Every finding on record at Majestic Care of South Bend

Based on interview, and record review, the facility failed to allow a hospitalized resident to return to the facility timely, failed to issue a 30 day involuntary discharge notice and failed to provide any documentation justifying the discharge or reason for delaying the readmission of the resident for 1 of 3 residents reviewed for transfer and discharge needs. (Resident D).Finding includes:Resident D's clinical record was reviewed on 8/13/26 at 1:16 P.M. Diagnoses included but were not limited to atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes, mild cognitive impairment, depression, dependence on supplemental oxygen, and functional quadriplegia.An MDS (Minimum Data Set) assessment dated [DATE] with an acceptance date of 7/9/24, for a Discharge Return Not Anticipated assessment, indicated Resident D was cognitively intact and independent for daily decision making and demonstrated no behaviors. The resident required substantial assistance for activities of daily living including dressing, bathing and toileting. The assessment indicated there was active discharge planning occurring for the resident to return to the community and that no referrals had been made to local health care agencies and indicated the resident had not wanted any referrals made.A second MDS assessment, also dated 7/4/26 for Discharge Return Anticipated (Modification) with an acceptance date of 7/24/26, indicated in section X that the reason for modification was due to an item coding error.A review of Resident D's Notice of Transfer or Discharge document, dated 7/4/26, indicated the resident was transferred to the local Emergency Room. The Bed Hold Policy included in the document included the resident's Appeal Rights and indicated that the resident could not be transferred from the facility during the Appeal process or earlier than 34 days.Resident D's Progress Notes included but were not limited to the following:On 7/4/26 at 6:21 P.M., Resident D complained of chest pain and palpitations. He was assessed to have a heart rate of 180 beats per minute. The resident had a previous diagnosis of atrial fibrillation. The Nurse Practitioner was notified and gave an order to send the resident to the local emergency room (ER).On 7/6/26 at 8:16 A.M., the facility's Interdisciplinary Team and the facility's Regional [NAME] President had discussed an immediate discharge due to the safety risk that Resident D posed to all other residents within the facility due to ongoing behaviors despite interventions, education and his verbalization of understanding the impact of his behaviors on others. The note also indicated that Resident D had been admitted to a local hospital and that the hospital's Case Management and Social Services had been notified that the resident had been discharged from the facility and the facility was unable to accept him back due to the reasons previously listed.On 7/21/2026 at 9:22 P.M., a progress note indicated Resident D arrived back at the facility after being transported to the facility by ambulance. Resident D's records from the local hospital indicated the following:The resident had been admitted to ER on [DATE], admitted as an inpatient on 7/5/26, and discharged from the hospital on 7/21/26. The resident's admission diagnoses included atrial fibrillation and rapid heart rate.A physician's note, dated 7/4/26 at 7:21 P.M. indicated the resident's primary cardiologist was to take over the care starting 7/6/26 and given his episodes of slight bradycardia (slow heart rate), the hospital would observe the resident one more night and if the resident was symptom free, he could be considered for discharge home (back to the facility) on 7/6/26.A nursing progress note, dated 7/5/26 at 6:02 P.M., indicated the hospital had attempted to contact the facility to confirm that Resident D could return to the facility, had called the main number, and two other contacts with no answer and was not able to leave a voicemail regarding Resident D's impending return to the facility. The hospital's Case Management indicated in a note, dated 7/7/26 at 10:17 A.M., that Resident D was medically stable for discharge on that day and the plan was to return the resident to the facility and that the resident had been declined for readmission to the facility. The note indicated the Case Manager had notified the facility's admission Liaison and Director of Nursing (DON), who both indicated they could not accept the resident back due to his abusive behaviors toward staff.A hospital Social Service note, dated 7/9/26 at 4:39 P.M., indicated that the facility needed to provide the resident with an involuntary discharge notice by 7/10/26 at 10:30 A.M., so that the Ombudsman could assist the resident with initiating an appeal to the involuntary discharge.On 7/14/26 at 8:15 A.M., a progress note indicated Resident D remained medically stable for discharge pending placement.The hospital Social Worker indicated in a note, on 7/16/26 at 3:26 P.M., that she had placed a Notice of Hearing in the resident's chart and had met with the resident to discuss a hearing that was scheduled for 7/22/26 at 2:00 P.M., regarding the facility's refusal to allow him back to the facility.A Case Management note, dated 7/17/26 at 4:25 P.M., indicated she had contacted a local attorney to notify him of the hearing on 7/22/26 and inquire about the possibility of representation for recovery of room and board for Resident D's hospital stay that was incurred by the facility's refusal to allow the resident to return to the facility.A Case Management note, dated 7/20/26 at 11:01 A.M. indicated that the facility's new Administrator had contacted Case Management to discuss Resident D and that she was aware of the upcoming hearing on 7/22/26 at 2:00 P.M. The note indicated that Case Management explained to the Administrator that the hospital was not interested in hearing any explanation regarding the eviction of the patient. The note indicated in a voicemail received from the Administrator at 11:23 A.M., she indicated some plans had been made and had further information for the Case Management team and the facility administrator had requested a return call. At 12:12 P.M., a call was received from the facility that they had the patient's room ready, and he could be transferred back to the facility.On 7/21/26 at 6:30 P.M., a progress note indicated Resident D had been discharged to the facility and the hospital RN (Registered Nurse) had attempted to give a report to the facility staff by calling the facility three times and the call was not answered. The resident was transported back to the facility at 6:29 P.M. by a local ambulance company.A hospital Social Worker note, dated 7 /22/26 at 11:10 A.M., indicated she had received confirmation from the area Long Term Care Ombudsman that she had contacted Resident D who had agreed to withdrawal from the hearing that had been scheduled for that day regarding the facility's inappropriate discharge.During an interview on 8/12/26 at 1:00 P.M., with the Ombudsman, she indicated she had had a meeting with the facility's Administrator and Director of Nursing towards the end of July 2026 and she felt the facility's refusal to readmitted Resident D was retaliatory. She indicated the resident had to stay in the hospital 2 weeks longer than he should have had to stay, because the facility had refused to have him back. The Ombudsman indicated she had made it clear to the Administrator that the facility was in violation of admission and discharge laws.During an interview on 8/13/26 at 12:20 P.M., Resident D indicated on 7/4/26 he was transferred to the local hospital for concerns of atrial fibrillation. He indicated he had returned to the facility on 7/21/26 after the Ombudsman and the hospital Social Service Representative had gotten involved.On 8/14/26 at 11:09 A.M., during an interview with the facility's Social Service Director, she indicated Resident D went out to the local hospital on 7/4/26 and when she returned to work on 7/7/26, the resident had not returned to the facility. The Social Service Director indicated the facility's administration had not allowed the resident to return due to his behavior. The Social Service Director indicated she had contacted the Regional Office and was told the facility had not wanted the resident back and that the resident had not required a 30 Day Discharge Notice because the resident had been properly discharged to the hospital.During an interview on 8/14/26 at 12:10 P.M., the Administrator indicated she had not been the administrator at the time the decision was made not to readmit the resident and that the facility should have taken the resident back on 7/7/26 when he was ready for discharge from the hospital. The Administrator indicated the resident had behaviors directed at staff, but facility staff had failed to document the behaviors.During an interview on 8/14/26 at 12:15 P.M., the Director of Nursing indicated that between 7/4/26 and 7/7/26, the hospital had been trying to find placement for the resident and the facility was directed not to have him return because he had been a threat to residents and staff due to his behaviors. The Director of Nursing indicated that the resident had had multiple behavioral issues over the past several months including two or three State Reportables that had involved behaviors directed at facility staff, but few behaviors had been documented since 6/2/26. The Director of Nursing indicated the facility had lost an involuntary discharge hearing on 6/2/26 regarding Resident D.On 8/14/26 at 9:00 A.M., a policy titled Transfer and Discharge-Including AMA, dated 5/2/25, was provided by the Director of Nursing. The policy indicated, .Once admitted , the Resident/Patient has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions:.The safety of individuals in the facility is endangered due to the clinical or behavioral status of the Resident.When a Resident/Patient exercises their right to appeal a transfer or discharge, the facility will not transfer or discharge the Resident/Patient while the appeal is pending.Generally, the notice must be provided at least 30 days prior to a transfer or discharge.A policy titled, Bed Hold, dated 9/1/25 was provided by the Social Service Director on 8/14/26 at 11:44 P.M. The policy indicated, .Purpose To ensure residents/patients.are informed of their rights and the facility's procedures regarding bed holds during temporary absences, including hospitalization.Each resident/patient will be permitted to remain in the facility and will not be transferred or discharged from the facility.This citation relates to Intakes 3105654 and 3110065.410 IAC (Indiana Administrative Code) 16.2-3.1-12(a)(3)(4)(7).

Based on interview and record review, the facility failed to notify a resident's representative of a medication change for 1 of 3 residents reviewed for resident rights. (Resident E)Finding includes:Resident E's clinical record was reviewed on 6/25/26 at 3:50 P.M. Diagnoses included, but were not limited to, restless leg syndrome, chronic pain, anxiety and hemiplegia following a stroke.A Minimum Data Set Quarterly Assessment, dated 6/9/26, indicated Resident E had moderate cognitive impairment.A review of the resident's POST (Indiana Physician Orders for Scope and Treatment) form, dated 10/10/25, indicated Resident E's legal representative was Family Member A.Resident E's Durable Power of Attorney form, dated 10/10/25, indicated the resident's Power of Attorney was Family Member A.The resident's physician orders included but were not limited to:Ropinirole Hydrochloride to give one -1 MG tablet by mouth one time a day related to restless legs syndrome, with a start date of 10/9/25 and an end date of 6/4/26.Ropinirole Hydrochloride to give 1 MG tablet, to give 1.5 tablet at bedtime related to restless legs syndrome, with a start date of 6/4/26 and no end date.Resident E's progress notes included, but were not limited to, a physician's note, dated 6/5/26 at 12:59 A.M., that indicated the chief reason for the visit with the resident was due to the resident's increased difficulties with restless legs and a request to increase the Ropinoril to see if the increase would help better control the symptoms. The note indicated the Ropinirole was increased from 1 mg daily to 1.5 mg at bedtime.A nursing progress note, dated 6/11/26 at 7:58 A.M., indicated Resident E's representative had been notified of the medication change. During an interview, on 6/26/26 at 9:52 A.M., the Director of Nursing indicated Resident E had a medication increase for restless legs syndrome on 6/4/26 and the resident's responsible party should have been notified of the medication change at the time of the change but had not been notified of the change until 6/11/26.On 6/26/26 at 11:04 A.M., the Director of Nursing provided the policy titled, Change in Condition/Physician Notification, dated 3/19/25 and indicated it was the current facility policy. The policy indicated, .Purpose To promptly identify, respond to, and report changes in Resident/Patient condition to the Resident's/Patient's physician/NP/PA and Resident/Patient and their representative.The nurse will notify.representative when [there is a].Need to alter medications or treatment.Notifications will be attempted withing 24 hours.This citation relates to Intake 3042643.410 IAC (Indiana Administrative Code) 16.2-3.1-5 (a)(3).

