/2/25 at 12:31 P.M., the DON indicated staff were trained verbally on how to care for the [NAME] Tube by the former DON. Care for a laryngeal tube was different from a tracheostomy tube so the Speech Pathologist from [name of hospital] instructed the former DON, and the former DON relayed the information verbally to staff. On 7/2/25 at 2:00 P.M, the DON provided a nursing staff skills check-off training list, dated 2/25/25, for the [NAME] Tube. On 7/3/25 at 10:04 A.M., the Administrator provided a current Tracheostomy Care policy, dated 1/2/24, but it lacked information regarding the care of a laryngectomy. On 7/3/25 at 10:04 A.M., the Administrator provided a current Comprehensive Care Plans policy, dated 11/1/24, that indicated .comprehensive care plans will describe, at a minimum .resident specific interventions that reflect the resident's needs . On 7/3/25 at 10:04 A.M., the Administrator provided a current Physician Orders policy, dated 1/2/24, that indicated .the purpose of the policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to the professional standards of quality . 3.1-35(a) 3.1-47(a)(6)

2. On 6/30/25 at 8:11 A.M., Resident 98's clinical record was reviewed. Resident 98 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, congestive heart failure. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/22/25, indicated Resident 98 was cognitively intact and was dependent on staff (staff does all of the effort) for toileting, bathing, and transfers. Physician orders included, but were not limited to: Metoprolol 50 milligrams (mg) Extended Release (ER) - Give one tablet by mouth one time a day; Start Date 9/1/21. Care plans included, but were not limited to: (Resident) is at risk for impaired cardiac output; Observe for signs/symptoms of cardiac dysfunction such as .increased or decreased heart rate or blood pressure. Document abnormal findings and notify physician. Date Initiated: 9/29/21 The electronic Medication Administration Record (eMAR) on 4/13/25 indicated Resident 98 had an abnormal low blood pressure of 68/53 and an abnormal high heart rate of 133. The clinical record lacked a rechecked blood pressure, or a notification to the physician of abnormal vitals. During an interview on 7/3/25 at 12:20 P.M., the Administrator indicated a second blood pressure was obtained and was within normal limits, but was not documented. The Administrator was unable to provide the second set of vitals obtained. On 7/3/25 at 10:04 A.M., the Administrator provided a Change in Condition / Physician Notification policy, revised 3/19/25, that indicated The charge nurse will document timely regarding the change in resident's/patient's condition, interventions, and notifications. On 7/3/25 at 10:04 A.M., the Administrator provided a Comprehensive Care Plan policy, revised 5/16/24, that indicated We will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident/patient and/or representative. On 7/3/25 at 10:04 A.M., the Administrator provided a Fall Prevention policy, dated 1/2/24, that indicated When any resident experiences a fall, the facility will .document all assessments and actions. On 7/3/25 at 10:04 A.M., the Administrator provided a Documentation in the Medical Record policy, dated 1/2/24, that indicated Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred . Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Documentation shall be timely and in chronological order. 3.1-50(a)(1) 3.1-50(a)(2) 3.1-50(a)(3) Based on observation, interview, and record review, the facility failed to ensure documentation was complete and accurate for 1 of 2 residents reviewed for falls and 1 of 1 residents reviewed for death. (Resident 95 and Resident 98) Findings include: 1. On 7/1/25 at 9:29 A.M., Resident 95's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and traumatic subdural hemorrhage. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 6/5/25, indicated that Resident 95 was cognitively intact, required partial to moderate assistance of staff (staff does less than half of the effort) to roll left to right and for a sit to stand transfer, and had one fall with injury since the prior assessment. A care plan conference was completed on 5/5/25. Falls and care plans were reviewed. A current risk for falls care plan, dated 3/31/25, included, but was not limited to, the following interventions: Door to room will be left open for visualization, dated 5/5/25 A nursing progress note, dated 5/4/25 at 8:02 A.M., indicated that Resident 95 sustained an unwitnessed fall. He was noted to be soiled with bowel movement. A nursing progress note, dated 5/4/25 at 8:18 A.M., indicated that at 9:30 P.M., Resident 95 had an unwitnessed fall while attempting to go to the closet. An Interdisciplinary Team (IDT) note, dated 5/5/25 at 10:55 A.M., indicated the fall on 5/3/25 at night was reviewed. Door to room will be left open for visualization was added to the care plan at that time. An IDT note, dated 5/5/25 at 11:24 A.M., indicated the fall on 5/4/25 was reviewed. The clinical record lacked documentation that the physician and resident representative was notified of the falls on 5/3/25 and 5/4/25 or that the resident was assessed after the fall on 5/3/25 at 9:30 P.M. until the next morning. An SBAR (Situation, Background, Assessment, Recommendation) note, dated 5/6/25 at 8:05 A.M., indicated that Resident 95 had a witnessed fall while attempting to get the TV remote from under his bed. The clinical record lacked documentation of an IDT meeting to review that fall or an intervention added to the care plan. On 7/1/25 at 11:00 A.M., Resident 95's door was observed closed. On 7/2/25 at 8:51 A.M., Resident 95's door was observed closed. On 7/2/25 at 9:32 A.M., the Director of Nursing (DON) provided risk management reports dated 5/3/25 at 9:30 P.M. and 5/4/25 at 7:25 A.M. The reports indicated that the resident was assessed, and the Nurse Practitioner (NP) and resident representative were notified of the falls at the time the resident fell. The risk management reports indicated they were not part of the medical record. At that time, the DON indicated that staff should put all fall incident report information into a progress note because the risk management report did not cross over into the clinical record. During an interview on 7/2/25 at 1:26 P.M., the DON indicated Resident 95 did not actually fall on 5/6/25. The nurse that charted the SBAR was instructed to chart it as a fall by the former DON, but it wasn't a fall because the resident was intentionally getting on the ground to look for the TV remote and he was able to stand back up by himself with the assistance of the side of the bed. During an interview on 7/3/25 at 8:29 A.M., the Administrator indicated that Resident 95 preferred his door closed and the facility failed to remove that intervention from the care plan. On 7/3/25 at 9:23 A.M., the DON provided a risk management report, dated 5/21/25 at 7:20 A.M., that indicated the resident and resident representative were educated on safety for fall interventions and the resident representative indicated to leave the door closed if that was what the resident preferred. The risk management report indicated it was not part of the medical record. At that time, the DON indicated that the facility failed to document the discussion with the resident representative and change of intervention in the clinical record.

Based on observation, interview, and record review, the facility failed to post a current Posted Nurse Staffing sheet for 1 of 5 days during the survey period. Finding includes: On 6/29/25 at 8:05 A.M., a Posted Nurse Staffing sheet was observed next to the reception window in the main lobby. It was dated 6/27/25. During an interview on 7/2/25 at 1:54 A.M., the Administrator indicated the scheduler filled out the Posted Nurse Staffing sheets. When the scheduler was not in the facility, she put the pre-filled out sheet behind the currently displayed sheet and night shift staff flipped it. During an interview on 7/3/25 at 10:31 A.M., the Administrator indicated that the facility did not have a policy for Posted Nurse Staffing, but they followed the federal regulation.

Based on interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed. A resident was given a straw to drink with, and hand splints were not applied. (Resident B) Findings include: On 7/15/24 at 10:30 a.m., an observation of wound dressing changes were observed for Resident B. Resident B's hand's were contracted, no hand splints were observed on. A sign was observed above the bed indicating no straws to be used. On 7/15/24 at 10:53 a.m., observation of morning care was observed on Resident B, no hand splints were applied. On 7/15/24 at 1:18 p.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified osteoarthritis unspecified site. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was intact, functional limitations in range of motion, upper and lower extremities, impairment both sides, self- care- eating, dependent. Care plans included, but were not limited to: (Resident B) needs assistance with activities of daily living r/t left hemiplegia, wounds. Interventions included, but were not limited to: Per therapy recommendation: apply resting hand splints to bilateral wrist/hand in the morning for up to 4 hours and afternoon for up to 4 hours. Remove splints during meals and at bedtime. Check skin for any redness every shift. Wife noted to be non-compliant with diet, thickened fluids, and recommendation no straws be used; education provided r/t risks of adverse reactions to non-compliance. Wife noted to use PEG tube for feeding at times as she did at home; Nursing provided education r/t proper technique. Date Initiated: 2/14/2024, revision on: 2/27/2024 Current physician orders for July 2024 were reviewed and included, but were not limited to: Per therapy recommendation: Apply resting hand splints to bilateral wrist/hand in the morning for up to 4 hours and afternoon for up to 4 hours. remove splints during meals and at bedtime. Check skin for any redness, every shift, order date 3/22/24. Regular diet, Dys( dysphagia) puree texture, nectar thickened liquids consistency, no straws, order date 2/13/24. The July 2024 EMAR (Electronic Medication Administration Record) was reviewed. July 1- 19th were signed by the nursing staff as done for the hand splints. No refusals were observed in the clinical record. On 7/17/24 at 8:17 a.m., RN 1 was observed to administer Resident B his medications. RN 1 was observed to put a straw in a cup of orange juice and give to Resident B to swallow his medications. A sign was observed above Resident B's bed that indicated no straws to be used. No hand splints were observed on. On 7/17/24 at 1:41 p.m., Resident B was observed in the dining room sitting in a wheelchair, no hand splints were observed on and no meal was being served. On 7/19/24 at 8:04 a.m., a cup of water was observed on the bedside table with a lid and straw in the lid. A cup with an amber liquid was observed with no lid, a straw was in the cup. Both liquids were not thickened. The table was not in reach of Resident B at the time of observation. On 7/19/24 at 9:10 a.m., RN 1 indicated Resident B's diet order was puree food, thickened liquids, regular diet. She was unaware there was an order for no straws, she had noticed liquids sitting on Resident B's bedside table that were not thickened. On 7/19/24 at 11:44 a.m., Resident B was observed up in a wheelchair being propelled down the hallway by a staff member, no hand splints were observed on and no meal was being served at that time. On 7/19/24 at 11:45 a.m., CNA 1 indicated Resident B had hand splints on in the past, it was not on the current CNA assignment sheet, she had not observed hand splints on Resident B recently and not applied them when she provided care. On 7/19/24 at 11:48 a.m., RN 1 indicated she worked on the unit Monday, Wednesday, and Friday, and was not aware Resident B had an order for hand splints. 