Based on interview, and record review, the facility failed to ensure foods were served under safe and sanitary conditions related to monitoring food temperatures before serving. This deficient practice had the potential to affect 69 of 70 residents who were served meals from the facility kitchen. Finding includes:On 1/7/25 at 10:45 A.M., facility Grievances from 10/1/25 to 1/7/25 were reviewed. On 12/16/25 the Resident Council had submitted a grievance that indicated Residents did not want their food served cold. A grievance, dated 12/20/25, indicated the food was served cold every day. A review of Resident Council Minutes, dated 11/18/25, indicated the residents had expressed concerns that breakfast was often cold when served to them and they wanted food to be served to them on time so that the food was hot when served. On 1/14/25, the Service Line Checklist logs from 12/1/25 to 1/14/26 were reviewed and indicated the following:12/1/25: Breakfast temp recorded without items named. Lunch had no beverage items listed with the temps. Dinner had no beverage temps.12/2/25: Breakfast temps recorded without items named. Lunch no fruit or dessert temp, no items listed. Dinner had no beverage temps. 12/3/25: Breakfast temps recorded without items named. Lunch had no alternate items listed, no dessert temps or item listed. Dinner had no beverage temps nor dessert item named or temp. 12/4/25: Breakfast temps recorded without items named. Lunch had no beverage temps no dessert temp or items listed. Dinner had no beverage temps. 12/5/25: Dinner had no beverage temps. 12/6/25: Breakfast temps recorded without items named. Lunch no fruit or dessert temp, no items listed. Dinner had no beverage temps.12/7/25: Breakfast had no main entree temps. Lunch had no beverage temps and no main entree temp. Dinner had no beverage temps.12/8/25: Breakfast had not main entree or breakfast meat temps. Lunch had no beverage temps. Dinner had not beverage temps. 12/9/25: Dinner had no beverage temps. 12/10/25: Breakfast temps recorded without items named. Lunch had no beverage temps. 12/11/25: Breakfast temps recorded without items named. Dinner had no beverage temps.12/12/25: Breakfast temps recorded without items named. Dinner had no beverage temps. 12/13/25: Lunch had no beverage temps. Dinner had no temp checks. 12/14-16/25: Breakfast temps recorded without items named. Dinner had no beverage temps. 12/17/25: Breakfast temps recorded without items named. Lunch had no beverage temps. Dinner had no beverage temps.12/18/25: Breakfast temps recorded without items named. Dinner had no beverage temps. 12/19/25: Breakfast temps recorded without items named. Lunch had no beverage temps. Dinner had no beverage temps and no dessert temp.12/20/25: There were no beverage temps for this day.12/21/25: No beverage temps for breakfast or lunch. 12/22/25: No beverage temps for lunch or dinner. 12/23/25: Breakfast temps recorded without items named. Dinner had no beverage temps.12/24/25: Breakfast temps recorded without items named. Lunch had no beverage temps. Dinner had no beverage temps and no dessert temp.12/25/25: Breakfast temps recorded without items named. Lunch had no beverage temps. Dinner had no beverage temps and no dessert temp.12/26/25: 12/19/25: Breakfast temps recorded without items named. Lunch had no beverage temps. Dinner had no beverage temps and no dessert temp.12/27/25: Breakfast temps recorded without items named. Dinner had no beverage temps. 12/28/25: Breakfast temps recorded without items named. Lunch had no beverage temps. Dinner had no beverage temps.12/29/25: Breakfast had no main entree or meat temps. Lunch had no beverage temps. Dinner had no beverage temps.12/30/25: Breakfast temps recorded without items named. Dinner had no beverage temps and no dessert temp.12/31/25: Breakfast temps recorded without items named. Lunch had no food temps. Dinner had no beverage temps and no dessert temp.1/1/26: Breakfast temps recorded without items named. Lunch temps recorded without items named. Dinner had no beverage temps.1/2/26: Breakfast temps recorded without items named. Dinner had no beverage temps.1/3/26: Breakfast temps recorded without items named. Lunch temps recorded without items named and had no beverage temps. Dinner temps recorded without items named and had no beverage temps.1/4/26: Breakfast temps recorded without items named. Lunch had no main entree temp, alternate entree, starch, or vegetable temps and had no beverage temps. Dinner had no beverage temps.1/5/26: Breakfast temps recorded without items named. Dinner had no beverage temps.1/6/26: Breakfast temps recorded without items named. Lunch had no beverage temps. Dinner had no temps for vegetables, alternate entree, or starch. 1/7/26: Breakfast temps recorded without items named. Lunch temps recorded without items named. Dinner had no beverage temps.1/8/26: Lunch had no beverage temps. Dinner had no beverage temps.1/9/26: Breakfast had no beverage temps. Lunch had no beverage temps. Dinner had no beverage temps.1/10/26: Breakfast temps recorded without items named. Dinner had no beverage temps.1/11/26: Breakfast temps recorded without items named. Lunch temps recorded without items named and had no beverage temps. Dinner had no beverage temps.1/12/26: Dinner had no beverage temps.1/13/26: Dinner had no beverage temps.1/14/26: No Dinner temps were recorded.During an interview on 1/13/26 at 11:58 A.M., Resident D indicated the meals were frequently cold when served and the kitchen did not follow the posted menus. During an interview on 1/13/26 at 2:08 P.M., Resident G indicated the meals were not very good and the menu was not followed very closely. Resident G indicated they served biscuits and gravy way too often and that the hot food was never very hot. On 1/14/26 at 10:40 A.M., during an interview, Resident C indicated the kitchen did not always follow the menu and the hot food was not always hot. On 1/14/26 at 2:30 P.M., the Administrator indicated he was aware of the residents' concern for hot foods being served cold and that the posted menus were not closely followed. The Administrator indicated a new dietary manager was hired and began working at the facility on 1/12/26 and he had not received any food concerns since 1/12/26. On 1/14/25 at 9:00 A.M., the Director of nursing provided a policy titled Food Production, with a revised date of 10/6/25, and indicated it was the current facility policy. The policy indicated, .All food production within the facility shall follow.safe food handling practices.All meats are heated through to a minimum temperature.a. 145 for fish, pork or beef roast, raw ham and bacon.b. 160 for eggs, ground beef and pork, ham, sausage. c. 165 for poultry, stuffed meats and stuffed pastas, and casseroles.This citation relates to Intake 2707368 and Intake 2695463.3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a resident's physician and responsible party were notified of the resident's refusal to be weighed and of the resident's significant weight loss, for 1 of 3 resident's reviewed for weight loss, (Resident E).Finding includes:Resident E's clinical record was reviewed on 1/12/26 at 11:38 A.M. Resident E was admitted to the facility with diagnoses that included but were not limited to, Alzheimer's Disease, neurocognitive disorder with behavioral disturbance, delusional disorder, insomnia, and muscle weakness.The most recent comprehensive Minimum Data Set (MDS) assessment, completed for a quarterly review, dated 10/22/25, indicated Resident B had severe cognitive impairment, had demonstrated negative behaviors not directed toward others, wandered daily, and utilized antipsychotic and antianxiety medications. The resident's weight was 170 pounds at the time of the assessment.An MDS assessment, dated 11/26/25 for a Discharge Assessment, indicated the resident had inattention and disorganized thinking that was continuously present, had demonstrated physical and verbal behaviors directed toward others, behaviors not directed toward others, and rejection of care for 1 to 3 days in the previous 7 days of the assessment period. The resident's weight was 156lbs at the time of discharge.Physician's Orders for Resident B included, but were not limited to: a regular diet, regular texture, thin consistency, dated 7/23/25 and ongoing, and to obtain monthly weights, dated 7/23/25.Resident E's Care Plans included but were not limited to behavioral symptoms of refusing vital signs to be obtained, dated 10/13/25. Interventions indicated if the resident became resistive, to allow the resident to regain their composure and reapproach as needed and also to notify the physician and psychiatric services for increases in behavioral symptoms. A Care Plan dated 10/19/25 indicated Resident E had potential for nutritional risk related to her diagnoses and a weight refusal in October 2025 and in November 2025 was noted to have significant weight loss of 14.7 % in the previous 90 days. Interventions included to document food and fluid intake, dated 10/19/25, and to observe for difficulties, and notify the physician of abnormal findings, dated 7/23/25.Resident E's monthly weights were documented as follows: 7/24/25; 178.0 lbs 7/28/25;177.0 lbs 8/5/25;178.0lbs 8/21/25; 171.0 lbs 9/2/25; 170.0 lbs 9/4/25; 170.0 lbs 11/6/25; 152.0 lbs, which indicated a 14% weight loss in less than 5 months, 11/11/25; 156.0 lbs.A local hospital emergency room (ER) History and Physical document dated 11/26/25, indicated Resident B was admitted to the ER due to an altered mental status, fever, and hypotension. The resident's weight was noted to be 146 pounds, which indicated a weight loss of over 17% in last five months.Review of Resident B's documented meal intakes from 10/1/25 to 11/26/25, indicated no meal intakes had been recorded for the following meals: No documentation of breakfast: 10/14/25, 10/19/25, 10/25/25, 10/26/25, 11/4/25, 11/11/25, 11/23/25, and 11/24/25.No documentation of lunch: 1/14/25, 10/19/25, 10/20/25, 10/25/25, 10/26/25, 11/4/25, 11/11/25, and 11/23/25.No documentation of supper: 10/4/25, 10/5/25, 10/14/25, 10/15/25, 11/4/25, 11/8/25, 11/12/25, 11/15/25, 11/21/25, and 11/22/25.Resident E's meal intake was documented as 0% intake to 25% on the following dates: 10/5/25 breakfast and lunch. 10/7/25 breakfast, 10/8/25 breakfast and lunch, 10/22/25 breakfast, 10/24/25 lunch, 10/27/25 breakfast, 10/29/25 breakfast, 10/31/25 supper, 11/1/25 breakfast, 11/5/25 breakfast, 11/9/25 breakfast no lunch, 11/15/25 breakfast, 11/19/25 lunch, 11/20/25 breakfast.Nursing Progress Notes for Resident B included but were not limited to the following: On 8/1/25 at 6:25 A.M., a nutrition review indicated the resident had an admission weight of 178 pounds on 7/24/25 and consumed 76-100% of most meals. No dietary recommendations were made. On 11/21/25 at 1:33 P.M., a nutrition/dietary Note for weight review indicated Resident E was on a regular diet and was not prescribed any dietary supplements. The resident's weight history included weights of 156 lbs on 11/11/25 and 156 on 11/6/25. The note indicated no weights had been entered for 30 days and that the resident had lost 26 pounds in 90 days for a 14.6% weight loss, dropping from 170 pounds to 152 pounds in 2 months. The dietary note indicated the resident's Body Max index (BMI) was 29.5 and in the overweight category. No recommendations due to a BMI of 29.5. were recommended The Registered Dietician indicated she would continue to monitor and follow up as needed. During an interview on 1/13/25 at 10:30 A.M., the Director of Nursing indicated there was no documentation of notification that Resident E's physician nor their responsible party had ever been notified of the resident's significant weight loss or weight refusals.During an interview, on 1/13/25 at 12:44 P.M. with Resident E's family member, they indicated the family was never notified of the resident's significant weight loss. On 1/14/25 at 9:00 A.M., the policy titled Weight Monitoring, dated 7/1/25, was provided by the Director of Nursing and indicated it was the current facility policy. The policy indicated, .To regularly measure and record a [resident's] body weight to assess changes in nutritional status.Monthly Weights; Should be taken by the 5th of the month with reweights verified and recorded in the [Electronic Medical Record].by the 7th of the month.The resident's.physician and family/guardian will be notified of any verified significant weight change.On 1/14/25 at 9:00 A.M., the policy titled Change in Condition/Physician Notification, dated 4/1/25, was provided by the Director of Nursing and indicated it was the current facility policy. The policy indicated, .Purpose [is to] promptly identify, respond to, and report changes in resident.condition to the resident's.physician.and.representative.The nurse will notify the physician.and resident representative when.abnormal weights.The charge nurse will document timely regarding the change in resident's condition, intervention, and notifications.This citation relates to Intake 2698522 3.1-5(a)(2)

Based on interview and record review, the facility failed to administer medications as ordered by the Physician for 9 of 9 residents reviewed for medications. (Residents 3, 8, 29, 51, 67, 69, 14, 1 and 4)Findings include:1. During an interview on 8/13/2025 at 10:00 A.M., Resident 3 indicated his medications were given late a lot and he was not receiving his insulin with his meals. Resident 3's record review was completed on 8/15/2025 at 12:00 P.M. Diagnoses included, but were not limited to: heart failure, type 2 diabetes mellitus, generalized anxiety disorder, major depressive disorder and chronic obstructive pulmonary disease. Resident 3's current Physicians' orders included, but were not limited to: -5 milligram (mg) tablet of amlodipine (treats hypertension) once daily -insulin Lispro - 12 units subcutaneously with meals, -insulin lispro - sliding scale based on blood glucose four times daily -insulin glargine - 45 units subcutaneously twice daily -multivitamin- 1 tablet daily -5 mg Eliquis (anticoagulant) tablet twice a day -5 mg Tradjenta (Anti-diabetic medication) -17 grams polyethylene glycol (laxative) powder once daily -100 mg gabapentin (nerve pain medication) capsule twice a day -325 mg ferrous sulfate tablet once daily -10 mg Jardiance (anti-diabetic) tablet once daily -0.4 mg tamsulosin capsule once daily -12.5 mg carvedilol (anti-hypertensive) twice a day A review of Resident 3's July and August 2025 Medication Administration Records (MAR) indicated the following medications were given late: -On 7/13/2025 12 units insulin lispro scheduled for 5:00 P.M. was not administered until 6:39 P.M. -On 7/17/2025 amlodipine, scheduled for 7:00 A.M.,, was not administered until 12:13 P.M.; Humalog insulin, scheduled for 8:00 A.M., was not administered until 11:05 A.M., 12 units of Insulin lispro, scheduled for 8:00 A.M.,, was not given until 11:06 A.M.; 45 units of insulin glargine, scheduled for 8:00 A.M., was not administered until 11:06 A.M. -On 7/19/2025 5 mg Eliquis, 5 mg Tradjenta, 17 grams polyethylene glycol powder, 100 mg gabapentin, 12.5 mg carvedilol, 10 mg Jardiance, 5 mg amlodipine, 0,4 mg tamsulosin, 20 mg torsemide scheduled for 7:00 A.M., were not administered until 12:09 P.M. Also, on 7/19/2025 ,45 units insulin glargine scheduled for 8:00 A.M., was not administered until 10:08 A.M. -On 7/20/205 insulin lispro sliding scale (dose will depend on the resident's blood glucose assessment), 45 units insulin glargine and 12 units insulin lispro scheduled for 8:00 A.M., were not administered until 10:09 A.M. -On 7/22/2025 5 mg Eliquis, 100 mg gabapentin, 12.5 mg carvedilol, 10 mg Jardiance, 20 mg torsemide, 0.4 mg tamsulosin, 5 mg amlodipine and 5 mg Tradjenta, scheduled for 7:00 A.M., were not administered until 12:08 P.M. -On 7/23/2025 the following medications were scheduled for 7:00 A.M., but were not administered until 12:04 P.M.: 5 mg of Eliquis, 5 mg Tradjenta, polyethylene glycol powder, 100 mg gabapentin, 325 mg ferrous sulfate, 10 mg Jardiance, 0.4 mg Tamsulosin, insulin lispro sliding scale (dose depended on blood glucose assessment) , 5 mg amlodipine and 12.5 mg carvedilol. -On 7/28/2025 insulin lispro sliding scale (dose depended on blood glucose assessment), 45 units insulin glargine and 12 units insulin lispro were scheduled for 8:00 A.M., but were not administered until 10:01 A.M. -On 7/29/2025 45 units insulin glargine, scheduled for 8:00 A.M.,, was not administered until 10:55 A.M. -On 7/30/2025 45 units insulin glargine, scheduled for 8:00 A.M., was not administered until 10:10. -On 7/30/2025 12 units insulin lispro and insulin lispro sliding scale (dose depended on blood glucose assessment) were scheduled for 12:00 P.M., but were not administered until 1:56 P.M. -On 7/31/2025 12.5 mg carvedilol and 5 mg amlodipine, scheduled for 7:00 A.M.,, were not given until 12:16 P.M. -On 7/31/2025 45 units insulin glargine, 12 units insulin lispro and insulin lispro sliding scale (dose depended on blood glucose assessment) were scheduled for 8:00 A.M., but were not administered until 10:50 A.M. -On 7/31/2025 12 units insulin lispro and insulin lispro sliding scale (dose depended on blood glucose assessment) scheduled for 12:00 P.M., were not administered until 5:56 P.M. -On 8/1/2025 325 mg ferrous sulfate, scheduled for 7:00 A.M., was not administered until 12:24 P.M. -On 8/2/2025 5 mg Eliquis, 100 mg gabapentin, scheduled for 7:00 A.M.,, was not administered until 11:05 A.M. -On 8/3/2025 5 mg Eliquis and 100 mg gabapentin, scheduled for 7:00 A.M., was not administered until 11:57 A.M. -8/3/2025 12 units insulin lispro and insulin lispro sliding scale (dose depended on blood glucose assessment) scheduled for 12:00 P.M., was not administered until 1:50 P.M. -On 8/5/2025 12 units insulin lispro and insulin lispro sliding scale (dose depended on blood glucose assessment),scheduled for 12:00 P.M., were not administered until 5:09 P.M. -On 8/10/2025 48 units insulin glargine, scheduled for 8:00 A.M., was not administered until 11:29 A.M. -On 8/12/2025 12 units insulin lispro, scheduled for 12:00 P.M., was not administered until 2:54 P.M. -On 8/13/2025 12.5 mg carvedilol, and 5 mg amlodipine, scheduled for 7:00 A.M., was not administered until 1:04 P.M. Resident 4's record lacked documentation indicating why the medications had not been administered timely 2. Resident 8's record review was completed on 8/15/2025 at 11:00 A.M. Diagnoses included, but were not limited to: malignant neoplasm of bladder, type 2 diabetes mellitus, anxiety disorder, malignant neoplasm of prostate and hypertension. Resident 8's current Physicians' orders included, but were not limited to: -36000-114000 unit creon capsule three times a day -20 mg oxycodone tablet every 4 hours -Novolog (insulin aspart) sliding scale (dose will depend on blood glucose) -25 mg trazodone (insomnia) tablet at bedtime -60 mg Nifedipine (anti-hypertensive) -40 mg pantoprazole capsule once a day -100 mg thiamine tablet once a day -CertaVite/antioxidants (multivitamin) tablet once a day -10 gram Lokelma (treats hyperkalemia) two times a day A review of Resident 8's July and August 2025 MARs indicated the following medications were given an hour and a half late or later: -On 7/18/2025 20 mg oxycodone, scheduled for 12:00 P.M., was not administered until 1:32 P.M. -On 7/18/2025 36000-114000 unit creon capsule, scheduled for 7:00 P.M, was not administered until 9:59 P.M. Also, 20 mg oxycodone, scheduled for 8:00 P.M., was not administered until 9:58 P.M. -On 7/22/2025 36000-114000 unit creon capsule, 60 mg nifedipine tablet, 40 mg pantoprazole tablet and 100 mg thiamine tablet, scheduled for 7:00 A.M., was not administered until 12:07 P.M. -On 7/25/2025 20 mg oxycodone, scheduled for 8:00 P.M., was not administered until 9:35 P.M. -On 7/26/2025 CertaVite/Antioxidant tablet, scheduled for 9:00 A.M., was not administered until 10:38 A.M. -On 7/27/2025 NovoLog (insulin) sliding scale (dose depended on blood glucose assessment),scheduled for 9:00 P.M., was not administered until 10:44 P.M. - On 7/29/2025 CertaVite/Antioxidant tablet, scheduled for 9:00 A.M., was not administered until 10:56 A.M. -On 7/31/2025 NovoLog (insulin aspart) sliding scale (dose will depend on blood glucose) was scheduled for 8:00 A.M., but had not been administered until 10:49 A.M. -On 7/31/2025 NovoLog (insulin aspart) sliding scale (dose will depend on blood glucose) was scheduled for 12:00 P.M., but had not been administered until 5:51 P.M. - On 8/1/2025 CertaVite/Antioxidant tablet was scheduled for 9:00 A.M., was not administered until 10:35 A.M. -On 8/3/2025 20 mg oxycodone tablet, scheduled for 12:00 P.M., was not administered until 1:51 P.M. -On 8/4/2025 25 mg trazodone, scheduled for 9:00 P.M., was not administered until 10:36 P.M. -On 8/5/2025 100 mg thiamine tablet, scheduled for 7:00 A.M., was not administered until 4:04 P.M. -On 8/5/2024 NovoLog (insulin ) sliding scale (dose depended on blood glucose assessment), scheduled for 12:00 P.M., was not administered until 5:11 P.M. -On 8/5/2025 20 mg oxycodone, scheduled at 8:00 P.M., was not administered until 9:29 P.M. Also, NovoLog (insulin) sliding scale (dose depended on blood glucose assessment), scheduled for 9:00 P.M., was not administered until 11:08 P.M. -On 8/7/2025 NovoLog (insulin) sliding scale (dose depended on blood glucose assessment), scheduled for 9:00 P.M., was not administered until 10:32 P.M. -On 8/11/2025 36000-114000 units creon, scheduled for 7:00 P.M., was not administered until 8:34 P.M. -On 8/13/2025 2025 NovoLog (insulin) sliding scale (dose depended on blood glucose assessment), scheduled for 9:00 P.M., was not administered until 11:55 P.M. -On 8/12/2025 10 gram lokelma packet, scheduled at 7:00 A.M., was not administered until 11:12 A.M. Resident 8's record lacked documentation regarding why medications had not been administered on time. 3. A review of Resident 29's record was completed on 8/15/2025 at 1:48 P.M. Diagnoses included, but were not limited to: Alzheimer's disease, insomnia and osteoarthritis. Resident 29's current Physicians' orders included, but were not limited to: - 25 mg quetiapine (regulates mood and behaviors) tablet 3 times daily - 50 mg quetiapine tablet 3 times a day -0.5 mg risperidone (an antipsychotic) tablet twice a day -50 micrograms (MCG) levothyroxine (treats hypothyroid) tablet once daily -15 mg Meloxicam (pain reliefer) tablet A review of Resident 29's July and August 2025 MARs indicated the following medications were given an hour and a half late (or later) past the scheduled administration time: - On 7/27/2025 25 mg quetiapine, scheduled for 7:00 A.M., was not administered until 9:57 A.M. - On 7/28/2025 25 mg quetiapine, scheduled for 11:15 A.M., was not administered until 2:42 P.M. - On 7/29/2025 25 mg quetiapine, scheduled for 7:00 A.M., was not administered until 8:34 A.M. - On 7/29/2025 25 mg quetiapine, scheduled for 11:15 A.M., was not administered until 12:55 P.M. - On 7/31/2025 25 mg quetiapine, scheduled for 7:00 A.M., was not administered until 8:32 A.M. - On 8/1/2025 25 mg quetiapine, scheduled for 7:00 A.M., was not administered until 9:28 A.M. -On 8/1/2025 0.5 mg risperidone, scheduled for 4:00 P.M., was not administered until 8:10 P.M. - On 8/2/2025 25 mg quetiapine, scheduled for 7:00 A.M., was not administered until 10:50 A.M. - On 8/3/2025 50 mg quetiapine, scheduled for 7:00 A.M., was not administered until 9:38 A.M. - On 8/6/2025 50 mg quetiapine, scheduled for 7:00 A.M., was not administered until 8:49 A.M. -On 8/8/2025 50 mg quetiapine, scheduled for 11:15 A.M., was not administered until 12:52 P.M. -On 8/9/2025 50 mg quetiapine and 15 mg meloxicam, scheduled for 7:00 A.M., was not administered until 12:20 P.M. - On 8/10/2025 75 MCG levothyroxine, scheduled for 6:00 A.M., 50 mg quetiapine and 15 mg meloxicam, scheduled for 7:00 A.M., were not administered until 10:25 A.M. -On 8/10/2025 50 mg quetiapine, scheduled for 11:15 A.M., was not administered until 3:44 P.M. Resident 29's record lacked any documentation indicating why medications had not been administered on time. 4. During an interview on 8/14/2025 at 11:05 A.M., Resident 51 indicated his medications were late four days out a typical week. A review of Resident 51's record was completed on 8/15/2025 at 2:08 P.M. Diagnoses included, but were not limited to: cellulitis, congestive heart failure, esophageal varices, atrial fibrillation and type 2 diabetes mellitus. Resident 51's current Physicians' orders included, but were not limited to: - 40 mg furosemide (diuretic) tablet twice a day -insulin Lispro inject 10 units before meals -20 mg omeprazole (stomach acid reducer) one time daily -20 mg escitalopram (anti-depressant) tablet once daily -150 mg bupropion (anti-depressant) tablet once daily -5 mg apixaban (blood thinner) tablet twice daily -25 mg metoprolol (anti-hypertensive) tablet once daily -20 milliequivalent (MEQ) Potassium chloride tablet once a day on Monday, Wednesday and Friday. A review of Resident 51's July and August 2025 MARs indicated the following medications were given an hour and a half late (or later) past the scheduled time: -On 7/17/2025 10 units insulin Lispro, scheduled for 7:30 A.M., was not administered until 11:07 A.M. - On 7/20/2025 20 mg omeprazole capsule, scheduled for 7:00 A.M., was not administered until 8:56 A.M. - On 7/22/2025 20 mg omeprazole capsule, scheduled for 7:00 A.M., 10 units insulin Lispro, scheduled for 7:30 A.M. and 40 mg furosemide, scheduled for 8:00 A.M., were not administered until 9:58 A.M. -On 7/23/2025 20 mg escitalopram tablet, 150 mg bupropion tablet, 25 mg metoprolol, 20 MEQ potassium chloride tablet, 40 mg furosemide tablet scheduled for 7:00 AM and 10 units insulin Lispro, scheduled for 7:30 A.M., were not administered until 12:22 P.M. -On 7/26/2025 20 mg omeprazole capsule, scheduled for 7:00 A.M., was not administered until 9:01 A.M. 10 units of insulin Lispro, scheduled for 7:30 A.M., was not administered until 10:19 A.M. -On 7/30/2025 20 mg omeprazole capsule, scheduled for 7:00 A.M. and 40 mg furosemide tablet, scheduled for 8:00 A.M., were not administered until 12:00 P.M. -On 7/31/2025 20 mg omeprazole capsule, scheduled for 7:00 A.M., was not administered until 9:07 A.M. 10 units insulin Lispro, scheduled for 7:30 A.M., was not administered until 11:03 A.M. 10 units insulin Lispro, scheduled for 12:30 P.M., was not administered until 5:55 P.M. -On 8/5/2025 40 mg furosemide tablet, scheduled for 8:00 A.M., was not administered until 10:09 A.M. 10 units insulin Lispro,scheduled for 12:30 P.M., was not administered until 5:15 P.M. -On 8/6/2025 20 mg omeprazole capsule, scheduled for 7:00 A.M., was not administered until 8:50 A.M. -On 8/8/2025 20 mg omeprazole capsule, scheduled for 7:00 A.M., was not administered until 8:46 A.M. -On 8/10/2025 20 mg omeprazole capsule, scheduled for 7:00 A.M., 500 mg cephalexin capsule and 40 mg furosemide tablet , scheduled for 8:00 A.M., were not administered until 9:46 A.M. Resident 51's record lacked any documentation indicating why medications had not been administered on time. 5. A review of Resident 67's record was completed on 8/15/2025 at 2:30 P.M. Diagnoses included, but were not limited to: alcoholic cirrhosis of liver with ascites, constipation, chronic kidney disease, generalized anxiety disorder, post-traumatic stress disorder and chronic pain. Resident 67's current Physicians' orders included, but were not limited to: - 1 drop carboxymethyl [NAME]-glycerin each eye twice a day - 8.6-50 mg sennosides-docusate (stool softener) tablet once daily - 25 mg lamotrigine (treats bipolar disorder) once daily -400 units ergocalciferol (Vitamin D2) tablet twice daily -50 mg doxepin (anti-depressant) capsule once daily -2.5 mg apixaban(blood thinner) tablet twice daily -81 mg aspirin tablet once daily -100 mg doxycycline (antibiotic) tablet two times daily for 7 days. A review of Resident 67's July and August 2025 MARs indicated the following medications were given an hour and a half late (or later), past the scheduled time: -On 7/16/2025 8.6-50 mg sennosides-docusate tablet, scheduled for 8:00 A.M., was not administered until 10:10 A.M. -On 7/17/2025 25 mg lamotrigine tablet, 10 MCG ergocalciferol tablet, 1 drop into each eye of carboxymethyl [NAME] – glycerin, 50 mg doxepin capsule and 2.5 mg apixaban tablet, scheduled for 7:00 A.M., were not administered until 2:07 P.M. 8.6-50 mg sennosides-docusate and 81 mg aspirin tablet once daily, scheduled for 7:00 A.M., were not administered until 2:07 P.M. -On 7/18/2025 100 mg doxycycline tablet, scheduled for 7:00 A.M., was not administered until 11:47 A.M. - On 7/21/2025 8.6-50 mg sennosides-docusate tablet, scheduled for 8:00 A.M., was not administered until 9:42 A.M. -On 7/25/2025 8.6-50 mg sennosides-docusate tablet, scheduled for 8:00 A.M., was not administered until 10:40 A.M. -On 7/27/2025 8.6-50 mg sennosides-docusate tablet was scheduled for 8:00 A.M., was not administered until 10:10 A.M. - On 7/31/2025 81 mg aspirin tablet, scheduled for 7:00 A.M., was not administered until 3:29 P.M. 8.6-50 mg sennosides-docusate tablet, scheduled for 8:00 A.M., was not administered until 10:10 A.M. -On 8/2/2025 8.6-50 mg sennosides-docusate tablet, scheduled for 8:00 A.M., was not administered until 11:01 A.M. -On 8/4/2025 1 drop into each eye of carboxymethyl [NAME] – glycerin, scheduled for 7:00 P.M., was not administered until 8/5/2025 at 12:33 A.M. -On 8/5/2025 10 MCG ergocalciferol tablet, 81 mg aspirin tablet, 50 mg doxepin capsule and 2.5 mg apixaban tablet, 25 mg lamotrigine and 1 drop into each eye of carboxymethyl [NAME] – glycerin, scheduled for 7:00 A.M., were not administered until 3:43 P.M. -On 8/12/2025 8.6-50 mg sennosides-docusate tablet, scheduled for 8:00 A.M., was not administered until 9:51 A.M. -On 8/13/2025 8.6-50 mg sennosides-docusate tablet, scheduled for 8:00 A.M., was not administered until 9:50 A.M. Resident 67's record lacked any documentation indicating why medications had not been administered on time. 6. During an interview on 8/14/2025 at 2:00 P.M., Resident 69 indicated her medications were late almost daily and the facility's staff had not followed the Physician's orders related to administering her blood pressure medication. A review of Resident 69's record was completed on 8/15/2025 at 2:55 P.M. Diagnoses included, but were not limited to: bradycardia, chronic obstructive pulmonary disease, generalized anxiety disorder, insomnia, Parkinson's disease, type 2 diabetes mellitus, end stage renal disease, major depressive disorder and paroxysmal atrial fibrillation. Resident 69's current Physicians' orders included, but were not limited to: -150 mg oxcarbazepine (anti-convulsant) tablet twice daily -800 mg sevelamer carbonate (phosphate binder) tablet with meals -75 mg pregabalin (treats nerve pain) capsule twice daily -100 mg docusate (stool softener) capsule one time a day. -10-325 mg hydrocodone-acetaminophen (pain reliever) three times daily -5 mg midodrine (raises blood pressure) tablet three times daily. Hold medication if systolic blood pressure is greater than 125. -25-100 mg carbidopa-levodopa (treats Parkinson's) tablet three times daily -81 mg aspirin tablet once daily -100-25 mcg fluticasone furoate-vilanterol (treats chronic obstructive pulmonary disease) 1 puff once daily -75 mg Rimegepant (treats migraines) tablet once daily -20 mg omeprazole (decreases stomach acid) tablet -0.5 mg lorazepam (anti-anxiety) A review of Resident 69's July and August 2025 MARs indicated the following medications were given an hour and a half late (or later), past the scheduled time: - On 7/14/2025 75 mg pregabalin capsule, 150 mg oxcarbazepine tablet and 100 mg docusate tablet, scheduled for 9:00 A.M., were not administered until 10:41 A.M. -On 7/18/2025 75 mg pregabalin capsule, 150 mg oxcarbazepine tablet and 100 mg docusate tablet , scheduled for 9:00, were not administered until 10:25 A.M. -On 7/20/2025 10-325 mg hydrocodone-acetaminophen tablet and 800 mg sevelamer carbonate tablet,scheduled for 7:00 A.M., were not administered until 8:57 A.M. -On 7/21/2025 800 mg sevelamer carbonate tablet, scheduled for 12:00 P.M., was not administered until 1:41 P.M. - On 7/22/2025 10-325 mg hydrocodone-acetaminophen tablet and 800 mg sevelamer carbonate tablet, scheduled for 7:00 A.M., and 5 mg midodrine tablet and 25-100 mg carbidopa-levodopa tablet, scheduled for 8:00 A.M., were not administered until 10:02 A.M. -On 7/23/2025 81 mg aspirin tablet, 1 puff 100-25 mcg fluticasone furoate-vilanterol and 75 mg Rimegepant tablet, scheduled for 7:00 A.M., and 5 mg midodrine tablet, scheduled for 8:00 A.M., were not administered until 12:25 P.M. -On 7/24/2025 5 mg midodrine tablet and 25-100 mg carbidopa-levodopa tablet, scheduled for 2:00 P.M., were not administered until 4:44 P.M. -On 7/26/2025 800 mg sevelamer carbonate tablet, scheduled for 7:00 A.M., was not administered until 8:42 A.M. -On 7/28/2025 800 mg sevelamer carbonate tablet and 10-325 mg hydrocodone-acetaminophen tablet, scheduled for 7:00 A.M., were not administered until 8:37 A.M. -On 8/1/2025 5 mg midodrine tablet and 25-100 mg carbidopa-levodopa tablet, scheduled for 2:00 P.M., were not administered until 3:33 P.M. -On 8/3/2025 75 mg pregabalin capsule, 150 mg oxcarbazepine tablet and 100 mg docusate tablet, scheduled for 9:00, were not administered until 11:58 A.M. -On 8/4/2025 5 mg midodrine tablet and 25-100 mg carbidopa-levodopa tablet, scheduled for 2:00 P.M., were not administered until 3:36 P.M. -On 8/5/2025 75 mg pregabalin capsule, 150 mg oxcarbazepine tablet and 100 mg docusate tablet, scheduled for 9:00, were not administered until 10:49 A.M. -On 8/6/2025 800 mg sevelamer carbonate tablet, scheduled for 11:00 A.M, was not administered until 3:15 P.M. 5 mg midodrine tablet and 25-100 mg carbidopa-levodopa tablet, scheduled for 2:00 P.M., were not administered until 3:15 P.M. -On 8/7/2025 800 mg sevelamer carbonate tablet, scheduled for 11:00 A.M, was not administered until 12:55 P.M. -On 8/8/2025 20 mg omeprazole tablet, scheduled for 7:00 A.M., was not administered until 12:27 P.M. -On 8/11/2025 250 mg cephalexin capsule, 81 mg aspirin tablet, 0.5 mg lorazepam tablet and 1 puff 100-25 mcg fluticasone furoate-vilanterol, scheduled for 7:00 A.M., were not administered until 12:14 P.M. -On 8/13/2025 5 mg midodrine tablet, scheduled for 2:00 P.M., was not administered until 4:22 P.M. Resident 69's record lacked any documentation indicating why medications had not been administered on time. During an interview on 8/18/2025 at 9:40 A.M., the Director of Nursing (DON) indicated she felt the staff had been administering medications timely, but were not signing off the medications in the electronic charting system until later. The DON indicated the facility's policy was to sign off on medications as soon as the medication had been administered. The DON indicated medications were considered late if they were administered one hour after the ordered administration time. The DON indicated Physicians orders should have been completed as ordered. During an interview on 8/18/2025 at 11:00 A.M., QMA 20 indicated she had not noticed the parameters in some of the medication orders and administered the medication without noting the parameters. QMA 20 indicated medications were to be signed off once the medication had been given. QMA 20 indicated she had received many skills validations, but was not sure if medication administration had been part of those validations. During an interview on 8/18/2025 at 2:00 P.M., QMA 2 indicated medications were to be signed off once the medication had been given to the resident. QMA 2 indicated if medications were given, but not signed off on in the chart, she would have add ed a note indicating what medications were given and what time they were given, and she would then have marked the medication as administered in the Medication Administration Record (MAR). QMA 2 indicated the facility had performed skills validations with her upon hire and yearly. She indicated she believed medication administration had been part of her skills validation. An interview with QMA 18 was completed on 8/18/2025 at 2:15 P.M. QMA 18 indicated if an order indicated to not give a medication based on the blood pressure, the medication should not have been given. QMA 18 indicated medications should be signed off as administered as soon as the medications were given. QMA 18 indicated she had been educated reagarding medication administration in the past and medication administration had been part of her skills validations. During a follow-up interview on 8/19/2025 at 9:50 A.M., the DON indicated it was the facility's policy to follow the Physician's orders as ordered. She indicated if a medication was scheduled to be administered, but administering the medication was dependent on a blood pressure, assessment a blood pressure assessment was to be obtained at the time, or shortly before the medication was to be administered. If the blood pressure was outside of the medication ordered parameters, the medication was not to be given. In addition, the DON indicated if the blood pressure assessment was within parameters of a medication administration, the medication should have been given. During an interview on 8/19/2025 at 10:00 A.M., RN 5 indicated she had plenty of time to get all her work done during the shift. RN 5 indicated medications should be signed off once they had been administered. RN 5 indicated she had received a skills validation on medication administration upon hire. RN 5 indicated she was unable to recall if timeliness was part of the facilities medication administration validation, but following the order, including checking parameters for vitals, had been included in the validation. 7. On 8/13/2025 at 10:15 A.M., Resident 15 was observed without TED hose (medical-grade compression stockings used to prevent blood clots and swelling in the legs) on her legs. On 8/14/2025 at 11:10 A.M., observed Resident 15 without compression hose on either leg. On 8/15/2025 at 1:49 P.M., observed Resident 15 without TED hose visible on legs. The clinical record of Resident 15 was reviewed on 8/14/2025 at 11:06 A.M. The resident's diagnoses included, but were not limited to: wedge compression fracture of T10-T11 vertebrae with subsequent encounter for fracture with delayed healing, heart failure, post-traumatic stress disorder, schizoaffective disorder - bipolar type, chronic pain syndrome, anxiety, chronic obstructive pulmonary disorder, cellulitis of left lower limb, hypertension and non-pressure ulcer of left lower leg. A Significant Change Minimum Data Set (MDS) assessment, dated 6/10/2025, indicated Resident 15 was cognitively intact. The Significant Change MDS assessment indicated the resident required supervision for upper body dressing and partial assistance for lower body dressing. A Physician order, dated 1/30/2025, indicated Resident 15 was to wear TED hose in the morning and have them removed in the evening. The August 2025 Medication Administration Record indicated nursing staff had applied the TED hose to Resident 15 on the following dates at the administration time of 0700: 8/13/2025, 8/14/2025 and 8/15/2025. During an interview, on 8/14/2025 at 11:28 A.M., Employee 13 indicated Resident 15 did not wear TED hose.During an interview, on 8/14/2025 at 1:08 P.M., Employee 2 indicated Resident 15 sometimes wore her TED hose, it just depended if the resident let the facility staff put the compression hose on her. Employee 2 indicated if Resident 15 refused, she would have notified the nurse. During an interview, on 8/15/2025 at 1:53 P.M., the Corporate Regional Nurse Consultant indicated when a resident refused treatment, the nurse should have documented on the Treatment Administration Record (TAR) and select refused and then would have been no other documentation. The Corporate Regional Nurse Consultant indicated if the nurse documented OTHER, the nurse should have documented in the progress notes and indicated the nurse should have tried to reapproach the resident but cause stress to the resident. 8. The clinical record for Resident 1 was reviewed on 8/18/2025 at 8:47 A.M. The resident's diagnoses included, but were not limited to: bipolar disorder, hypertension, restless leg syndrome, hemiparesis and hemiplegia following cerebral infarction affecting left non-dominant side, schizoaffective disorder, diabetes mellitus and atrial flutter. A Quarterly Minimum Data Set (MDS) assessment, dated 7/17/25, indicated Resident 1 was cognitively intact and received antipsychotic, antidepressant, anticoagulant and insulin medications. A Physician Order, dated 7/26/2024, indicated Resident 1 was to receive an Accu Check (refers to a brand of blood glucose monitoring systems and related products designed for people with diabetes) four times daily before meals and at bedtime. A Physician Order, dated 4/22/2025, indicated Resident 1 was to receive Humalog Injection Solution 100 unit/milliliter (mL) injection per sliding scale: if 151-200 = 3 units; 201-250 = 5 units; 251-300 = 8 units; 301-350 = 10 units; 351-400 = 12 units; greater than 400 = 15 units and notify MD, subcutaneously before meals and at bedtime. A current Care Plan, revised on 7/15/2025, indicated Resident 1 had interventions including, but not limited to: blood sugars as ordered by the doctor. The August 2025 Medication Administration Record (MAR) indicated Resident 1 had not had his blood sugar monitored as ordered on the evening of 8/5/2025 and had not received any subsequent sliding scale insulin on the evening of 8/5/2025. During an interview, on 8/18/2025 at 10:49 A.M., Employee 14 indicated Resident 1 had his blood sugar checked before every meal and at bedtime. Employee 14 indicated Resident 1 had sliding scale coverage for any blood sugar that was out of range according to the orders. Employee 14 indicated if a resident refused a blood sugar check, then she re-approached the resident and educated the resident on the importance of having their blood sugar monitored. Employee 14 indicated if the blood sugar assessment had been forgotten and not performed, she would have checked the resident's blood sugar as soon as possible and then notified the doctor and notified the supervisor regarding the delay in care. During an interview, on 8/18/2025 at 12:12 P.M., the Director of Nursing (DON) indicated she believed the nurse had performed the blood sugar on 8/5/2025 and the nurse should have signed off the Medication Administration Record (MAR). 9. The clinical record for Resident 4 was reviewed on 8/14/2025 at 2:05 P.M. The resident's diagnoses included, but were not limited to: urinary tract infection, diabetes mellitus with neuropathy, giant cell arteritis, prosthetic heart valve, dissection of aorta, vascular dementia, depression, anxiety, abnormal coagulation profile and chronic pain syndrome. A Significant Change Minimum Data Set (MDS) assessment, dated 7/14/2025, indicated Resident 4 was moderately cognitively impaired. A Physician Order, dated 8/4/2025, indicated Resident 4 received Ertapenem Sodium Solution Reconstituted 1 gram (an antibiotic) intravenously every 24 hours for ESBL (refers to a urinary tract infection caused by bacteria that produce extended-spectrum beta-lactamases) for 13 days. The August MAR indicated Resident 4 had not received the dose of Ertapenem Sodium scheduled for 8/15/2025. A current Care Plan, dated 7/29/2025, indicated Resident 4 required intravenous (IV) antibiotics due to urinary tract infection and interventions included but were not limited to: administer IV antibiotics as ordered. During an interview, on 8/19/2025 at 9:12 A.M., Employee 15 indicated the nurse had probably forgotten to chart the antibiotic on 8/15/2025 for Resident 4. Employee 15 indicated the nurse had until the end of her shift to chart all of the medications she had administered. On 8/15/2025 at 9:00 A.M., the DON provided a policy titled, &ldq