7/19/24 at 11:58 a.m., RN 1 indicated Resident B's hand splints were in a drawer in his room, herself and a CNA had just tried to apply the splints and Resident B shook his head no for refusal. On 7/19/24 at 11:55 a.m., the Administrator provided the current policy on comprehensive care plans with an effective date of 1/2/24. The policy included, but was not limited to: .7. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . The facility did not provide a policy on following physicians orders. This citation relates to Complaint IN00434521 and IN00437811. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure food was stored, and served in a sanitary manner for 2 of 2 kitchen observations. The kitchen floors had debris build up, and equipment was soiled. ( Kitchen) Findings include: On 7/15/24 at 8:55 a.m., the kitchen was observed to have the following: 1. Floor debris build up, including along the edges of the the walls, under storage racks and tables, behind the stove, and warmers, under the dish machine, three compartment sink, under the steam table. The dry pantry floor had debris build up on floors, under racks, condiment packets observed on the floor and under the food racks. 2. Debris build up on the sides of the stove, the shelf above the stove, shelves on the stainless steel table the steamer was sitting on, top of steamer. The same was observed on 7/16/24 at 11:40 a.m. On 7/16/24 at 2:00 p.m., kitchen cleaning schedules were reviewed and included, but were not limited to: AM cook: 3 compartment sink- please clean outside and the floor underneath. AM cook : stove top & stove- clean stove top, backslash, and side of stove, clean gas ovens. PM cook & servers: floor/walls- clean and sanitize shelves, walls, and floors. On 7/10/24 at 12:04 p.m., the District Dietary Manager indicated daily the floor is swept and spot mopped during the day, every night the floor is fully swept and mopped. On 7/19/24 at 11:35 p.m., the Administrator provided the current policy on food environment for the kitchen, with a revision date of 2/23. The policy included, but was not limited to: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Procedures: 1. The Dining Service Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation .4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . This citation relates to Complaint IN00435625. 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the failed to ensure a resident who entered the facility with an indwelling urinary catheter was effectively assessed for adverse outcomes of an indwelling urinary catheter, received treatment and services to prevent infection in accordance with the physician orders and the plan of care, or was effectively monitored for complications of bloody urine after the catheter was suspected to be pulled for 1 of 4 residents reviewed for urinary catheters. This deficient practice resulted in Resident 35 being hospitalized for the treatment of urethral obstruction and sepsis. (Resident 35) Finding includes: On 5/2/24 at 9:30 A.M., a family member indicated Resident 35 had been admitted to the hospital with sepsis due to a UTI (urinary tract infection). The family member indicated she told the facility there was blood in the tubing and bag on 4/17/24 and staff told her they did not change catheters anymore. On 5/3/24 at 8:44 A.M., Resident 35's clinical record was reviewed. The resident was admitted to the facility on [DATE] with an indwelling Foley (urinary) catheter and a history of UTIs, chronic kidney disease, and dementia. The most current Annual Minimum Data Set (MDS) Assessment, dated 4/23/24, indicated that Resident 35 had severe cognitive impairment, had no behaviors, required substantial/maximal assistance with toileting (helper does more than half), had an indwelling catheter, and did not have a UTI in the last 30 days. A current indwelling catheter care plan, initiated 6/30/23, indicated that Resident 35 was at risk for infections and complications related to indwelling catheter use. The interventions included, but were not limited to: Assess quarterly and as needed for appropriateness of continued use of catheter, catheter/peri care at least every shift and as needed, encourage fluids, keep drainage bag and tubing below level of the bladder, notify MD (medical doctor) of abnormal findings, observe for signs of pain or discomfort related to catheter, observe for symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Physician orders related to the indwelling catheter included, but were not limited to: Foley catheter care every shift - every shift document mL (milliliters) output in POC (point of care, a certified nursing aide charting system), dated 6/30/23. Change Indwelling Catheter/Tubing/Bag every month on the first day of month every night shift starting on the 1st and ending on the 1st every month, dated 8/1/23. May change Foley catheter PRN (as needed) for dislodgement/occlusion, dated 4/19/24. May irrigate Foley Catheter with 10 mL sterile H2O (water) or normal saline as needed for maintenance, dated 4/19/24. An Admission Nursing Assessment, dated 6/29/23, indicated Resident 35 had a chronic indwelling Foley catheter, urine that was cloudy and white, and a UTI within the last 30 days. The assessment indicated Resident 35 required an indwelling urinary catheter due to a history of urinary retention with greater than 200 ml (milliters) of residual urine. The resident's medical record did not include any other nursing assessments or assessments for appropriateness of continued use of catheter. A Nursing Progress Note, dated 1/2/24, indicated the indwelling Foley catheter was changed on 1/2/24 with a return of pink tinged urine. The Treatment Administration Record (TAR) indicated Resident 35's indwelling Foley catheter was changed on 2/1/24 and 3/1/24. The progress notes, weekly nursing summaries, focused charting, or evaluations from 1/3/24 to 3/31/24 did not include documentation to specifically determine the characteristics of the procedure or to show the resident was effectively monitored for signs/symptoms of adverse outcome of indwelling urinary catheter placement. An Orders-Administration note, dated 3/2/24 at 3:08 A.M., indicated the indwelling Foley catheter was changed. The note did not include documentation to specifically determine the characteristics of the procedure or to show the resident was effectively monitored for signs/symptoms of adverse outcome of indwelling urinary catheter placement. Foley catheter care and catheter output was not documented on the TAR on the following days: January Day Shift - 1/16/24, 1/17/24, 1/18/24 January Night Shift - 1/5/24, 1/13/24, 1/14/24, 1/16/24, 1/19/24, 1/25/24, 1/30/24, 1/31/24 February Day Shift - 2/8/24 February Night Shift - 2/1/24, 2/10/24, 2/18/24, 2/21/24, 2/23/24, 2/24/24, 2/26/24 March Day Shift - 3/2/24, 3/4/24, 3/8/24, 3/13/24, 3/24/24, 3/26/24 March Night Shift - 3/2/24, 3/5/24, 3/8/24, 3/14/24, 3/15/24, 3/17/24, 3/18/24, 3/19/24, 3/21/24, 3/23/24, 3/25/24, 3/26/24, 3/27/24, 3/29/24, 3/30/24 April Day Shift - 4/3/24, 4/7/24, 4/18/24 April Night Shift - 4/1/24, 4/5/24, 4/9/24, 4/13/24, 4/18/24, 4/22/24, 4/25/24, 4/26/24, 4/29/24 The January through March 2024 TARs indicated indwelling urinary catheter care was not provided every shift in accordance with the physician orders and the plan of care. The TAR, progress notes, weekly nursing summaries, focused charting, or evaluations from 1/3/24 to 3/31/24 did not include documentation to show the resident was effectively monitored for signs/symptoms of adverse outcomes of indwelling urinary catheter placement or a UTI. The April 2024 TAR indicated the indwelling urinary catheter was changed on 4/1/24. The progress notes, weekly nursing summaries, focused charting, or evaluations from 4/1/24 to 4/29/24 did not include documentation to specifically determine the characteristics of the procedure, to show the resident was effectively monitored for signs/symptoms of adverse outcomes, or for indwelling urinary catheter placement. The nursing progress notes and TAR, dated 4/30/24 through 5/1/24 at 12:44 P.M., did not include documentation to show Resident 35 experienced bloody urine or had potentially pulled on the catheter tubing. The records did not include sufficient documentation to determine Resident 35 was effectively monitored for bloody urine, catheter placement, or urine output. A Change in Condition Evaluation, dated 4/30/24, indicated the primary care physician (PCP) was notified on, 4/30/24 at 12:45 P.M., due to the resident having increased sweat, generalized weakness, generalized pain, and a fever of 100.0 Fahrenheit (F). 650 mg (milligrams) of Tylenol were given. The PCP ordered a chest x-ray, complete blood count (Complete Blood Count), and basic metabolic panel (Basic Metabolic Panel). A nursing progress note, dated 4/30/24, indicated Pulled up completed labs and WBC [white blood count] was 20.8 [elevated level indicating infection] and Lymphs [lymphocytes, a type of white blood cell] 4.8 [elevated level indicating infection], resident restless, skin warm and dry, B/P [blood pressure] -94/57,P [pulse] -101 at 22:00 [11:00 P.M.] now B/P-89/55, P-97, respiration even and nonlabored, color satis [sic], urine dark yellow. Will continue to monitor. A Physician Telehealth note, dated 5/1/24 at 12:24 A.M., indicated the resident had some mental status change, fever, and appeared to be uncomfortable. Blood pressure was 89/50, oxygen saturation was closer to 90 percent on room air, and the resident was tachycardic (increased heart rate) and mildly tachypneic (increased rate of breathing). The chest x-ray did not show any acute changes. Creatinine (used to measure kidney function) and WBC were elevated. An order was given to send the resident to the emergency room (ER) for treatment and evaluation. An ER Admission Note, dated 5/1/24, indicated Resident 35 was admitted to the hospital to be treated for obstructive uropathy, sepsis secondary to UTI, and acute kidney injury. A CT (computed tomography) scan indicated the Foley catheter balloon was inflated in the urethra. Hospital staff changed the Foley catheter and had quite a bit of purulent [thick, milky] drainage come out. The resident was started on IV (intravenous) Vancomycin (antibiotic medication) and IV ertapenem (antibiotic medication). On 5/2/24 at 12:58 P.M., Registered Nurse (RN) 5 indicated that the facility policy changed on or around 4/19/24 to reflect the Center for Disease Control and Prevention (CDC) guidance to only change out indwelling foley catheters as needed unless the doctor orders say otherwise. The nurses did change catheters if required. On 5/3/24 at 10:55 A.M., a family member indicated Resident 35 was in the hospital for treatment of a UTI and sepsis. She indicated that she observed blood in the resident's urine in both the catheter tubing and bag on multiple occasions and that the resident had less urine output than normal over the past two weeks. She indicated that she told staff about her concerns and requested for the catheter to be changed but was told that staff don't change the catheters anymore. On 5/3/24 at 12:00 P.M., Licensed Practical Nurse (LPN) 8 indicated she was working the day Resident 35 was sent to the hospital. She indicated Resident 35 had a fever of 100 F that morning, was sweaty, and not acting like himself so she called the Nurse Practitioner (NP) who ordered a CBC, BMP, and chest x-ray. She indicated the resident had blood in his urine the day before, but they thought he had pulled on the tube and irritated his urethra because it cleared up. She indicated the resident had no obvious signs of UTI and his baseline urine was cloudy. At that time, she indicated there was no place to document a catheter assessment. The TAR was marked complete when Foley catheter care was completed and any abnormalities would get reported to the nurse, assessed, and documented in a progress note. On 5/6/24 at 9:15 A.M., the Director of Nursing (DON) indicated catheter assessments were charted as a general progress note or in a change of condition form. If the assessment was normal nothing would be documented. At that time, she indicated that if tasks were not initiated on the TAR, the task was not completed. She indicated that Foley catheter care and output from the catheter was not completed, assessed, or documented on the days missing a signature or appropriate charting code. On 5/8/24 at 8:45 A.M., all documentation related to Resident 35's indwelling Foley catheter including, but not limited to, assessments, monitoring, progress notes, Interdisciplinary Team (IDT) notes, evaluations, provider notes, change of condition forms, and TAR notes was requested. On 5/8/24 at 10:53 A.M., the Infection Preventionist (IP) indicated all applicable documentation had been provided. On 5/8/24 at 12:42 P.M., the IP indicated that she tracked CAUTI (catheter associated urinary tract infections) using a form and looked at all residents who had a catheter or received peri care. The IP indicated the current CAUTI tracking form did not include documentation related to Resident 35. On 5/8/24 at 1:04 P.M., the IP provided a CAUTI tracker form that indicated Resident 35 had not been tracked for UTI or related urinary symptoms since 9/22/23. On 5/6/24 at 1:58 P.M., the Administrator provided an Indwelling Catheter Use and Removal policy, dated 2023, that indicated The facility will conduct ongoing assessments for .residents with indwelling catheters to determine if the catheter needs to be continued or removed if the catheter is no longer necessary. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: .timely and appropriate assessments related to the indication for use of an indwelling catheter; . insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures; response of the resident during the use of the catheter; and ongoing monitoring for changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes. On 5/8/24 at 10:53 A.M., the IP provided a current Catheter Care, Urinary policy, revised September 2014, that indicated Observe the resident for complications associated with urinary catheters. Check the urine for unusual appearance (i.e., color, blood, etc.). Notify the physician of supervisor in the event of bleeding . Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. The following information should be recorded in the resident's medical record: 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure that food was served at an appetizing temperature for 1 of 1 trays tested for temperature. (Resident 21, Resident 246, Resident 74, Resident 73, Resident 87, Resident 4, Resident 24, Resident 55, Resident 25) Finding includes: On 4/30/24 at 9:33 A.M., Resident 21 indicated the food was cold. On 4/30/24 at 9:59 A.M., Resident 246 indicated the food was cold. On 4/30/24 at 10:10 A.M., Resident 74 indicated the food was tough, overcooked, and cold. On 4/30/24 at 10:44 A.M., Resident 73 indicated the food was cold. On 4/30/24 at 12:40 P.M., Resident 87 indicated the food tasted cold. On 4/30/24 at 12:58 P.M., Resident 4 indicated the food was hard and cold. On 4/30/24 at 1:23 P.M., Resident 24 indicated the food was warm or cold. On 5/1/24 at 8:35 A.M., Resident 55 indicated the food was always cold. On 5/1/24 at 8:46 A.M., Resident 25 indicated the food was burnt and cold. On 5/2/24 at 1:06 P.M., a test tray was obtained. Food temperatures for that meal were: - Baked chicken 100 degrees F (Fahrenheit) - Mac and cheese 92 degrees F - Carrots 88 degrees F - Pumpkin pie 76 degrees F On 5/2/24 at 1:16 P.M., the Dietary Manager indicated foods should be no more than 10 degrees less than what it was prior to serving. He indicated he expected meat to be served at 155 F and vegetables at 140 F. On 5/8/24 at 10:53 A.M., the Infection Preventionist (IP) provided a current Food: Preparation policy, revised 2/2024, that indicated .minimize the time that food items are exposed to temperatures greater than 41 degrees F and/or less than 135 degrees F. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions during 4 of 4 kitchen observations and 1 of 1 nutrition pantry observation. Food was not labeled, left open to air, and expired food was not disposed of from the refrigerator, hair nets were not worn, and hand hygiene was not completed. (Kitchen, 100 hall nutrition pantry, Dietary Aide 3, Dietary Aide 21, Dietary Manager) Findings include: 1. On [DATE] at 8:29 A.M., during the full kitchen tour with Dietary Aide 3 the following was: - Dirt, food debris, a rag, and an ice scoop were on the floor under the dishwasher. Food debris was on the clean side of the dishwasher. - Liquid was on the floor by the juice cart. - In the freezer, Marzetti frozen pasta and beef patties were open to air. - In the walk-in refrigerator, the following items were observed: shredded mozzarella cheese - no label/date small cup white liquid - no label/date bologna - no label/date yogurt - lid not closed and no label/date square tin of yellow substance - no label/date onion, sliced - no label/date cucumber, sliced - no label/date tomato sliced - no label/date green salad - no label/date - In the reach-in refrigerator, the following items were observed: ravioli - dated ,d+[DATE], use by ,d+[DATE] eggs for puree - dated ,d+[DATE], use by ,d+[DATE] gravy - use by ,d+[DATE] beef base - use by ,d+[DATE] diced chicken - dated ,d+[DATE], used by ,d+[DATE] salad - dated ,d+[DATE], used by ,d+[DATE] - In the dry pantry, the floor was observed to be sticky and a brown liquid was observed on the floor. Two tomato soup cans were stored on floor under a shelf. A Clean Sign was observed hanging between the walk-in refrigerator and freezer that indicated always clean up any spills immediately. On [DATE] at 8:26 A.M., during a follow up walk through of the kitchen the following was observed: - Dirt, food debris, a rag, and an ice scoop were on the floor under the dishwasher. Food debris was on the clean side of the dishwasher. - In the freezer, beef patties were observed to be open to air - In the walk-in refrigerator, the following items were observed: Shredded cheddar cheese - no date parmesan cheese - open to air, no date lemonade - no label/date hard boiled eggs - open to air, no label/date lettuce, wrapped - no label/date - In the reach-in refrigerator, beef base was observed with a use by date of ,d+[DATE]. - In the dry pantry, the floor was observed to by sticky and a brown liquid was observed on the floor. One can of tomato soup was stored on floor under shelf. Dirt was observed under the shelves. A can of blackeyed peas and [NAME] pears were observed to be dented. During an interview at that time, the Dietary Manager indicated the dented cans were set aside and returned. He indicated the can of blackeyed peas and [NAME] pears should have been set aside. 2. On [DATE] at 8:29 A.M., Dietary Aide 3 had loose hair coming out of the back of her hair net. Dietary Aide 21 had loose hair coming out of the back of her hair net. On [DATE] at 10:27 A.M., the Dietary Manager had his beard net on backwards. On [DATE] at 8:47 A.M., the Dietary Manager was not wearing a beard cover. On [DATE] at 11:37 A.M., the Dietary Manager was observed in the kitchen without wearing a beard net. 3. On [DATE] at 11:00 A.M., Dietary Aide 3 was observed preparing the puree meal items. During that time, Dietary Aide 3 was observed performing hand hygiene on 5 separate occasions during the food preparation process. On the first occasion she lathered her hands for 10 seconds. On the second occasion she lathered her hands for 7 seconds. On the third occasion she lathered her hands for 4 seconds. On the fourth occasion she lathered her hands for 2 seconds. On the fifth occasion she lathered her hands for 2 seconds. 4. On [DATE] at 1:46 P.M., the following items were observed in the nutrition pantry on the 100 hall: lemonade in a container with a blue lid - dated ,d+[DATE] - ,d+[DATE] lemonade in a container with a red lid - dated ,d+[DATE] - ,d+[DATE] milk - dated [DATE] bag of Little [NAME] snacks in a clear bag - not dated On [DATE] at 12:42 P.M., the Infection Preventionist (IP) indicated that staff should lather their hands with soap for 40 seconds while performing hand hygiene. She further indicated kitchen staff should wear hair and beard nets when they were past the door of the kitchen and no hair should be sticking out of them. On [DATE] at 10:53 A.M., the IP provided a current Staff Attire policy, revised ,d+[DATE], that indicated All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. On [DATE] at 10:53 A.M., the IP provided a current Handwashing/Hand Hygiene policy, revised ,d+[DATE], that indicated employees must wash their hands for twenty (20) seconds using antimicrobial or non-antimicrobial soap and water . On [DATE] at 10:53 A.M., the IP provided a current Food Storage: Dry Goods policy, revised ,d+[DATE], that indicated all packaged and canned food items will be kept clean, dry, and properly sealed. On [DATE] at 10:53 A.M., the IP provided a current Food Storage: Cold Foods policy, revised ,d+[DATE], that indicated all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to immediately notify the resident's family of a resident to resident altercation for 1 of 1 residents reviewed for notification of changes. (Resident 35) Finding includes: On 5/2/24 at 9:30 A.M., a family member indicated a previous roommate attacked Resident 35 with a walker and a drawer in February, and the facility did not contact her until 11:00 A.M. the next morning. On 5/3/24 at 8:44 A.M., Resident 35's clinical record was reviewed. The diagnoses included, but were not limited to, dementia and major depressive disorder. The most recent Annual Minimum Data Set (MDS) assessment, dated 4/23/24, indicated Resident 35 had severe cognitive impairment and had no behaviors during the assessment period. A late entry Social Services Note, dated 2/27/24 at 11:01 A.M., indicated that on the previous evening (2/26/24), Resident 35 was asleep in his bed when his roommate threw a walker and drawer from the nightstand at him resulting in bruising to Resident 35's hand. An Incident Note, dated 2/27/24 at 11:07 A.M., indicated the resident's family member was notified of the resident to resident altercation incident On 5/3/24 at 9:11 A.M., the Administrator indicated that a resident's family would be notified immediately if the resident experienced an emergency no matter what time it was. If a non-emergent incident occurred after 10:00 P.M., the emergency contact would be notified by 7:00 A.M. the next morning. An emergency was defined as anything for which the resident would need to be sent out of the facility, any injury, and resident to resident altercations. On 5/6/24 at 9:15 A.M., the Director of Nursing (DON) indicated notifications to the family were documented as a progress note or in the change of condition form. On 5/6/24 at 1:36 P.M., the DON provided an incident note that indicated Resident 35's family was not notified of the incident that occurred on 2/26/24 at 11:05 P.M., until 2/27/24 at 11:07 A.M. On 5/2/24 at 1:00 P.M., the Administrator provided a Change in Condition policy, dated October 2019, that indicated the responsible party or emergency contact will be notified per care profile that there has been a change in the resident's condition. 3.1-5(a)