Based on record review and interview, the facility failed to ensure nursing staff had the competencies to administer medications timely and/or administer medications as ordered by the Physician for 8 of 8 residents (Resident's 1, 3, 4, 8, 29, 51, 67 and 69.) See F684 for additional information regarding Resident's 1, 3, 4, 8, 29, 51, 67 and 69. Findings include: 1. A record review of Resident 1 was completed on 8/15/2025 at 11:00 A.M. Resident 1's record indicated Physician orders for administering insulin before meals. RN 3 administered the breakfast time insulin on 7/17/2025 at 1:30 P.M. and administered the lunch time insulin on 7/17/2025 at 1:30 P.M. On 7/19/2025, RN 3 administered the breakfast insulin at 11:30 A.M. On 7/23/2025, the breakfast insulin was administered at 11:38 A.M by QMA 22. On 7/29/2025 the lunch (12:00 P.M) insulin was administered by RN 3 at 3:05 P.M. On 8/14/2025 RN 3 administered the lunch meal insulin at 2:24 P.M. Between 7/15/2025 and 8/15/2025, Resident 1 received medications at least an hour and a half (90 minutes) late 24 out of the last 60 shifts. (2 shifts per day)During an interview on 8/18/2025 at 9:40 A.M., the Director of Nursing (DON) indicated she felt the staff had been administering medications timely, but were not signing off the medications until later. The DON indicated the facility's policy was to sign off on medications as soon as the medication were administered. The DON indicated medications were considered late if they were administered one hour after the ordered administration time. The DON indicated Physicians orders should have been completed as ordered. A review of the scheduled mealtimes provided at the survey entrance conference indicated breakfast at the facility was served at 8:00 A.M. and lunch was served at 12:00 P.M.2. Resident 3's record review was completed on 8/15/2025 at 12:00 P.M. Resident 3's record indicated Physician orders for administering insulin before meals. On 7/17/2025, RN 3 administered the breakfast mealtime insulin at 11:05 A.M. On 7/23/2025, the Social Service Director (SSD) administered the breakfast mealtime insulin at 12:27 P.M. On 7/29/2025, QMA 22 administered the breakfast time insulin at 10:55 A.M and the lunch time insulin at 1:56 P.M. On 7/31/2025, RN 3 administered the breakfast time insulin at 10:49 A.M. and the lunch time insulin at 5:56 P.M. On 8/3/2025, RN 6 administered the lunch time insulin at 1:50 P.M. On 8/5/2025, RN 3 administered the lunch time insulin at 5:09 P.M. On 8/12/2025, QMA 22 administered the lunch time insulin at 1:54 P.M. Between 7/15/2025 and 8/15/2025, Resident 3 received medications at least an hour and a half (90 minutes) late 22 out of the last 60 shifts. (2 shifts per day)During an interview on 8/18/2025 at 1:10 P.M., RN 3 indicated she had not given the breakfast and lunch insulin at the same time on 7/17/2025, but had administered the breakfast meal time insulin around 8:00 A.M. (breakfast time) without signing off the electronic record. RN 3 indicated she administered medications timely, but was signing off on the medication administrations later in the shift. She indicated medications should be signed off as administered in the EMR (Electronic Medical Record) as soon as the medication had been given. 3. A record review for Resident 4 was completed on 8/15/2025 at 1:00 P.M. Resident 4's record included a Physician's order to receive insulin at 8:00 P.M. On 7/16/2025, QMA 8 administered the 7/15/2025 8:00 P.M. insulin at 3:12 A.M. On 7/26/2025 at 4:53 A.M.RN 23 administered the 7/25/2025 8:00 P.M. insulin. Resident 4's record also included Physician's orders for administering ertapenem (an antibiotic) once every day. On 8/15/2025, Resident 4 did not receive her dose of ertapenem. Between 7/15/2025 and 8/15/2025, Resident 4 had been administered medications at least an hour and a half (90 minutes) late on 28 out of the last 60 shifts. (2 shifts per day)4. A review of Resident 8's record was completed on 8/15/2025 at 1:30 P.M. Between 7/15/2025 and 8/15/2025, Resident 8 had been administered medications at least an hour and a half late on 29 out of the last 60 shifts. (2 shifts per day)5. A review of Resident 29's record was completed on 8/15/2025 at 1:48 P.M. Between 7/15/2025 and 8/15/2025, Resident 29 had been administered medications at least an hour and a half late on 17 out of the last 60 shifts. (2 shifts per day)6. A review of Resident 51's record was completed on 8/15/2025 at 2:08 P.M. Between 7/15/2025 and 8/15/2025, Resident 51 had been administered medications at least an hour and a half late on 16 out of the last 60 shifts. (2 shifts per day)7. A review of Resident 67's record was completed on 8/15/2025 at 2:30 P.M. Between 7/15/2025 and 8/15/2025, Resident 67 had been administered medications at least an hour and a half late 12 out of the last 60 shifts. (2 shifts per day)8. A review of Resident 69's record was completed on 8/15/2025 at 2:55 P.M. Resident 69's record indicated Physician orders for administering midodrine (increases blood pressure) when Resident 69's systolic blood pressure (bp) was 125 or less and administering hydralazine (decreases blood pressure) when Resident 69's systolic bp was greater than 160. On 7/10/2025 at 8:00 P.M., Resident 69's systolic bp was 141 and QMA 16 administered the midodrine medication. On 7/13/2025 at 8:00 P.M., Resident 69's systolic bp was 143 and QMA 18 administered the midodrine medication. On 7/16/2025 at 8:00 P.M., Resident 69's systolic bp was 130 and QMA 16 administered the midodrine medication. On 7/20/2025 at 8:00 A.M., Resident 69's systolic bp was 155 and QMA 21 administered the midodrine medication. On 7/20/2025 at 8:00 P.M., Resident 69's systolic bp was 134 and QMA 21 administered the midodrine medication. On 7/23/2025 at 8:00 A.M., Resident 69's systolic bp was 142 and the SSD administered the midodrine medication. On 7/27/2025 at 8:00 P.M., Resident 69's systolic bp was 153 and QMA 19 administered the midodrine medication. On 7/31/2025 at 8:00 A.M., Resident 69's systolic bp was 149 and QMA 20 administered the midodrine medication. On 7/31/2025 at 2:00 P.M., Resident 69's systolic bp was 151 and QMA 20 administered the midodrine medication. On 8/4/2025 at 8:00 A.M., Resident 69's systolic bp was 150 and QMA 7 administered the midodrine medication. On 7/31/2025 at 2:00 P.M., Resident 69's systolic bp was not recorded in the resident's record and QMA 7 administered the midodrine medication. On 8/5/2025 at 8:00 A.M., Resident 69's systolic bp was 159 and QMA 17 administered the midodrine medication. On 8/5/2025 at 2:00 P.M., Resident 69's systolic bp was 142 and QMA 17 administered the midodrine medication. On 8/6/2025 at 8:00 A.M., Resident 69's systolic bp was 185 and QMA 18 administered the midodrine medication, but did not administer the hydralazine. medication On 8/15/2025 at 8:00 A.M., Resident 69's systolic bp was 152 and QMA 20 administered the midodrine medication. Between 7/15/2025 and 8/15/2025, Resident 69 had been administered medications at least an hour and a half hour late 19 out of the last 60 shifts. (2 shifts per day)During an interview on 8/18/2025 at 11:00 A.M., QMA 20 indicated she had not noticed the parameters in the order for the midodrine and administered the medication. QMA 20 indicated medications were to be signed off on once the medications had been given. QMA 20 indicated she had received many skills validations, but was not sure if medication administration had been part of those validations. During an interview with QMA 18, completed on 8/18/2025 at 2:15 P.M, she indicated if an order indicated to not give a medication based on a blood pressure, the medication should not have been given. QMA 18 indicated medications should be signed off as administered as soon as the medications were given. QMA 18 indicated she had been educated on medication administration in the past and medication administration had been part of her skills validations. During an interview on 8/18/2025 at 2:00 P.M., QMA 2 indicated the midodrine medication should not have been given to the resident any time the resident's systolic bp was over 125. QMA 2 indicated medications were signed off once the medication had been given to the resident. QMA 2 indicated if medications were given, but not signed off on in the chart, she would have added a note indicating what medications had been given and what time they were given, and she would then have marked the medication as administered in the Medication Administration Record (MAR). QMA 2 indicated the facility had performed skills validations with her upon hire and yearly. She indicated she believed medication administration had been part of her skills validations. During an interview on 8/19/2025 at 9:50 A.M., the DON indicated it is the facilities policy to follow the Physician's orders as ordered. She indicated if a medication was scheduled to be administered, but administering the medication was dependent of a blood pressure, a blood pressure should be obtained at the time, or shortly before the medication should be administered. If the blood pressure was outside of the medication parameters, the medication should not have been given, and if the blood pressure was within the parameters of a medication administration, the medication should have been given. During an interview on 8/19/2025 at 10:00 A.M., RN 5 indicated she had plenty of time to get all her work done during the shift. RN 5 indicated medications should be signed off on once they had been administered. RN 5 indicated she had received a skills validation on medication administration upon hire. RN 5 indicated she was unable to recall if timeliness was part of the facilities medication administration validation, but following the orders, including checking parameters for vitals, had been included in the validation. On 8/18/2025 at 11:50 A.M., the DON provided three documents titled, Medication Administration Competency for QMAs 7, 8 and 16. The facility was not able to provide the Medication Administration Competency documents for QMA 2, RN 3, the SSD or QMAs 19 or 22. On 8/15/2025 at 9:00 A.M., the DON provided a policy titled, Medication Administration, dated 12/12/2023 and indicated the policy was the one currently used by the facility. The policy indicated .Physicians will be notified timely of medication omissions. Instructions on how to proceed (example: administer medication when it becomes available) will be followed per physician order .On 8/18/2025 at 3:00 P.M., the DON provided a policy titled, Physician Orders, dated 11/13/2023 and indicated the policy was the one currently used by the facility. The policy indicated, .purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality .On 8/19/2025 at 1:10 P.M., the Executive Director provided a policy dated 1/2/2024 and title, Orientation. The ED identified the policy as the one currently used by the facility. The policy indicated, .b. Departmental orientation checklist reflect the skills and competencies that each new team member will require to fulfill his or her job responsibilities .5. Checklists will be used to document training and competency evaluations conducted during the orientation process .9. Competency evaluation form process: a. Each new team member is responsible for keeping track of his/her competency evaluation form throughout the orientation process. b. The preceptor, or designee, shall verify competency in each skill or content area a the time competency is demonstrated. The preceptor's initials/signature indicate competency . d. The compiled form is forwarded to the IPSD (if the community has one assigned) otherwise the Director of Nursing, to verify competency in all areas .11. All documentation to support completion of the orientation process shall be maintained in the team member's personal file. 3.1-14 (i)

Based on observation, interview, and record review, the facility failed to revise care plans to reflect the current status for 1 of 22 residents whose care plans were reviewed. (Residents 29)Findings include: During a record review on 8/14/20205 at 11:39 A.M., an admission Minimum Data Set (MDS) assessment indicated Resident 29's cognition was severely impaired, his mobility and locomotion required the use of a manual wheelchair and his activity preferences that were very important to him included listening to music and being around animals and pets. An Activity Care Plan problem, initiated on 7/27/2025, indicated Resident 29 preferred playing cards, watching reality shows, and enjoyed rock and roll music. An intervention indicated that the resident would be verbally reminded of the time and place of the activity. There was no intervention to ensure the resident was physically assisted and taken to the desired activities and there was no intervention to ensure the resident was invited to activities including any animals or pet visits. During an interview on 8/18/2025 at 12:10 P.M. the DON indicated Resident 29 was not able to take herself to any of the activities programs. On 8/18/2025 the DON provided a current policy, dated 5/16/2024, and titled, Comprehensive Care Plan. The policy indicated, .Resident/patient specific interventions that reflect the resident's/patient's needs and preferences and .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to provide personalized activity programs for 2 of 3 residents reviewed for activities. (Resident 29 and 10)Findings included: 1. On 8/13/2025 at 12:36 P.M., Resident 10 was observed seated in her room, watching television. During a continuous observation, on 8/15/2025 from 1:54 P.M. through 2:12 P.M., Resident 10 was observed seated in her room by herself, while bingo was being held by Activities staff in the dining hall. During an interview, on 8/15/2025 at 10:33 A.M., the Activities Director (AD) indicated the activity interventions for a resident depended on their likes and abilities. The AD indicated Resident 10 liked to be around people, listen to music and play bingo. During an interview, on 8/15/2025 at 2:19 P.M., Resident 10 indicated she liked to drink and go outside. During an interview, on 8/18/2025 at 10:23 A.M., the AD indicated outdoor time means the resident was taken outside by facility staff. The AD indicated the resident was recently taken outside by her sister. The Activity Director indicated she had not taken the resident out lately due to the severe heat but the AD indicated the resident liked to play bingo. The clinical record of Resident 10 was reviewed on 8/15/2025 at 2:19 P.M. The resident's diagnoses included, but were not limited to: hemiparesis and hemiplegia following non-traumatic subarachnoid hemorrhage affecting left non-dominant side, malignant neoplasm of left kidney, extrapyramidal and movement disorder, chronic obstructive pulmonary disorder, aphasia following cerebral infarction, vascular dementia, traumatic cerebral edema, schizophrenia, hypertension, depression and dysphagia. A Significant Change Minimum Data Set (MDS) assessment, dated 6/18/2025, indicated the resident was rarely or never understood. and was dependent on staff for all activities of daily living. The Significant Change MDS assessment indicated it was somewhat important for the resident to have music, very important to have pets, somewhat important for the resident to do things with groups of people and very important for the resident to go outside. A current Activity Care Plan, revised on 6/30/2025, included interventions but were not limited to: provide assistance/escort to activity functions. An Activity Report, for Resident 10 for June 2025 and July 2025 indicated the resident participated in her preferred activities on the following dates: - 6/13/2025: social - 6/13/2025: music -7/24/2025: music During an interview, on 8/15/2025 at 10:49 A.M., the AD indicated social means a group activity and not applicable means hydration and movie is a group activity. This is in regards to the printed activity report sheet from the Electronic Medical Record (EMR). 2. During observations on 8/12/2025 at 10:52 A.M. and 8/13/2025 at 10:28 A.M., Resident 29 was in her wheelchair wandering without any noted purpose about the unit. During an observation on 8/14/2025 at 1:38 P.M., Resident 29 was in the dining room on the unit. There was CNA staff in the dining room, but Resident 29 was not engaged in meaningful activity. During an observation on 8/15/2025 at 2:21 P.M., Resident 29 was at the nurses desk picking at her clothes. The nurse was at the desk, but Resident 29 was not engaged in any activity. During an observation on 8/18/2025 at 10:34 A.M., Resident 29 was in bed. CNA 12 indicated the resident had days when she sometimes slept late into the day and then was up all evening. During an interview on 8/18/2025 at 10:14 A.M., the Activity Director indicated Resident 29 had a sensory box in her room and would use it on occasion. She also occasionally attended activities but was a passive observer. The AD indicated the resident liked Rusty, the facility cat, and staff sometimes brought the cat to the activity room to visit with the resident. During an observation of Resident 29's room, on 8/18/2025 at 2:28 P.M., the sensory box was not present where the resident would have been able to access it. During a record review for Resident 29, completed on 8/14/20205 at 11:39 A.M., an admission Minimum Data Set (MDS) assessment indicated Resident 29's cognition was severely impaired and her activity preferences that were very important to her included listening to music and being around animals and pets. An Activity Care Plan problem, initiated on 7/27/2025, indicated Resident 29 preferred playing cards, watching reality shows, and enjoyed rock and roll music. Interventions included verbally reminding the resident of the time and place of the activities ;and reminding the resident that she could leave activities at any time. Activity documentation indicated Resident 29 had been engaged in independent activities on a daily basis for the current month and she had only attended one group activity during the current month. During an interview on 8/18/2025 at 12:10 P.M. The DON indicated the resident was not able to propel her wheelchair by herself to any activity program. On 8/18/2025 at 12:10 P.M. the DON provided a current policy titled, Activity Services, and dated 11/1/2024. The policy indicated, .Activities will be designed with the intent to: .i. Reflect choices of the residents/patients 3.1-33(a)