Based on record and interview the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 3 of 19 residents reviewed. Antipsychotic medications, dental status, and significant weight loss were coded inaccurately. (Resident 25, Resident 246, Resident 55) Findings include: 1. On 5/1/24 at 10:00 A.M., Resident 25's clinical record was reviewed. The diagnoses included, were not limited to, Parkinson's Disease, major depressive disorder, and anxiety disorder. The current Quarterly MDS (Minimum Data Set) assessment, dated 3/4/24, indicated Resident 25 was cognitively intact and did not receive an antipsychotic medication during the seven day look back period. The current Physician Orders included but were not limited to: Aripiprazole (antipsychotic medication) 2 mg (Milligrams), give 2 mg by mouth at bedtime related to unspecified mood disorder, dated 12/6/23. On 5/3/24 at 2:58 P.M., the Social Worker indicated there was a mistake on the MDS assessment. Resident 25 was on an antipsychotic for seven days during the assessment and was coded as not taking the medication. She indicated that was a mistake and needed to be recoded. 48057 2. On 5/1/24 at 8:34 A.M., Resident 55's clinical record was reviewed. Resident 55's diagnoses included, but were not limited to, Alzheimer's disease, Parkinson's disease, and low back pain. Resident 55's most recent Quarterly MDS (Minimum Data Set) assessment, dated 3/7/24, indicated severe cognitive impairment, required moderate assistance with eating, required substantial assistance with bathing and transfers, was receiving a mechanically altered diet, and did not have significant weight loss of 5% in the last 30 days or 10% in the last 180 days. The clinical record included, but was limited to, the following dates and weights: 3/7/24- 98.0 Lbs (pounds) 3/4/24- 98.5 Lbs 2/23/24- 116.0 Lbs 1/11/24- 119.0 Lbs 1/3/24- 122.6 Lbs 11/9/23- 125.0 Lbs 10/5/23- 125.0 Lbs 8/22/23- 128.0 Lbs 8/12/23- 141.0 Lbs Weights recorded, in the previous 180 days of the 3/7/24 MDS Assessment, showed a weight loss of 18.37% within 30 days, and 27.55% within 180 days. During an interview on 11:43 A.M., the MDS Coordinator indicated she was unsure why the MDS assessment indicated Resident 55 did not have significant weight loss because the Registered Dietician completed that portion of the assessment. During an interview on 5/9/24 at 12:10 P.M., the Registered Dietician indicated she was unsure why the MDS assessment indicated Resident 55 did not have significant weight loss; Resident 55 was reviewed for significant weight loss in the NAR (nutrition at risk) meeting during that time. 48147 3. On 4/30/24 at 10:00 A.M., a family member indicated Resident 246 had no natural teeth and had a full set of dentures. On 5/2/24 at 9:35 A.M., Resident 246's clinical record was reviewed. The diagnoses included, but were not limited to, intestinal malabsorption, major depressive disorder, and generalized anxiety disorder. The most recent Admission MDS assessment, dated 9/6/23, indicated Resident 246 was cognitively intact, was not edentulous (without teeth), and had no broken teeth. An Admission Nursing Assessment, dated 9/1/23, indicated Resident 246 had his own natural teeth that were broken. An Admission Nutrition Assessment, dated 9/19/24, indicated Resident 246 had no teeth. A care plan, initiated 9/4/23, indicated Resident 246 had full upper and lower dentures. On 5/6/24 at 2:40 P.M., the MDS Coordinator indicated she had not observed the resident's mouth and was unsure whether he had teeth or not. She indicated she coded the MDS based on word of mouth from other staff, and the Admission MDS Assessment could have been wrong. On 5/8/24 at 10:53 A.M., the Infection Preventionist (IP) provided a current Resident Assessment - RAI policy, dated 2023, that indicated the current version of the RAI [Resident Assessment Instrument] (MDS 3.0) will be utilized when conducting a comprehensive assessment of each resident in accordance with the instructions found in the RAI Manual. 3.1-31(d)

Based on observation, record review, and interview the facility, failed to ensure care plan interventions were implemented for 1 of 2 residents reviewed for falls. The call light was not within reach. (Resident 26) Findings include On 5/1/24 at 8:50 A.M., Resident 26 was observed sitting in a chair with the call light wrapped around the call light monitor and not within reach of the resident. On 5/6/24 at 10:05 A.M., Resident 26 was observed sitting in a recliner with the call light lying across the bed not within reach of the resident. On 5/6/24 at 9:00 A.M., Resident 26's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's Disease with late onset, dementia, and generalized anxiety disorder. The current Quarterly MDS (Minimum Data Set) assessment, dated 3/6/24, indicated Resident 26 was moderately cognitively impaired, needed substantial to maximum assistance for mobility, transfer, and eating, and was a fall risk. Care plan interventions for fall risk included but were not limited to call light and personal items within reach, assisting with toileting, bilateral fall mats to both sides of the bed. On 5/8/24 at 10:53 A.M., the Infection Preventionist (IP) provided a current Fall Management policy, revised June 2023, that indicated All falls will be discussed by the interdisciplinary team .to determine root cause and other possible intervention to prevent future falls . 3.1-35(g)(2)

Based on observation, record review, and interview the facility, failed to ensure that documentation of interventions were not revised for 1 of 2 residents reviewed for falls. (Resident 56) Findings include: On 4/29/24 at 11:05 A.M., Resident 56 was observed wearing a cast on her left arm. On 5/3/24 at 1:55 P.M., Resident 56's clinical record was reviewed. The diagnoses included, but were not limited to, vascular dementia, aphasia following cerebral infarction, unspecified fracture of the lower end of right radius, and nondisplaced fracture of right ulna styloid process. The most current Quarterly MDS assessment, dated 4/17/24, indicated Resident 56 had moderate cognitive impairment, was independent in sit to stand transfers and toileting, did not use any mobility devices, and had 1 fall with major injury since the prior assessment on 2/16/24. A current falls care plan, revised 2/4/23, indicated Resident 56 was at risk for falls or fall related injury due to a history of CVA (cerebrovascular accident), diabetes, decreased vision, and neuropathy. An Event Note, dated 4/12/24 at 11:25 A.M., indicated Resident 56 had an unwitnessed fall in the activity room. The resident complained of pain to the right wrist. An x-ray revealed two fractures to the resident's right wrist. An Interdisciplinary Team (IDT) note, dated 4/16/24 at 9:40 P.M., indicated the resident had decreased safety awareness, communication deficits, and ambulated independently aimlessly about the facility. Continue with current interventions on keeping [name of resident] safe and free from injury as resident will not allow staff to assist with transfers and ambulation was added to the care plan on 4/17/24. On 5/6/24 at 9:15 A.M., the Director of Nursing (DON) indicated that after a resident fell , the IDT met, and determined a root cause and reviewed the care plan to place a new intervention to prevent falls. She further indicated continue with current interventions was not a typical or appropriate intervention. On 5/8/24 at 10:53 A.M., the Infection Preventionist (IP) provided a current Fall Management policy, revised June 2023, that indicated All falls will be discussed by the interdisciplinary team .to determine root cause and other possible intervention to prevent future falls . The care plan will be reviewed and updated. 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure medication was given according to physician orders for 1 of 5 residents reviewed for unnecessary medications. A blood pressure medication was given outside of parameters and glucagon was administered without an order. (Resident 246) Finding includes: On 5/2/24 at 9:35 A.M., Resident 246's clinical record was reviewed. Diagnoses included, but were not limited to, hypotension, type 1 diabetes mellitus, and disease of the pancreas. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/29/24, indicated Resident 246 was cognitively intact, required setup assistance for eating, and received a hypoglycemic medication during the 7-day look back period. Physician orders included, but were not limited to: Midodrine (a medication to treat low pressure) HCl Oral Tablet 5 MG (milligrams) - Give 3 tablets by mouth three times a day for hypotension hold if SBP (systolic blood pressure) more than 110, dated 4/24/24. Baqsimi (a medication used to treat low blood sugar) One Pack 3 MG/DOSE (milligrams per dose) Powder - 1 dose in nostril every 15 minutes as needed for hypoglycemia, dated 4/5/2024. Discontinued physician orders included, but were not limited to: Glucagon (a medication used to treat low blood sugar) Emergency Injection Kit 1 MG (milligram) - Inject 1 mg intramuscularly every 15 hours as needed for hypoglycemia, dated 4/5/24 and discontinued 4/5/24 for a therapeutic exchange. The April 2024 Medication Administration Record (MAR) indicated midodrine was given on the following days that Resident 246's SBP was greater than 110: 4/26/24 at 6:30 A.M. - blood pressure was 119/72 mm/Hg (millimeters of Mercury) 4/27/24 at 6:30 A.M. - blood pressure was 119/68 mm/Hg 4/28/24 at 6:30 A.M. - blood pressure was 142/102 mm/Hg A Nursing Progress Note, dated 5/1/24 at 2:31 A.M., indicated Resident 246 was found non-responsive with a blood sugar level of 32. IM glucagon was given in the right leg. Blood sugar was taken again 10 minutes later with a result of 33. IM glucagon was given in the left leg. Blood sugar was taken again 10 minutes later with a result of 44. The resident remained non-responsive. Emergency Medical Services (EMS) were called and the resident was transported to the hospital for evaluation and treatment. The Medical Doctor was notified of the resident's condition. A SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated 5/1/24 at 2:00 A.M., indicated the primary care clinician was notified and orders were given to send the resident to the emergency room (ER). The form lacked documentation of an order for IM glucagon. An Interdisciplinary Team (IDT) Note, dated 5/2/24 at 11:08 A.M., indicated the resident had a hypoglycemic episode and IM glucagon was administered twice before sending the resident to the ER for evaluation and treatment. The clinical record lacked an active order for IM glucagon on 5/1/24. The clinical record lacked documentation that the primary care clinician verbally gave an order for IM glucagon to be administered or the intranasal Baqsimi that the resident had ordered was to be held. On 5/6/24 at 9:15 A.M., the Director of Nursing (DON) indicated that midodrine was given outside of parameters on 4/26, 4/27, and 4/28 and the medication should not have been given on those days. The DON indicated all diabetic residents had IM glucagon ordered and that the doctor set the parameters of that administration as part of the emergency hypoglycemic protocol. She indicated that pharmacy sometimes had to substitute intranasal Baqsimi for IM glucagon because there was frequently a back order of IM glucagon. On 5/6/24 at 1:32 P.M., the DON indicated the IM glucagon order on 4/5/24 was therapeutically exchanged for nasal administration because the pharmacy said the IM glucagon was on back order. LPN 15 was on duty 5/1/24 and saw the resident previously had glucagon IM ordered and called the doctor who gave the order to administer IM glucagon. She indicated it was too busy that night to document or put in an order. She was unsure if the IM glucagon was pulled from the EDK (emergency drug kit) or if it was a dose the facility had on hand and would have to check where the nurse got the medication. On 5/6/24 at 2:17 P.M., the DON indicated the IM glucagon administered to Resident 246 on 5/1/24 was in the top drawer of the medicine cart with the resident's name on it. It was from a past order they had on hand that was never returned to the pharmacy. She was unsure how long the medication had been in the medicine cart. She indicated that because the resident had a history of hypoglycemia and pharmacy frequently had glucagon on back order, the facility just kept the medication instead of returning it to the pharmacy. At that time, she indicated medications that had been discontinued should be sent back to the pharmacy. On 5/8/24 at 10:53 A.M., the Infection Preventionist (IP) provided a current Unnecessary Drugs - Without Adequate Indication for Use policy, dated 2024, that indicated The indications for initiating, withdrawing, or withholding medications, as well as the use of non-pharmacological approaches, will be determined by assessing the resident's underlying condition . On 5/8/24 at 10:53 A.M., the Infection Preventionist (IP) provided a current Medication and Treatment Orders policy, revised July 2016, that indicated Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state . Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. 3.1-35(g)(2)

Based on interview and record review, the facility failed to transfer a resident to the hospital due to a change in condition per the family's wishes, for 1 of 9 residents sampled for neglect, in a sample of 12. This resulted in a delay in transferring the resident to the hospital, in which the resident was admitted to the hospital with [REDACTED]. (Resident G) Findings include: On [DATE] at 11:25 A.M., the wife and Power-of-Attorney (POA) of Resident G was interviewed. She received a phone call at approximately 2:30 A.M. on [DATE]. The nurse informed her that Resident G was not doing well at all, and was not going to make it. She indicated the nurse told her, You need to sign a DNR (do not resuscitate). The POA indicated the resident was a Full Code (requiring cardiopulmonary resuscitation, or CPR), and she told the nurse to send the resident to the hospital. The POA indicated the nurse said, He's too weak, too fragile. He won't ever make it to the hospital. The POA indicated she told the nurse, Please send him to the hospital. The nurse told the POA that the resident was not strong enough to make the trip. The POA indicated she and her sister-in-law made the 1 hour trip to the facility, and that they didn't arrive until approximately 4:00 A.M.-4:30 A.M. due to bad road conditions. The POA indicated she fully expected him to be gone when they got there. The POA indicated when she arrived at the facility, the resident was not alert, and had labored breathing. She indicated he had not been that way the evening prior. She indicated she begged the nurse 2 or 3 times to send him to the hospital. She indicated the nurse told her, You need to sign this DNR or he will be like a vegetable. The POA indicated, in hindsight, she wished she would have just called 911 herself, but that she listened to the nurse. The POA indicated the night shift nurse informed the POA that she had been a hospice nurse, and knew that the resident was near the end of his life. The POA indicated at approximately 6:30 A.M., the day shift nurse arrived, and asked, What is going on? The POA indicated the day shift nurse was stunned, and told her he would get the resident transferred to the hospital right then. The POA indicated the resident was immediately transferred to the hospital. The clinical record of Resident G was reviewed on [DATE] at 3:00 P.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders, dated [DATE], indicated: Advanced Directive, Full Code. Nurses Notes included the following notations: [DATE] at 10:53 A.M.: .resident responsive et (and) more alert upon arrival, mental status declined throughout evening .lungs clear, resp. (respirations) even, unlabored, no cough or shortness of breath [DATE] at 3:39 A.M.: .breathing even and unlabored .no SOB (shortness of breath) A Daily Skilled Nurse's Note, dated [DATE] at 8:11 A.M., indicated the resident was alert with no memory problems, had some shortness of breath, no cough, and was on continuous oxygen. A Daily Skilled Nurse's Note, dated [DATE] at 3:30 A.M., indicated, Resident responds to verbal communication by talking but does not open eyes at this time. Bi-pap placed on resident with oxygen on at 2 liters continuously. Pulse ox (Oximeter, or level of oxygen in blood) is 90%. Respirations 40 and slightly labored .Lung sounds auscultated and rhonchi heard bilaterally. Nurses Notes continued: [DATE] at 4:08 A.M., documented by RN 2, indicated, Resident has had a change in condition. Resident is now unresponsive. Residents (sic) respirations are labored at 40 breaths per minute .Temp 100.7 .Residents spouse (name) notified of residents change in condition. Spouse unsure whether she wants resident to go to hospital. Discussed code status. Spouse on her way to facility. Triage notified of residents change in condition. Order received for Tylenol suppository for elevated temperature. Will update triage later on families decision and residents condition. [DATE] at 9:37 A.M., documented by LPN 1,: Res. (resident) noted to have labored breathing with use of accessory muscles. Respirations noted to be ,[DATE] .Temp is 100.4 temporal (forehead). At this time res. is not responding to verbal stimuli. Full Code status noted .Spoke with family, their wishes are to send res. to ER .(ambulance service) arrived at 0730 (7:30 A.M.), res. in transit to (hospital) An ambulance report, dated [DATE] at 7:26 A.M., indicated, Per Pt's (patient's) nurse 'on night shift' Pt had an acute 'change in mental status.' After receiving report at shift change nurse went to assess Pt. Pt. was found to be less responsive than normal. Pt had a fever of '100.4.' Pt had 'labored respirations.' Pt was placed on his [MEDICAL CONDITION] (continuous positive airway pressure) machine to assist with the respiratory difficulties and 911 was called .Per family Pt was alert and oriented 'yesterday.' Hospital emergency room notes included: [DATE] at 8:04 A.M.: Pt. arrives from (name of facility) with c/o (complaints of) altered mental status and sob (shortness of breath) starting last night [DATE] at 8:22 A.M.: (Name of physician) and rt (respiratory therapy) at bedside for intubation. A emergency room physician's note, dated [DATE] at 9:41 A.M., indicated, .presents to the emergency department via (ambulance) from the nursing home .having worsening shortness of breath, confusion, and increased swelling since yesterday .Final Impression: Acute [MEDICAL CONDITIONS] exacerbation. Respiratory distress A Hospital History and Physical, dated [DATE] at 10:30 A.M., indicated, Chief Complaint: Confusion and Shortness of Breath. History .He was reported to have become short of breath and lethargic last night, he was placed on his Bi-Pap, but failed to improve. His wife reports that she got a call from the NH (nursing home) around 0230 (2:30 A.M.) this morning stating that he was doing well (sic) and was not expected to make it through the night. His wife then asked them to call (the ambulance) and have him transferred to the ED (emergency department), but she was told that he would not make the trip. Once she got to the NH he was not responding and she demanded that they call (the ambulance service) On [DATE] at 9:00 A.M., RN 2 was interviewed. RN 2 indicated she remembered working with Resident G. She indicated the resident had a change in condition, and was not being real responsive, and took a turn for the worse. She indicated she was able to speak with the family. She indicated she didn't remember ever saying she would not send the resident to the hospital. She indicated she discussed code status, but did not demand the wife to sign a DNR. She indicated it was the family's decision. On [DATE] at 9:00 A.M., the Administrator, Interim Director of Nursing (DON), the Unit Manager, and LPN 2 were interviewed. The DON indicated she was not the DON at that time. The Administrator indicated she never saw a DNR paper. The Administrator indicated she vaguely recalled hearing that the night shift nurse wanted the family to sign a DNR, but that the family wanted him sent to the ER. She indicated she thought the previous DON had probably spoken to RN 2. At that time, the Unit Manager (UM) indicated she was at the facility on [DATE], at approximately 6:00 A.M. She indicated LPN 1 came and got her from her office, and informed her that Resident G's family wanted him sent to the ER, but that the night shift nurse didn't think he would make it. The UM indicated she went and assessed the resident, and helped transfer him to the hospital. She indicated she heard there was a DNR paper, but she had not seen it. At that time, LPN 2 indicated she received a phone call from LPN 1 on [DATE], as she was driving to work. She indicated LPN 1 informed her that the night shift nurse didn't want to send Resident G to the hospital, and said he wouldn't make it. LPN 2 indicated LPN 1 informed her the family wanted the resident sent to the hospital. LPN 2 indicated she never saw a DNR paper, but heard there was one. She indicated she was unsure if maybe LPN 1 had torn it up after the family told him they felt forced to sign it. LPN 1 did not return multiple phone calls, and no longer worked at the facility. On [DATE] at 10:55 A.M., the Administrator provided the current facility policy, Abuse, Neglect and Misappropriation of Property, reviewed [DATE]. The policy included: It is (name of facility's) policy to prevent the occurrence of abuse, neglect .Definitions: Neglect: Means failure to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress This Federal tag relates to Complaint IN 417. 3XXX,[DATE](a)(3)

Based on observation, record review and and interview, the facility failed to ensure services were provided to prevent falls for 1 of 3 residents reviewed. A resident who required assist of two (2) staff and a hoyer (mechanical lift) for transfers, had a fall when rolling over in bed. Resident B had to be transferred the to emergency room for a hematoma on his forehead, a laceration on his nose, skin tears on his arms and hands, and bruising around his eyes. Resident B had 5 (five) falls since (MONTH) (YEAR), fall interventions were not in place at time of fall to prevent injury. (Resident B) Findings include: During an observation on 6/4/18 at 8:58 a.m., Resident B was observed lying in bed. Resident B was observed to have a scabbed over laceration on his nose, a hematoma on his forehead, purplish bruising around both eyes, and bruising on both arms. He indicated he had rolled out of bed recently and was found in a pool of blood. During a record review on 6/4/18 at 9:16 a.m., Resident B's [DIAGNOSES REDACTED]. A nursing intervention, dated 3/27/18, indicated the resident was to be transferred by hoyer lift. The record indicated that five falls occurred (MONTH) (YEAR)-June (YEAR): 5/31/18- Resident B rolled over in bed and fell out of bed hitting the floor face first, hematoma on forehead, laceration on nose, skin tears on arms and hands, bruising on arms, around eyes. Complaints of left wrist pain, unwitnessed. During a review of Care Plans, the fall risk care plan was implemented on 5/6/18, the interventions indicated: Use fall risk screen to identify risk factors on admission and quarterly. Report falls to physician and responsible party. Observe for side effects of any drugs that can cause orthostatic [MEDICAL CONDITION] weakness, sedation, lightheadedness, and/or dizziness. Gait disturbance was discontinued on 6/4/18. Report to physician any side effects associated with the resident's medications. Keep area free of clutter. Remind resident to lock brakes on wheelchair. Monitor for appropriate footwear when out of bed. Invite resident to activity programs consistent with his interest to enhance physical strengthening needs. Pharmacy consultant and/or physician to review medication usage for possible reductions. Staff to assist with ambulation and/or locomotion as needed. Staff to assist with transfers. Hoyer lift for transfers. New interventions were put in place on 6/4/18: Bariatric bed with 1/2 side rails. A care plan indicated resident was at risk for skin breakdown d/t altered mobility and balance, it indicated, but was not limited to the following interventions: New intervention added 6/4/18, requires staff assist 1-2 for repositioning. The Significant Change MDS (Minimum Data Set), dated 3/28/18, indicated Resident B was moderately cognitively impaired. It further indicated Resident required the following: Extensive assist x 2 for bed mobility Extensive assist x 2 for transfers Extensive assist x 2 for dressing Extensive assist x for toilet use Assist in part of bathing x 1 An admission fall risk assessment, dated 2/28/17, had a fall risk score of 10, which indicated a risk for falls. The clinical record lacked a quarterly fall risk assessment. A progress note, dated 5/31/18 at 7:40 a.m., indicated nursing staff was called to Resident B's room, due to a CNA hearing Resident B call out. Resident B was found face down on the floor in a pool of blood. Resident B indicated he had rolled over in bed and fell out of the bed. Resident B had a hematoma on right forehead, skin tears on both elbows and right hand, and he complained of pain in hands and face. Vital signs were taken: Temperature 98.8, pulse 