Based on observation and interview, the facility failed to serve food in a sanitary manner for 1 of 1 dining rooms observed during the lunch meal service. This had the potential to affect 70 of 70 residents in the facility.Finding includes: During a continuous observation on 8/12/2025, from 12:16 P.M. through 12:28 P.M., CNA 11 was observed to serve food with her thumb over the rim of the plate for 2 of 2 residents in the dining hall. During an interview, on 8/12/2025 at 12:29 P.M., CNA 11 indicated she always held plates from the bottom. On 8/13/2025 at 11:30 A.M., the Regional [NAME] President of Operations provided a policy titled, Meal Supervision, dated 12/12/2023 and indicated the policy was the one currently used by the facility. The policy indicated .The facility will utilize a systemic approach to ensure safety throughout the resident's environment .3.1-21(i)(3)

Number of residents sampled:Number of residents cited:Based on observation, record review and interview, the facility failed to ensure aseptic technique and enhanced barrier precautions were maintained during PICC (peripherally-inserted central catheter) care for 1 of 1 residents reviewed for PICC line care. (Resident 7). In addition, the facility failed to ensure oxygen equipment was cleaned for 1 of 2 residents reviewed for respiratory care. (Resident 4) Findings included:1.During an observation, on 8/12/2025 at 2:33 P.M., Resident 4's had a PICC (a peripherally inserted central catheter, or a long, thin, flexible tube inserted into a vein into the arm and threaded into a larger vein near the heart) line dressing on her right upper arm but the date on the dressing not legible because the ink was smudged. The clinical record of Resident 4 was reviewed on 8/14/2025 at 2:05 P.M. The residents' diagnoses included, but were not limited to: urinary tract infection, diabetes mellitus with neuropathy, giant cell arteritis, prosthetic heart valve, dissection of aorta, vascular dementia, depression, anxiety, abnormal coagulation profile and chronic pain syndrome. A Significant Change Minimum Data Set (MDS) assessment, dated 7/14/2025, indicated Resident 4 was moderately cognitively impaired. A Physician Order, dated 8/14/2025, indicated Resident 4 was to have her PICC line dressing changed every 7 days. An August 2025 Medication Administration Record (MAR) indicated Resident 4 had been sent to an acute care center's emergency room for an evaluation and placement of a PICC line for IV (intravenous) antibiotics on 8/1/2025 at 8:08 A.M. A PICC line dressing change was not documented as having been completed until 8/14/2025., 14 days after the PICC line had been placed. A current Care Plan, initiated on 7/29/2025, indicated Resident 4 required intravenous (IV) antibiotics due to urinary tract infection and interventions included but were not limited to: change dressing as ordered. During an interview, on 8/14/2025 at 2:23 P.M., the South Unit Manager indicated the PICC line dressings should be changed once a week, and the PICC line dressing changes should be documented on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). During an interview on 8/19/2025 at 12:22 P.M., the Director of Nursing (DON) indicated nursing employees completed a skill check off for the PICC lines upon hire and at their yearly skill check-off. On 8/19/2025 at 1:05 P.M., the DON provided a policy titled, Assessment, Care and Dressing Changes of Vascular Access Devices, dated 4/6/2018 and indicated the policy was the one currently used by the facility. The policy indicated .Site care, including skin antisepsis and dressing changes, are performed at established intervals .A sterile dressing is applied and maintained on all peripheral, non-tunneled, peripherally inserted central catheters (PICCs) .Dressings are labeled with the date performed or the date to be changed based on facility policy . During an observation of flushing of a peripherally inserted central catheter (PICC line, a flexible tube inserted into a vein in the arm and threaded into a larger vein near the heart. It was used to administer and antibiotic) for Resident 4 on 8/15/2025 at 10:50 A.M., RN 6 did not don a gown before performing the flush until asked when a gown should have been donned. RN 6 also attempted to apply a contaminated cap to the end of the PICC line until the issue was brought to her attention after she was stopped from applying the contaminated cap. During an interview on 8/15/2025 at 10:59 A.M., RN 6 indicated she should have donned a gown before flushing the PICC line per Enhanced Barrier Precaution guidelines. She further indicated she should have used sterile technique to apply the cap to the PICC line. On 8/19/2025 at 12:47 P.M. the DON provided a current policy titled, Enhanced Barrier Precautions and dated, 5/1/2024. The policy indicated, .High-contact resident care activities include: .g. Device care or use: central lines 2. During an observation on 8/13/2025 at 10:15 A.M., Resident 7's oxygen concentrators' filter had a heavy buildup of dust and the nasal canula attached to the concentrator was dated 8/3/2025. Resident 7's record review was completed on 8/15/2025 at 9:20 A.M. Diagnosis included, but were not limited to: chronic obstructive pulmonary disease, end stage renal failure, major depressive disorder and generalized anxiety disorder. A current Physician's order indicated Resident 7 was to have her nasal cannula changed weekly and the oxygen filter was to be cleaned weekly. Resident 7's August Treatment Administration Record (TAR) indicated the nasal cannula had been changed on 8/10/2025, despite the observation on 8/13/2025 with a date of 8/3/2025. In addition, the TAR indicated the the oxygen filter had been cleaned on 8/10/2025. During an observation and interview, on 8/14/2025 at 2:45 P.M. with the Director of Nursing (DON) of Resident 7's oxygen concentrator, the DON indicated the nasal cannula should have been changed weekly and the filter of the oxygen concentrator should not have had a build up of dust. On 8/20/2025 at 1:40 P.M., the Executive Director provided an undated policy titled, Oxygen Concentrator and identified the policy as the one currently used by the facility. The policy indicated, .a. Follow the manufacturer recommendations for the frequency of cleaning filters and servicing the device .c. Nurse responsibilities: i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated 3.1-18 (a)

Based on record review and interview, the facility failed to ensure care plan conferences were completed every quarter for 4 of 4 residents reviewed for care plans. (Residents 13, 8, 59 & 26) Findings include: 1. During an interview on 9/30/2024 at 2:21 P.M., the family of Resident 13 indicated the resident had not had a care plan conference for the [AGE] year. On 10/3/2024 at 9:05 A.M., a record review was completed for Resident 13. The record indicated the resident had been admitted to the facility on [DATE] and a care conference was completed on 4/14/2023. The record lacked documentation a care plan conference had been completed for the [AGE] year. 44111 2. During an interview on 10/1/2024 at 11:04 A.M., Resident 26 indicated she had not had a care plan meeting. A record review was completed on 10/1/2024 at 11:40 P.M., for Resident 26. Diagnoses included, but not limited to: end stage renal disease and peripheral vascular disease. During an interview on 10/3/2024 at 1:59 P.M., the Social Service Director indicated care plan meetings were documented under the evaluation tab titled, IDT care plan conference summary. She indicated Resident 26 should have had a care plan conference in June or July (of 2024). 47419 3. During an interview on 9/30/2024 at 2:25 P.M. Resident 8 indicated he had not been to a Care Conference. A record review for Resident 8 was completed on 10/01/2024 at 2:25 P.M. Diagnoses included type 2 diabetes mellitus with neuropathy, bladder cancer, anxiety and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 7/10/2024, indicated Resident 8's cognition was intact and the resident had participated in planning and goal setting. An IDT Care Conference Summary, dated 1/22/2024, indicated a conference had been held and the resident was in attendance. The record lacked any further meetings or care conferences since that date. During an interview on 10/4/2024 at 2:51 P.M., the Unit Manager indicated Care Conferences had not taken place for Resident 8 as required. 4. During an interview on 10/1/2024 at 8:55 A.M., Resident 59 indicated he did not think he had ever been invited to a Care Conference. A record review was completed on 10/02/2024 at 1:34 P.M. for Resident 59. Diagnoses included, but were not limited to: end stage renal disease, chronic obstructive pulmonary disease and type 1 diabetes with neuropathy. A Quarterly Minimum Data Set (MDS) assessment for Resident 59 indicated his cognition was intact. The assessment indicated the resident had participated in the assessment and goal setting. On a Significant Change MDS assessment, dated 5/7/2024, Resident 59 had indicated it was very important to have a relative or friend involved in discussions about his care. On 9/5/2024 there was documentation a care plan meeting had taken place and Resident 59 had attended. The record lacked any documentation care plan meetings had taken place between 9/1/2023 and 9/5/2024. During an interview on 10/4/2024 at 2:51 P.M., the Unit Manager indicated Care Conferences had not taken place for Resident 59 as required. On 10/4/2024 at 2:51 P.M. the Unit Manager provided a current policy, dated 12/12/2023 and titled, Comprehensive Care Plan. The policy indicated, .The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: The resident and the resident's representative, to the extent practicable . 3.1-35(e)