68, respirations 20, and blood pressure 150/72. Resident B was alert and conversing with staff. Staff assisted him to bed. Triage was called and was informed and a request was made to send to the ER. Triage agreed and (local ambulance service) was contacted for transfer. A progress note, dated 5/31/18 at 5:38 p.m., indicated the resident returned from the ER with a new order for [MEDICATION NAME] (antibiotic) 875/125 mg (milligram)twice a day for 10 (ten) days for a facial laceration. Progress note, dated 6/2/18, indicated light purple discoloration under right eye. Resident complained of left wrist pain, no [MEDICAL CONDITION], no redness, able to use hand without difficulty. Triage contacted for X-ray order for the left wrist. New order received for X-ray left wrist. During an interview with the DON on 6/5/18 at 11:28 a.m., she indicated Resident B was a 2 (two) assist and should be transferred with a hoyer lift. She further indicated the care plan should have been implemented upon the fall risk assessment and revised after each fall with new interventions. During review of the policy, Falls, revised 6/1/15, on 6/5/18 at 9:48 a.m., it indicated: It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. All residents will have a comprehensive fall risk assessment on admission, quarterly, and with significant change of condition and appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each patient. The care plan will be reviewed following each fall, quarterly, annually, and with each significant change. Interventions are to be revised as indicated by the assessment. If a fall occurs the following will occur: Assess resident .Assess resident each shift for 72 hours .Pain will be evaluated every shift for 72 hours .Begin investigation .IDT to determine root cause of fall .Update care plan .IDT/MDS/ADON reviews revises care plan as appropriate quarterly and as needed. This Federal tag relates to Complaint IN 250. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure services were provided to prevent falls for 1 of 3 residents reviewed. A resident who required assist of two (2) staff and a hoyer (mechanical lift) for transfers, had a fall when rolling over in bed. Resident B had to be transferred out the to emergency room for a hematoma on his forehead, a laceration on his nose, skin tears on his arms and hands, and bruising around his eyes. Resident B had 5 (five) falls since (MONTH) (YEAR), fall interventions were not in place at time of fall to prevent injury. (Resident B) Findings include: During an observation on 6/4/18 at 8:58 a.m., Resident B was observed lying in bed. Resident B was observed to have a scabbed over laceration on his nose, a hematoma on his forehead, purplish bruising around both eyes, and bruising on both arms. He indicated he had rolled out of bed recently and was found in a pool of blood. During a record review on 6/4/18 at 9:16 a.m., Resident B's [DIAGNOSES REDACTED]. A nursing intervention, dated 3/27/18 indicated the resident was to be transferred by hoyer lift. The record indicated the five falls occurred (MONTH) (YEAR)-June (YEAR): 5/31/18- Resident B rolled over in bed and fell out of bed hitting the floor face first, hematoma on forehead, laceration on nose, skin tears on arms and hands, bruising on arms, around eyes. Complaints of left wrist pain, unwitnessed. During a review of Care Plans, the fall risk care plan was implemented on 5/6/18, the interventions indicated: Use fall risk screen to identify risk factors on admission and quarterly. Report falls to physician and responsible party. Observe for side effects of any drugs that can cause orthostatic [MEDICAL CONDITION] weakness, sedation, lightheadedness, and/or dizziness. Gait disturbance was discontinued on 6/4/18. Report to physician any side effects associated with the resident's medications. Keep area free of clutter. Remind resident to lock brakes on wheelchair. Monitor for appropriate footwear when out of bed. Invite resident to activity programs consistent with his interest to enhance physical strengthening needs. Pharmacy consultant and/or physician to review medication usage for possible reductions. Staff to assist with ambulation and/or locomotion as needed. Staff to assist with transfers. Hoyer lift for transfers. New interventions were put in place on 6/4/18: Bariatric bed with 1/2 side rails. A care plan indicated resident was at risk for skin breakdown d/t altered mobility and balance, it indicated, but was not limited to the following interventions: New intervention added 6/4/18, requires staff assist 1-2 for repositioning. The Significant Change MDS (Minimum Data Set), dated 3/28/18, indicated Resident B was moderately cognitively impaired. It further indicated Resident required the following: Extensive assist x 2 for bed mobility Extensive assist x 2 for transfers Extensive assist x 2 for dressing Extensive assist x 2 for toilet use Assist in part of bathing x 1 An admission fall risk assessment, dated 2/28/17, had a fall risk score of 10, which indicated a risk for falls. The clinical record lacked a quarterly fall risk assessment. A progress note, dated 5/31/18 at 7:40 a.m., indicated nursing staff was called to Resident B's room, due to a CNA hearing Resident B call out. Resident B was found face down on the floor in a pool of blood. Resident B indicated he had rolled over in bed and fell out of the bed. Resident B had a hematoma on right forehead, skin tears on both elbows and right hand, and he complained of pain in hands and face. Vital signs were taken: Temperature 98.8, pulse 68, respirations 20, and blood pressure 150/72. Resident B was alert and conversing with staff. Staff assisted him to bed. Triage was called and was informed and a request was made to send to the ER. Triage agreed and (local ambulance service) was contacted for transfer. A progress note, dated 5/31/18 at 5:38 p.m., indicated the resident returned from the ER with a new order for [MEDICATION NAME] (antibiotic) 875/125 mg (milligram) twice a day for 10 (ten) days for a facial laceration. Progress note, dated 6/2/18, indicated light purple discoloration under right eye. Resident complained of left wrist pain, no [MEDICAL CONDITION], no redness, able to use hand without difficulty. Triage contacted for X-ray order for the left wrist. New order received for X-ray left wrist. During an interview with the DON (Director of Nursing) on 6/5/18 at 11:28 a.m., she indicated Resident B was a 2 (two) assist and should be transferred with a hoyer lift. She further indicated the care plan should have been implemented upon the fall risk assessment and revised after each fall with new interventions. During review of the policy, Falls, revised 6/1/15,on 6/5/18 at 9:48 a.m., it indicated: It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. All residents will have a comprehensive fall risk assessment on admission, quarterly, and with significant change of condition and appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each patient. The care plan will be reviewed following each fall, quarterly, annually, and with each significant change. Interventions are to be revised as indicated by the assessment. If a fall occurs the following will occur: Assess resident .Assess resident each shift for 72 hours .Pain will be evaluated every shift for 72 hours .Begin investigation .IDT to determine root cause of fall .Update care plan .IDT/MDS/ADON reviews revises care plan as appropriate quarterly and as needed. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure services were provided to prevent falls for 1 of 3 residents reviewed. A resident who required assist of two (2) staff and a hoyer (mechanical lift) for transfers, had a fall when rolling over in bed. Resident B had to be transferred out the to emergency room for a hematoma on his forehead, a laceration on his nose, skin tears on his arms and hands, and bruising around his eyes. Resident B had 5 (five) falls since (MONTH) (YEAR), fall interventions were not in place at time of fall to prevent injury. (Resident B) Findings include: During an observation on 6/4/18 at 8:58 a.m., Resident B was observed lying in bed. Resident B was observed to have a scabbed over laceration on his nose, a hematoma on his forehead, purplish bruising around both eyes, and bruising on both arms. He indicated he had rolled out of bed recently and was found in a pool of blood. During a record review on 6/4/18 at 9:16 a.m., Resident B's [DIAGNOSES REDACTED]. A nursing intervention, dated 3/27/18 indicated the resident was to be transferred by hoyer lift. The record indicated the five falls occurred (MONTH) (YEAR)-June (YEAR): 5/31/18- Resident B rolled over in bed and fell out of bed hitting the floor face first, hematoma on forehead, laceration on nose, skin tears on arms and hands, bruising on arms, around eyes. Complaints of left wrist pain, unwitnessed. During a review of Care Plans, the fall risk care plan was implemented on 5/6/18, the interventions indicated: Use fall risk screen to identify risk factors on admission and quarterly. Report falls to physician and responsible party. Observe for side effects of any drugs that can cause orthostatic [MEDICAL CONDITION] weakness, sedation, lightheadedness, and/or dizziness. Gait disturbance was discontinued on 6/4/18. Report to physician any side effects associated with the resident's medications. Keep area free of clutter. Remind resident to lock brakes on wheelchair. Monitor for appropriate footwear when out of bed. Invite resident to activity programs consistent with his interest to enhance physical strengthening needs. Pharmacy consultant and/or physician to review medication usage for possible reductions. Staff to assist with ambulation and/or locomotion as needed. Staff to assist with transfers. Hoyer lift for transfers. New interventions were put in place on 6/4/18: Bariatric bed with 1/2 side rails. A care plan indicated resident was at risk for skin breakdown d/t altered mobility and balance, it indicated, but was not limited to the following interventions: New intervention added 6/4/18, requires staff assist 1-2 for repositioning. The Significant Change MDS (Minimum Data Set), dated 3/28/18, indicated Resident B was moderately cognitively impaired. It further indicated Resident required the following: Extensive assist x 2 for bed mobility Extensive assist x 2 for transfers Extensive assist x 2 for dressing Extensive assist x 2 for toilet use Assist in part of bathing x 1 An admission fall risk assessment, dated 2/28/17, had a fall risk score of 10, which indicated a risk for falls. The clinical record lacked a quarterly fall risk assessment. A progress note, dated 5/31/18 at 7:40 a.m., indicated nursing staff was called to Resident B's room, due to a CNA hearing Resident B call out. Resident B was found face down on the floor in a pool of blood. Resident B indicated he had rolled over in bed and fell out of the bed. Resident B had a hematoma on right forehead, skin tears on both elbows and right hand, and he complained of pain in hands and face. Vital signs were taken: Temperature 98.8, pulse 68, respirations 20, and blood pressure 150/72. Resident B was alert and conversing with staff. Staff assisted him to bed. Triage was called and was informed and a request was made to send to the ER. Triage agreed and (local ambulance service) was contacted for transfer. A progress note, dated 5/31/18 at 5:38 p.m., indicated the resident returned from the ER with a new order for [MEDICATION NAME] (antibiotic) 875/125 mg (milligram) twice a day for 10 (ten) days for a facial laceration. Progress note, dated 6/2/18, indicated light purple discoloration under right eye. Resident complained of left wrist pain, no [MEDICAL CONDITION], no redness, able to use hand without difficulty. Triage contacted for X-ray order for the left wrist. New order received for X-ray left wrist. During an interview with the DON (Director of Nursing) on 6/5/18 at 11:28 a.m., she indicated Resident B was a 2 (two) assist and should be transferred with a hoyer lift. She further indicated the care plan should have been implemented upon the fall risk assessment and revised after each fall with new interventions. During review of the policy, Falls, revised 6/1/15,on 6/5/18 at 9:48 a.m., it indicated: It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. All residents will have a comprehensive fall risk assessment on admission, quarterly, and with significant change of condition and appropriate care plan interventions will be implemented and evaluated as indicated by assessment. A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each patient. The care plan will be reviewed following each fall, quarterly, annually, and with each significant change. Interventions are to be revised as indicated by the assessment. If a fall occurs the following will occur: Assess resident .Assess resident each shift for 72 hours .Pain will be evaluated every shift for 72 hours .Begin investigation .IDT to determine root cause of fall .Update care plan .IDT/MDS/ADON reviews revises care plan as appropriate quarterly and as needed. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to discover a pressure ulcer until it was a Stage 3. The facility also staged the pressure ulcer as a Stage 2 even though slough was present. This affected 1 of 6 residents reviewed for pressure areas in a sample of 22. (Resident K) Findings include: During a tour of the facility on 11/17/17 at 10:35 a.m., the DON (Director of Nursing) indicated Resident K had a new skin area on his ankle. During an observation on 11/20/17 at 9:59 a.m., Resident K was observed to have an open area with yellow slough (dead subcutaneous tissue in a wound that is usually white or yellow in appearance) to the right outer ankle. LPN 1 indicated a wound culture was collected on 11/17/17 and she was waiting on results. LPN 1 also indicated Resident K was to have a Bunny Boot to the right foot at all times when in bed. Resident K's record was reviewed on 11/20/17 at 11:00 a.m. Resident K's current MDS (Minimum Data Set) assessment, dated 11/8/17, indicated a BIMS (Brief Interview of Mental Status) of 8 which indicated the resident was moderately impaired. [DIAGNOSES REDACTED]. The MDS assessment indicated the resident had no pressure ulcers, no venous ulcers, and no arterial ulcers. Resident K's current care plans were reviewed on 11/20/17 at 11:10 a.m. A current care plan dated 11/15/17, indicated a Stage 2 Pressure Ulcer to right ankle. A current care plan dated 6/17/14, indicated Resident K may be at risk for developing skin breakdown. The care plan indicated the resident needed extensive/total assist with bed mobility. Resident K's progress notes were reviewed on 11/20/17 at 11:20 a.m. A progress note dated 11/15/17 indicated, Open area noted to right ankle 1.5 cm x 1.0 cm x 0.4 cm with yellow slough and peri wound is red, swollen and tender; area cleaned with NS (normal saline), skin prep to peri wound and foam dressing applied as ordered. Resident K's current orders were reviewed on 11/20/17 at 11:30 a.m. Current orders included, Order Date 12/9/16. Apply Bunny Boot to right foot when in bed. DX (diagnosis): Pressure reduction of outer ankle. Current orders also included, Order Date 11/15/17. Cleanse open area to right ankle with NS, skin prep peri wound and apply a foam dressing daily. Dx: Wound. Resident K's weekly wound assessments were reviewed on 11/20/17 at 1:35 p.m. An initial weekly wound assessment, dated 11/15/17, indicated a Stage 2 Pressure Ulcer to Right Lateral Foot. This assessment indicated slough was present and the wound measured at 1.5 x 1.0 x 0.4 cm. A weekly wound assessment, dated 11/20/17, indicated the Stage 2 Pressure Ulcer was healed on 11/20/17. An initial weekly wound assessment, dated 11/20/17, indicated a Stage 3 Pressure Ulcer to Right Lateral Ankle. This assessment indicated the wound measured at 1.5 x 1.0 x 0.4 cm. During an interview on 11/20/17 at 1:49 p.m., RN 1 indicated Resident K received weekly skin assessments on Sunday night shifts. RN 1 also indicated the pressure ulcer was discovered on 11/15/17 by a CNA (Certified Nursing Assistant) when removing Resident K's socks During an interview on 11/20/17 at 1:52 p.m., LPN 1 indicated the Stage 2 Pressure Ulcer was inadvertently marked as healed while charting on 11/20/17. LPN 1 indicated the wound had yellow slough which would make it a Stage 3. LPN 1 indicated the wound had yellow slough the entire time. During an interview on 11/21/17 at 1:40 p.m., the DON indicated the wound was a Stage 3 Pressure Ulcer due to the presence of yellow slough. The DON also indicated, it should have been noticed sooner. An undated current policy titled, Pressure Ulcer Risk Evaluation was provided by the DON on 11/21/17 at 9:02 a.m. The policy indicated, Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Staff will perform routine skin inspections (with daily care). Nurses are to be notified to inspect the skin if skin changes are identified. Nurses will conduct skin evaluations at least weekly to identify changes. An undated current policy titled, Pressure Ulcer Treatment was provided by the DON on 11/21/17 at 9:02 a.m. The policy indicated, Stage 2 Pressure Ulcer: Partial-thickness loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. This Federal tag relates to Complaint IN 842. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the written plan of care was followed for 2 of 37 residents reviewed during stage 2 of the survey. Gripper socks were not placed on a resident per the plan of care which resulted in a fall that required sutures and wound care was not provided according to the physician's orders [REDACTED]. (Resident 69, Resident G) Findings include: On 2/15/17 at 2:00 p.m., Resident 69 was observed in a wheelchair in the hallway. Resident 69 was observed have sutures to the forehead. On 2/16/17 at 11:30 a.m., the DON indicated Resident 69 had a fall on 2/15/17. The DON further indicated Resident 69 had a laceration to her head which required sutures. On 2/16/17 at 12:53 p.m., Resident 69's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) Assessment, dated 2/15/17 indicated Resident 69 had severe cognitive impairment. The Progress Notes included, but were not limited to: 2/15/17 at 12:01 a.m., recorded at 3:31 a.m., CNA walking in corridor and started to enter room and observed resident sitting at end of residents bed on buttocks with bilateral legs out in front of her barefoot with loungewear on and brief was soiled with urine acquired laceration of left forehead with moderate amount of bright red drainage and area cleansed with soap and water acquired skin tear to left wrist and attempted to approximate with steri strips after cleansing with soap and water also acquired skin tear to right thigh which was cleansed and steri strips applied . 2/15/17 at 1:40 a.m., recorded at 8:19 a.m., Triage called back and new orders to send resident to (Name of Hospital) 2/15/17 at 6:05 a.m., recorded at 8:30 a.m., Call received from (Name of Hospital) that resident was on her way back to facility and had to have sutures to left of forehead. The Care Plans included, but were not limited to: (Name of Resident) may be at risk for fall related to injury. The interventions included, but were not limited to: gripper socks on (undated) The CNA Assignment sheets, received from the DON on 2/9/17 at 2:14 p.m., included but were not limited to: Resident 69 gripper socks at all times. On 2/16/17 at 1:06 p.m., the DON indicated she could not find documentation whether Resident 69 was wearing gripper socks at the time of her fall. On 2/15/16 at 1:40 p.m., the Nurse Consultant provided the Care Planing-Interdisciplinary Team policy, undated. The policy included, but was not limited to, a comprehensive care plan for each resident is developed . 2. On 2/8/17 at 7:45 a.m., Resident G was observed to be lying in bed. Resident G had a loose dressing on his right lower leg and foot and a dressing to his left stump. The clinical record for Resident G was reviewed on 2/14/17 at 1:01 p.m. Resident G had [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 12/27/16, indicated Resident G had a BIMS (Brief Interview for Mental Status) assessment score of 15, indicating no cognitive impairment. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Clean with wound cleanser, pat dry, then apply [MEDICATION NAME] wound and burn gel 100% (an antibacterial wound gel), and cover with Kerlix daily. During an observation on 2/14/17 at 3:05 p.m., RN 3 and RN 4 were observed to be providing care to Resident G's right lower extremity and left stump. RN 3 was observed to remove the old dressing, cleanse the right dorsal foot, right lateral foot, right dorsal 2 nd (second) toe and right shin with wound cleanser. RN 3 patted the areas dry and applied [MEDICATION NAME] to the areas. RN 3 then wrapped the right lower extremity with Kerlix and applied tape. RN 3 was observed to remove the old dressing to Resident 40's stump. RN 3 indicated someone had placed a barrier cream on the stump and she was unable to remove it as it was too thick on the stump. RN 3 cleansed the stump with wound cleanser, and patted the area dry. RN 3 was observed to apply [MEDICATION NAME] to the left stump, wrap the stump with a Kerlix bandage, and apply tape. During an interview on 2/14/17 at 5:30 p.m., the DON (Director of Nursing) indicated the treatment of [REDACTED]. The DON indicated the resident had venous stasis wounds to the right lower extremity and the left stump. The facility lacked documentation of a policy for following the physician's orders [REDACTED]. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure assistive devices were provided to prevent accidents for 1 of 1 falls reviewed. Gripper socks were not placed on a resident which resulted in a fall that required sutures. (Resident 69) Findings include: On 2/15/17 at 2:00 p.m., Resident 69 was observed in a wheelchair in the hallway. Resident 69 was observed have sutures to the forehead. On 2/16/17 at 11:30 a.m., the DON indicated Resident 69 had a fall on 2/15/17. The DON further indicated Resident 69 had a laceration to her head which required sutures. On 2/16/17 at 12:53 p.m., Resident 69's clinical record was reviewed. The Quarterly MDS (Minimum Data Set) Assessment, dated 11/10/16 indicated Resident 69 had severe cognitive impairment. The MDS indicated Resident 69 had not had any falls since the prior assessment. The Progress Notes included, but were not limited to: 2/15/17 at 12:01 a.m., recorded at 3:31 a.m., CNA walking in corridor and started to enter room and observed resident sitting at end of residents bed on buttocks with bilateral legs out in front of her barefoot with loungewear on and brief was soiled with urine acquired laceration of left forehead with moderate amount of bright red drainage and area cleansed with soap and water acquired skin tear to left wrist and attempted to approximate with steri strips after cleansing with soap and water also acquired skin tear to right thigh which was cleansed and steri strips applied . 2/15/17 at 1:40 a.m., recorded at 8:19 a.m., Triage called back and new orders to send resident to (Name of Hospital) 2/15/17 at 6:05 a.m., recorded at 8:30 a.m., Call received from (Name of Hospital) that resident was on her way back to facility and had to have sutures to left of forehead The clinical record indicated Resident 69 had a fall on 2/6/17 and 12/24/16. The Care Plans included, but were not limited to: (Name of Resident) may be at risk for fall related to injury. The interventions included, but were not limited to: gripper socks on (undated) The CNA Assignment sheets, received from the DON on 2/9/17 at 2:14 p.m., included but were not limited to: Resident 69 gripper socks at all times. On 2/16/17 at 1:06 p.m., the DON indicated she could not find documentation whether Resident 69 was wearing gripper socks at the time of her fall. On 2/16/17 at 2:44 p.m., the Nurse Consultant provided the Falls policy, reviewed 6/1/15. The policy included, but was not limited to: A comprehensive care plan will be implemented . 3.1-45(a)(2)