Based on observation, interview and record review the facility failed store and prepare food in a sanitary manner related to labeling and dating of opened food in the walk-in cooler and disposing of expired spices in 1 of 1 kitchens observed. This had the potential to effect 72 of 74 residents who received their meals from the kitchen. Finding includes: 1. During the initial kitchen tour with the DM (Dietary Manager) on [DATE] at 9:44 A.M., the following food items were observed in the walk-in cooler: -Eight single serve cheese cups did not have a made on or use by date. -Half a bag of salad mix was open but did not have an opened on or use by date. -A bag of celery was open and did not have an opened on or use by date. -7 bowls of salad with clear cellophane wrap did not have a made on or use by date. 2. During the initial kitchen tour with the DM on [DATE] at 9:52 A.M., the following food items were observed in the dry storage areas: - Whole celery seed was opened [DATE] and had an expiration date of [DATE]. - Poultry seasoning was opened but had no opened on date and had an expiration date of [DATE]. - Cayenne pepper was opened but had no opened on date and had an expiration date of [DATE]. - [NAME] sprinkles was opened but had no opened on date and had an expiration date of [DATE]. During an interview on [DATE] at 9:54 A.M., the DM indicated the bag of salad mix and bag of celery should have been labeled with an opened on and a discard date. The 8 cheese cups and 7 bowls of salad should have been labeled with the made on and discard date. All of the spices should have been discarded by the expiration date on the package. During an interview on [DATE] at 1:30 P.M., the DDM (District Dietary Manager) indicated dry spices were good for three years after opening, but spices were not used past the manufactures expiration dates. The DM indicated the facility did not have a policy specific to spices. On [DATE] at 2:52 P.M., the DM provided an undated policy titled, Food Preparation, and indicated it was the policy currently used by the facility. The policy indicated, . 17. All refrigerated, ready-to-eat Time/Temperature Control for Safety prepared foods that are to be held for more than 24 hours at a temperature of 41 degrees Fahrenheit or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7) 3XXX,d+[DATE](i)(3)

Based on observation and record review, the facility failed to provide a dependent resident an assistive device for 1 of 1 residents reviewed for accommodation of needs. (Resident 3) Finding includes: During a family interview on 9/30/2024 at 2:25 P.M., the responsible party for Resident 3 indicated he was concerned Resident 3 did not have a wheelchair to get out of bed. The family member indicated Resident 3 was always in bed when he visited and did not see a wheelchair in his room. Resident 3's family member indicated he would like him to get out of the bed. During an observation on 10/1/2024 at 9:53 A.M., 10/2/2024 at 9:45 A.M., 10/2/2024 at 2:24 P.M., 10/3/2024 at 9:09 A.M., 10/3/2024 at 11:57 A.M., and 10/4/2024 at 1:29 P.M. Resident 7 was in bed and no wheelchair was in the room. A record review was completed on 10/2/2024 at 1:37 P.M., for Resident 3. Diagnoses included, but not limited to: hemiplegia, unspecified affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance, and acquired absence of right leg below knee. A Quarterly Minimum Data Set (MDS) assessment, dated 9/25/2024, indicated Resident 3 had severe cognitive impairment and was dependent on two staff for transfers. The current Care Plans and Nursing Progress Notes were reviewed and there was no indication Resident 3 had refused to get out of bed. During an interview on 10/2/2024 at 2:34 P.M., QMA 3 indicated Resident 3 did not get up from bed because he did not have a chair. She had taken care of Resident 3 a couple of weeks ago and had gotten him up out of bed. She had gone down to therapy and asked for a wheelchair. She indicated she had returned it when she was done. She had asked the therapy department why Resident 3 did not have a wheelchair and they told her there was a process to getting a chair. During an interview on 10/4/2024 at 10:07 A.M., CNA 12 indicated she had worked at this facility for about four years and had taken care of Resident 3 frequently. CNA 12 indicated Resident 3 did not get up and did not have a chair. Although she was aware Resident 3 had been assisted out of bed by QMA 3 a few weeks ago, she did not offer to get him out of bed when she cared for him. During an interview on 10/4/2024 at 10:19 A.M., the Director of Rehab indicated the last time he was in physical therapy (PT) and occupational therapy (OT) was in 2022. She indicated Resident 3 did not know why he did not have a chair, but he should have had one. She indicated some residents preferred to stay in bed. An OT Discharge Summary, dated 8/15/2022-9/8/2022, indicated that he owned a Broda chair (a high back reclining chair with adjustable supports). On 10/4/2024 at 1:41 P.M., the Administrator indicated the facility did not have a policy related to accommodation of resident's needs. 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure a SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Form was provided following the end of Medicare skilled services for 1 of 1 resident who discharged from Medicare services and remained in the facility. (Resident 45) Finding includes: During a review of Beneficiary Notification forms, conducted on 10/4/2024 at 8:45 A.M., a Notice of Medicare Non-Coverage (NOMNC) form had been provided to Resident 45 on 6/26/2024 and indicated the resident's Medicare coverage was ending on 6/28/2024. There was no SNF-ABN (a form that informs a beneficiary that medicare may not pay for a service or item they intend to receive) provided to Resident 45. During an interview on 1/4/2024 at 8:54 A.M., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed. The form was blank in response to whether Resident 45 received the SNF-ABN form. Resident 45 was provided a Notice of Medicare Non-Coverage (NOMNC) Form which indicated Resident 45's Medicare coverage would end on 6/28/2024. On 10/4/2024 at 9:52 A.M., the Social Services Director indicated Resident 45 remained in the facility and did not receive a SNF-ABN form. On 10/4/2024 at 11:10 A.M., the Administrator provided the policy titled Beneficiary Liability Protection Notices ABN, dated 7/2018, and indicated it was the one currently being used by the facility. The policy did not indicate when a SNF-ABN form should have been provided to the resident. 3.1-4(f)(2)

Based on interview and record review, the facility failed to provide the resident, or the resident's representative, with a notice of transfer form for 2 of 2 residents reviewed for hospitalization . (Residents 8 and 59) Findings include: 1. A record review was completed on 10/3/2024 at 2:47 A.M. for Resident 8. Diagnoses included type 2 diabetes mellitus with neuropathy, bladder cancer, anxiety and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 7/10/2024, indicated Resident 8's cognition was intact. During an interview on 9/30/2024 at 2:30 P.M., Resident 8 indicated he had been hospitalized a few months ago but did not remember the specific date. Resident 8 had been sent to the emergency room and was admitted to the hospital on the following dates: -2/21/2024. -3/11/2024. -8/12/2024. The record lacked documentation the facility had provided Resident 8 a Notice of Transfer/Discharge for any of the hospitalization s. During an interview on 10/3/2024 at 2:35 P.M., the Executive Director (ED) indicated there was no documentation the Notice of Transfer/Discharge form was provided to Resident 8. 2. A record review was completed on 10/02/2024 at 1:34 P.M. for Resident 59. Diagnoses included, but were not limited to: end stage renal disease, chronic obstructive pulmonary disease and type 1 diabetes with neuropathy. A Quarterly Minimum Data Set (MDS) assessment for Resident 59 indicated his cognition was intact. During an interview on 10/01/2024 at 9:07 A.M. Resident 59 indicated he had been hospitalized several times but did not know the dates. Resident 59 was sent to the emergency room and hospitalized on the following dates: -6/10/24 -7/1/24 -7/31/24 -9/10/24. The record lacked documentation the facility had provided Resident 59 a Notice of Transfer/Discharge form for any of the hospitalization s. During an interview on 10/3/2024 at 2:35 P.M., the ED indicated there was no documentation the Notice of Transfer/Discharge form was provided to Resident 59. On 10/4/2024 at 2:21 P.M. the ED provided a current policy, dated 12/12/23 and titled, Transfer & Discharge. The policy indicated, .Emergency Transfer/Discharge - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) .Provide a notice of transfer and the facilities bed hold policy to the resident and representative as indicated 3.1-12(8)(D)

Based on interview and record review, the facility failed to provide the resident, or the resident's representative, with a copy of the Bed Hold Policy when sent to the hospital for 2 of 2 residents reviewed for hospitalization . (Residents 8 and 59) Findings include: 1. A record review was completed on 10/3/2024 at 2:47 A.M. for Resident 8. Diagnoses included type 2 diabetes mellitus with neuropathy, bladder cancer, anxiety and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 7/10/2024, indicated Resident 8's cognition was intact. During an interview on 9/30/2024 at 2:30 P.M., Resident 8 indicated he had been hospitalized a few months ago but did not remember the specific date. Resident 8 was sent to the emergency room and admitted to the hospital on the following dates: -2/21/2024. -3/11/2024. -8/12/2024. The record lacked documentation the facility provided Resident 8 a copy of the Bed Hold Policy for any of the hospitalization s. During an interview on 10/3/2024 at 2:35 P.M., the Executive Director (ED) indicated there was no documentation a copy of the facility Bed Hold Policy was provided to Resident 8. 2. A record review was completed on 10/02/2024 at 1:34 P.M. for Resident 59. Diagnoses included, but were not limited to: end stage renal disease, chronic obstructive pulmonary disease and type 1 diabetes with neuropathy. A Quarterly Minimum Data Set (MDS) assessment for Resident 59 indicated his cognition was intact. During an interview on 10/01/2024 at 9:07 A.M. Resident 59 indicated he had been hospitalized several times but did not know the dates. Resident 59 had been sent to the emergency room and hospitalized on the following dates: -6/10/24 -7/1/24 -7/31/24 -9/10/24. The record lacked documentation the facility provided Resident 59 a copy of the Bed Hold Policy for any of the hospitalization s. During an interview on 10/3/2024 at 2:35 P.M., the Executive Director (ED) indicated there was no documentation a copy of the Bed Hold Policy was provided to Resident 59. On 10/4/2024 at 2:21 P.M. the ED provided a current policy, dated 12/12/2023 and titled, Bed Hold. The policy indicated, .In the event of an emergency transfer of the resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated on the State's plan 3.1-12(a)(25)(26)

Based on interview and record review, the facility failed to develop a person-centered care plan regarding fluid needs for 1 of 18 residents whose care plans were reviewed. (Resident 8) Finding includes: A record review was completed on 10/01/2024 at 2:25 P.M. for Resident 8. Diagnoses included type 2 diabetes mellitus with neuropathy and congestive heart failure. A Quarterly Minimum Data Set (MDS) assessment, dated 7/10/2024, indicated Resident 8's cognition was intact. Physician's Orders for Resident 8 included, but were not limited to: -6/28/2024 2000 milliliter (ml) daily fluid restriction for edema and congestive heart failure. -4/3/2024 Furosemide 40 milligrams (mg) by mouth two times a day related to hypertensive heart disease and congestive heart failure. A current Care Plan, initiated on 9/12/2022, indicated Resident 8 was at risk for a fluid imbalance related to acute kidney failure and diuretic use. Interventions included, but were not limited to: staff was to educate the resident and family on the importance of the fluid restriction, as well as the risks and the potential negative outcomes of not adhering to the recommended fluid restrictions. There were no specific instructions regarding the amount of fluids each shift and department were allotted to maintain the ordered fluid restrictions. During an interview on 10/04/2024 at 9:42 A.M., the Unit Manager indicated the fluid restriction should have been broken down as to how much each shift and department had available per day, and the care plan should have included this information. 3.1-35(d)(1)(2)(A)(B)