Based on interview and record review, the facility failed to consistently and accurately assess a pressure wound, resulting in an infection in the wound and the wound doubling in size, for 1 of 3 residents reviewed with pressure ulcers, in a sample of 5. Resident A Findings include: The closed clinical record of Resident A was reviewed on 2/24/16 at 10:45 A.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/5/15, indicated the resident had a short term and long term memory problem and was severely impaired in cognitive skills for daily decision-making. The resident required extensive assistance of two+ staff for bed mobility, and was always incontinent of bowels and bladder. The MDS assessment indicated the resident had 1 Stage 3 area, measuring 5 centimeters (cm) x 3.6 cm x 0 cm, which was present upon admission. A Resident Care Plan, initially dated 5/11/15 and updated 12/1/15, indicated, Problem, Increased protein, MVI (multivitamin) due to compromised skin, Stage III coccyx, 12/1/15 coccyx area having (increased) drainage. The Approaches included, Dressing chgs (changes) per orders. Monitor improvements. Notify MD/family if none. A Weekly Wound record indicated Wound Location: coccyx, Wound Type: Pressure Ulcer and included the following: 12/30/15, Wound Measurements: (L X W) (Length x Width): 2.6 x 4 cm, Depth: 0.2 cm .Wound Stage: Stage 4, Exudate (drainage): Moderate, Exudate Type: (left blank) .Periwound: Macerated, Tissue Types: Granulation .Nutritional Interventions: (left blank) .Physician Notified: (left blank), Family Notified: (left blank) Other Treatments: alginate with foam dressing 1/14/16, Wound Measurements: 3.4 x 3.2 cm, Depth: 0.2 cm .Wound Stage: Stage 3, Exudate: Moderate, Exudate Type: (left blank) . Periwound: Macerated, Tissue Types: Granulation .Nutritional Interventions: (left blank) .Treatment(s): Calcium Alginate, Thin Foam with Cover, Physician Notified: (left blank), Family Notified: (left blank) 1/17/16, Wound Measurements: 2.5 x 3.0 cm, Depth: 0 cm, Exudate: Light, Exudate Type: (left blank) .Periwound: Intact, Tissue Types: Granulation .Nutritional Interventions: (left blank) .Treatment(s): Absorbent Foam Dressing, Physician Notified: (left blank), Family Notified: (left blank) A Nurses Note, dated 1/20/16 at 6:00 A.M., indicated, .Treatment to area on coccyx performed and moderate amount tan, non-odorous drainage with wound bed bright red, beefy in color with slightly raised wound edges and partial white in color A physician's orders [REDACTED]. Cover with [MEDICATION NAME] BID (twice daily) and PRN (as needed) for soiling and increased drainage x 14 days Dx (diagnosis): Pressure Ulcer. The most recent Wound Measurement form, dated 1/30/16, indicated, Wound Measurements: 3.0 x 3.0 cm , Depth: 0 cm .Wound Stage: Stage 2, Exudate: Light, Exudate Type: (left blank) .Periwound: Intact, Tissue Types: [MEDICATION NAME] .Nutritional Interventions: Vitamin C .Treatment(s): Absorbent Foam Dressing, Calcium Alginate, Physician Notified: (left blank), Family Notified: (left blank) Documentation regarding physician notification of the pressure ulcer following the 14 days of treatment was not found in the clinical record. A Quarterly Nursing Information, dated 2/4/16 indicated the resident was at High Risk for skin concerns. The form did not document impairments in skin. The last Nurse's Note regarding the coccyx pressure ulcer was on 2/4/16 at 9:00 P.M., which indicated, Tx (treatment) to coccyx. PEG tube intact A Nurse's Note, dated 2/7/16 at 12:00 P.M., indicated, Call received from triage (with) N.O. (new order) to send resident to ER for (evaluation and treatment) A Nursing Home to Hospital Transfer Form, dated 2/7/16 at 12:30 P.M., included: Reason(s) for transfer: [MEDICAL CONDITION](rapid heart rate) .Receiving [MEDICATION NAME] (an antibiotic) .[MEDICAL CONDITION] (Urinary Tract Infection) .Skin/Wound Care: Stage 2 to coccyx An emergency room record, dated 2/7/16 at 1:35 P.M., indicated, The patient did have a large sacral decubitus (pressure ulcer) .Final Impression, 1.[MEDICAL CONDITION], due to unspecified organism, 2. Decubitus ulcer A Hospital Wound Assessment, dated 2/7/16, indicated, Wound Pressure Ulcer Coccyx Mid: Left .Present on admission? Yes, Wound Type: Pressure Ulcer .Dry, Fragile, Painful, Pale .Wound Length (cm) 6 cm, Wound Width (cm) 6 cm, Wound edges, Unattached edges, Periwound Fragile A hospital History and Physical, dated 2/9/16, indicated, admitted for :[MEDICAL CONDITION] .Infected sacral decubitus ulcer On 2/24/16 at 2:45 P.M., during an interview with RN # 1, she indicated pressure area assessments were kept in the WoundSense. She indicated it was a computerized documentation system. She indicated that there was not a designated wound care nurse who assessed the pressure areas, but that which ever nurse was working when a wound assessment was due would assess the wound. RN # 1 indicated the computer system would turn the resident's name yellow, and that would notify the nurse on duty if an assessment was due. At that time, the Assistant Director of Nursing (ADON) indicated that pressure wound assessments were not necessarily done every 7 days, but were done weekly. On 2/25/16 at 2:00 P.M., the ADON reviewed the resident's WoundSense pressure wound assessments. The ADON indicated he was sure there were more assessments of the pressure ulcer than what was provided. The ADON indicated the facility was looking into having 1 specific staff member assessing the pressure wounds. The ADON indicated nursing staff were told not to stage wounds backward, that if a resident had a Stage 4 wound, it would always be a Stage 4 wound. On 2/25/16 at 2:15 P.M., during an interview with MDS Staff # 1, she reviewed the resident's WoundSense assessments and other skin assessments. There was no skin assessment after 1/30/16. In STAGES OF PRESSURE ULCERS, AMDA - 2008, the following was included: Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence .Note: This area may be painful, firm, soft, warmer or cooler compared to adjacent skin. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling. On 2/25/16 at 2:40 P.M., the ADON provided the current facility policy on Pressure Ulcer Risk Assessment, undated. The policy included: .Pressure ulcers are often made worse by continual pressure, heat, moisture .decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition .Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown At that time, the ADON provided the current facility policy on their wound care program, WoundSense, undated. The policy included: .WoundSense is a comprehensive, electronic skin and wound care documentation and management reporting system .WoundSense will be used for all resident skin and wound care evaluations and documentation .If a resident has an alteration in skin integrity .this tool (with photos) will be used weekly to complete the resident's skin assessment This Federal tag relates to Complaint IN 630. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a dependent resident was positioned properly in bed, resulting in a fall from the bed and left leg fracture, for 1 of 3 residents reviewed for falls, in a sample of 9. Resident A Findings include: 1. On 2/18/13 at 9:45 A.M., during the initial tour, the Director of Nursing (DON) and Case Manager indicated Resident A had fallen recently. On 2/18/13 at 11:20 A.M., Resident A was observed lying in a low bed, with a mat on the floor next to the bed. The resident had a splint on her left leg. The resident's eyes were open, but she did not respond when spoken to. The clinical record of Resident A was reviewed on 2/18/13 at 12:00 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 11/7/12, indicated Resident A had a short-term and long-term memory problem, and was severely impaired in cognitive skills for daily decision-making. The MDS assessment indicated the resident was totally dependent on two+ persons physical assist for bed mobility and transfer. A test for balance during surface-to-surface transfer, indicated, "Not steady, only able to stabilize with staff assistance." A care plan, dated 1/4/13, included: "(Resident A) has an ADL (activities of daily living) Self Care Performance Deficit...Interventions:...Bed Mobility: (Resident A) is totally dependent on staff for repositioning and turning in bed...Transfer: (Resident A) requires a hoyer lift for transfers...." Progress Notes included the following notations: 1/25/13 at 8:18 A.M.: "CNA had gotten resident dressed and she was laying in the middle of the bed. CNA left for 1 minute at the most and returned with hoyer lift and found resident on the foor (sic). She was laying on her right side with her head down toward the door. Resident contracted in all extremities. ROM (range of motion) was normal for resident. Nuero (sic) checks within normal limits. Bed it an (sic) air mattress and was filled to an appropiate (sic) amount. Both side rails up with pads on either side. Resident unable to explain how this fall happened. 3 scratches found on body no skin broken. MD notified and family called...." Progress Notes from 1/25/13 through 1/29/13 indicated the resident had no complaints of pain, and normal ROM. A Hospice Aide Visit Note, dated 1/30/13 at 6:30 A.M., indicated, "...RN... Notified of: (Left) foot has swelling and is bruised. Bruise goes up leg and is yellow...." Progress Notes included: 1/30/13 at 10:37 A.M.: "0745 (7:45 A.M.) hospice cna reported that leg is yellowish in color, ankle and foot is swollen, purplish bruise on toes...faxed MD requesting x-ray of LT (left) leg, ankle and foot stat." X-Rays were obtained on 1/30/13 and indicated: "...Results: There is a fracture involving distal tibia and fibula with no displacement...Conclusion: Acute left lower leg fracture as described...." On 2/19/13 at 9:55 A.M., during interview with the DON and Case Manager, the DON indicated he did an investigation into the fall and resulting leg fracture of Resident A, and it was reported to the Indiana State Department of Health. The DON indicated CNA # 1 had dressed Resident A, and had placed a hoyer lift pad under her. CNA # 1 had then left the room to obtain the hoyer lift and assistance.The DON indicated the resident was contracted, was on an air bed, and the 1/2 siderails were in the up position. The DON indicated CNA # 1 demonstrated to him how she had positioned the resident's legs, with knees up and ankles toward outward. The DON indicated when CNA # 1 returned to the room, the resident was on the floor. The DON indicated he concluded the resident's leg must have slid, and she fell out of bed. The DON indicated initial assessments demonstrated scratches on her arms and back. The DON indicated he spoke to several staff members, including hospice staff, and no one noted bruising or swelling of the resident's leg. The DON indicated he speculated the resident did fracture her leg with the fall, but then it was aggravated by transferring and turning and positioning the resident. The DON indicated the resident never did demonstrate pain, even when he assessed her on 1/30/13. On 2/19/13 at 12:05 P.M., during interview with CNA # 1, she indicated she was the CNA who usually cared for Resident A. She indicated on the day of the resident's fall, she had placed the resident on a "sling pad," placed her on her back, and went to get the hoyer lift. CNA # 1 indicated when she came back into the room, Resident A was on the floor. CNA # 1 indicated the air bed was set on the firmest position, and both siderails were up. CNA # 1 indicated the resident's legs were contracted, and were left with her knees up, and "the gravity must have pulled her over." When queried how the resident could have fallen past the siderails, CNA # 1 indicated the resident was in the center of the bed, but her head was not at the headboard. On 2/19/13 at 2:15 P.M., during interview with the DON, he indicated he had counseled CNA # 1 on proper positioning of residents. 2. On 2/18/13 at 3:10 P.M., the DON provided the current facility policy on "Accidents and Supervision to Prevent Accidents," dated 4/26/11. The policy included: "...Center assess (sic) patient to determine the patient's degree of mobility and physical impairment and the proper transfer method...." This federal tag relates to Complaint IN 185. 3.1-45(a)(2)