Based on observation, interview and record review, the facility failed to ensure resident were assisted with personal hygiene and showers for 3 of 4 records reviewed for Activities of Daily Living (ADL). (Resident 3 & 24) Findings include: 1. During a family interview on 9/30/2024 at 3:08 P.M., the responsible party indicated he did not think Resident 3 had been getting up out of bed to be given a shower. During an observation on 10/1/2024 at 9:53 A.M., 10/3/2024 at 9:09 A.M. and on 10/4/2024 at 9:03 A.M., Resident 3 had long finger nails with a brown substance under them. A record review was completed on 10/2/2024 at 1:37 P.M., for Resident 3. Diagnoses were included, but not limited to: hemiplegia, unspecified affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance and acquired absence of right leg below knee. A Quarterly Minimum Data Set (MDS) assessment, dated 9/25/2024, indicated Resident 3 had severe cognitive impairment, had limited range of motion to one side of his body and bathing and personal hygiene needs were not documented on the assessment. A current Care Plan, dated 6/23/2019, titled Activities of DailyLiiving, had interventions including bathing/showering and nail care on bath day, bathing/showering staff to provide assist. A current Care Plan, initiated on 8/17/2021, titled At Risk for Adverse Consequences: Refused Hygiene after Bathing. Interventions included, but were not limited to: document behaviors and if resident becomes combative or resistive, postpone care/activity and allow resident to regain their composure and reapproach as needed. Resident 3 was scheduled every Monday and Thursday evening for a shower. A review of recent Nursing Progress Notes did not indicate he had refused care. The documentation for showers for Resident 3, from 9/1/2024 - 10/1/2024, indicated he had not received a shower. Refusal of care/showers was not documented. The bathing section indicated he was dependent for bathing. A review of behavior charting indicated there had been no documentation of rejection of care or any behaviors for the past 30 days, 9/1/2024 - 10/1/2024. A review of bathing/bed bath, dated 9/1/2024 -10/2/2024, indicated Resident 3 had received five complete bed baths, on 9/2/2024, 9/5/2024, 9/19/2024, 9/23/2024 and 9/30/2024. A review of shower sheets indicated he had received a bed bath on 9/19/2024. During an interview on 10/2/2024 at 2:34 P.M., QMA 3 indicated when she performed morning care she washed the residents face, underarms and peri area, let the resident pick out their outfit then dressed the resident, set the resident up for oral care and changed the sheets. During an interview on 10/4/2024 at 10:07 A.M., CNA 12 indicated when she provided morning care, she assisted with washing the residents up for the day and dressed them. She indicated she had provided Resident 3 a shave, washed his face and peri area, pulled him up in bed and assisted him with his breakfast. She had not looked at his nails and had not seen the dirt or long length of his nails. She indicated if a resident refused a shower, she documented it in the point of care (POC) and informed the nurse. She indicated Resident 3 had not had any behaviors or refusals. During an interview on 10/4/2024 at 11:12 A.M., the DON indicated refusals should be documented in the POC or in the progress notes. She indicated she did not see documentation for bathing on 9/9/2024, 9/12/2024, 9/16/2024 and 9/26/2024 and he should have been offered bathing. Every resident should be offered two showers a week. She would have expected the plan of care to reflect his preference and it did not. On 10/3/2024 at 10:54 A.M., the Unit Manager provided a policy titled, Interdisciplinary Team (IDT) Risk Review Meeting, dated 1/2/2024, and indicated the policy was the one currently used by the facility. The policy indicated, 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises . 48145 2. During an observation on 9/30/2024 at 2:15 P.M., Resident 24 was in the hallway by the Activities room and her bottom teeth had a build-up of a thick white substance. During an observation on 10/1/2024 at 9:04 A.M., Resident 24 had a brown substance around her mouth and her bottom teeth had a build-up of a thick white substance. During an observation on 10/2/2024 at 2:23 P.M., Resident 24's bottom teeth had a build-up of a thick white substance. Resident 24's record review was completed on 10/2/2024 at 2:45 P.M. Diagnoses included, but were not limited to: hemiplegia and hemiparesis affecting right side, aphasia, dysphagia, vascular dementia, major depressive disorder and generalized anxiety disorder. A Quarterly MDS (Minimum Data Set) assessment, dated 8/28/2024, indicated Resident 24 had severe cognitive impairment, was rarely able to make herself understood, sometimes understood others and required supervision or assistance with oral care. A current Care Plan, initiated on 11/21/2021 and revised on 1/11/2023, indicated Resident 24 needed assistance with activities of daily living related to a personal history of a cerebrovascular accident resulting in right sided hemiplegia. The Care Plan included a goal for the resident to have her daily care needs met with the assistance of staff. Interventions included, but were not limited to: Staff to assist/encourage oral care twice daily and as needed. Notify nurse of any redness, irritation or complaints of oral pain. A current Care Plan, initiated on 8/1/2021, indicated Resident 24 had oral/dental health problems related to missing teeth. The goal of the Care Plan was for the resident to be free of infection, pain or bleeding in the oral cavity. Interventions to the Care Plan included, but were not limited to: Provide mouth care or encourage resident to perform oral care twice daily and as needed. Documentation of oral care for Resident 24, for the past month indicated oral care had only been offered once a day for the following dates: 9/6/2024, 9/7/2024, 9/8/2024, 9/9/2024, 9/10/2024, 9/12/2024, 9/13/2024, 9/14/2024, 9/22/2024, 9/23/2024, 9/24/2024, 9/25/2024, 9/30/2024 and 10/1/2024. There was no documentation Resident 24 had refused oral care. During an interview on 10/3/2024 at 2:34 P.M., QMA (Qualified Medication Aid) 3 indicated oral care was part of AM (morning) and PM (evening) care. She indicated Resident 24 was not able to brush her own teeth without encouragement and most days, the resident required the staff to manually brush her teeth for her. QMA 3 indicated the resident's teeth appeared like they had not been brushed due to the amount of build-up on the resident's bottom teeth. On 10/3/2024 at 2:52 P.M., the Unit Manager provided an undated policy titled, Oral Care, and indicated it was the policy used by the facility. The policy indicated, It is the practice of this facility to provide oral care to residents in order to prevent and control plaque-associated oral diseases 3.1-38 (a)(2)(A) 3.1-38 (a)(3)(C) 3.1-38 (a)(3)(E)

Based on interview, observation and record review, the facility failed to follow the Physician's orders related to flushing a G-tube (gastrointestinal tube) and changing the tubing for 2 of 2 residents who were reviewed for a G-tube. (Resident 222 & 7) Findings include: 1. During an interview on 10/1/2024 at 9:57 A.M., Resident 222 indicated his G-tube was not being used for nutrition or medications but it was supposed to be flushed twice a day. He indicated his G-tube had only been flushed once since his admission on 9/24/2024. During an interview on 10/2/2024 at 10:40 A.M., Resident 222 indicated his G-tube had not been flushed the last two days. During an observation on 10/2/2024 at 10:41 A.M., no medical equipment for flushing a G-tube was located in the residents room, bathroom or trash can. Resident 222's record review was completed on 10/2/2024 at 11:45 A.M. Diagnoses included, but were not limited to: paraplegia, fusion of lumbar spine, neurogenic bowel and neuromuscular dysfunction of bladder. A current Physician's order, dated 9/26/2024, indicated the resident's G-tube was to be flushed with 60 milliliters of water every shift. A current Care Plan, initiated on 9/26/2024, indicated the resident was at risk of complications of tube feeding and had a goal of being free from complications of G-tube flushes. Interventions included, but were not limited to: Check for tube placement and gastric contents/residual volume per facility protocol and record, and provide water flushes per Physician's orders. Resident 222's record lacked the documentation he had refused any G-tube flushes. The October 2024 TAR (Treatment Administration Record) indicated Resident 222's G-tube had been flushed twice on 10/1/2024 and once on 10/2/2024. During an interview on 10/02/2024 at 11:50 A.M., Resident 222 indicated staff had not flushed his G-tube in the past two days. During an interview on 10/2/2024 at 11:55 A.M., LPN 2 indicated she had flushed Resident 222's G-tube earlier in the morning. However, she was unable to locate the equipment she had used after the flush. She then indicated she had not flushed his G-tube that morning and marked the documentation complete by mistake. She indicated treatments should not be documented as completed in the medical record until after the task had been completed. During an interview on 10/2/2024 at 11:57 A.M., the Unit Manager indicated she knew the resident's G-tube had been flushed yesterday because she was the one that had flushed his G-tube during the second shift. When asked if it was her initials on the October 2024 TAR for the October 1st second shift G-tube flush, she indicated it was not her initials and she had not signed off on the TAR. She indicated treatments should be signed off in the medical record after the treatment was performed and by the staff member who completed the treatment. 44111 2. During an observation on 10/1/2024 at 9:09 A.M., there was a bottle of tube feeding formula for Resident 7 hanging with a date of 10/1 and time of 0500 in red marker on the side of the bottle. The rest of the label to indicate the resident's name, room number, rate of infusion and nurse's initials were left blank. There was also a bag of clear liquid, dated 10/1 at 0500 hanging on the pole. During an observation on 10/2/2024 at 9:00 A.M., the bag with clear liquid dated 10/1 with a time of 0500 in red marker and a bottle of tube feeding formula dated 10/2 with a time of 2 A.M. were noted hanging. A package with a syringe was dated 6/21/2024 without a name. A record review was completed on 10/2/2024 at 9:39 A.M., for Resident 7. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side and vascular dementia. A Physician's Order, dated 3/28/2024, indicated to change the container, G-tube tubing and syringe every 24 hours, every night and to label with the resident's name and date. During an interview on 10/2/2024 at 9:39 A.M., RN 11 indicated the tube feeding formula and the bag of clear liquid had different dates and the system should have been changed daily with labels filled out and on the syringe. She indicated the syringe was just opened this morning and she did not put the resident's name or date on the syringe. She indicated she had not see the 6/21/24 date. On 10/2/2024 at 12:19 P.M., the Unit Manager provided an undated policy, titled, Documentation in the Medical Record and indicated it was the policy used by the facility. The policy 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 .b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care On 10/2/2024 at 12:19 P.M., the Unit Manager provided a policy titled, Enteral Feeding, dated 1/2/2024, and indicated the policy was the one currently used by the facility. The policy indicated .It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . 3.1-44

Based on observation, record review and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 2 of 4 residents (Resident 28 & 35) observed during medication pass. There were 25 opportunities observed with 2 medication errors, resulting in a medication error rate of 8 percent. Findings include: 1. During an observation and interview on 10/2/2024 at 9:15 A.M., RN 11 did not have Resident 28's fluticasone propionate available to administer and indicated she would call the pharmacy. A record review was completed on 10/2/2024 at 10:00 A.M., for Resident 28. Diagnoses included but were not limited to: chronic pain syndrome and allergies. A Physician's Order, dated 3/28/2024, indicated Fluticasone Propionate suspension 50 micrograms (MCG) one spray in each nostril one time a day for allergies. 2. During an observation and interview on 10/2/2024 at 10:11 A.M., for Resident 35, RN 11 indicated she did not know why there were two inhalers in the opened bag in the medication drawer. She indicated neither inhaler had an opened date on them, she was not going to administer the medication. She indicated she would notify pharmacy to send a new one. A record review was completed on 10/2/2024 at 10:05 A.M., for Resident 35. Diagnoses included but were not limited to: chronic obstructive pulmonary disease. A Physician's Order, dated 8/9/2023, indicated Albuterol Sulfate 90 mcg, give two puffs three times a day. During an interview on 10/3/2024 at 2:28 P.M., the DON indicated the Albuterol was available in the emergency kit (EDK) located in the medication room. If a medication was not available in the EDK, the nurse should notify the pharmacy. The DON indicated their back up pharmacy was (name of two local pharmacies) and medications could be provided in about four hours. On 10/4/2024 at 11:22 A.M., the DON provided a policy titled, Medication Administration, dated 1/2/2024, and indicated the policy was the one currently used by the facility. The policy indicated .Procedure: 21. Medications that are not readily available for administration will be obtained from the Emergency Kit, drop shipped from the pharmacy, or obtained from an alternative pharmacy . 3.1-48(c)(1)

Based on interview and record review, the facility failed to ensure residents who required dialysis services continued to receive those services in accordance with physician orders when the facility-based dialysis center closed on 8/12/2024 for 6 of 7 residents reviewed for dialysis services. (Resident D, E, F, R, S and V) This deficient practice resulted in Resident D and Resident E missing two dialysis treatments and required transfer to an acute care hospital for treatment of critical laboratory results and emergency dialysis treatments. The Immediate Jeopardy began on 8/12/24, when the facility failed to ensure the provision of dialysis services were continued for the residents who previously had an order for Dialysis on Monday-Friday until the facility-based dialysis unit closed on Friday, 8/10/24, without residents having arrangements in place for when their next dialysis treatment would occur, on Monday 8/12/2024. The Interim Administrator, Interim Director of Nursing and the Regional Nurse Consultant were notified of the Immediate Jeopardy (IJ) on 8/22/24 at 1:40 P.M. Findings include: The former in-house dialysis clinic provided a letter, sent to the facility and addressed to the previous Administrator, on 4/25/24, which indicated they were requesting repairs, due to the (Indiana) Department of Health (IDOH) had surveyed the den in May of 2023 and noted several deficiencies. The letter indicated, since the survey, the dialysis staff had asked former and current Administrators to make repairs via email, meetings and in-person conversations, but to date, the repairs had not been made. The letter indicated a failure to repair would result in termination of the in-house dialysis agreement due to unsafe conditions/violations deemed by the (I)DOH. A letter, dated 6/10/24, provided by the former in-house dialysis provider, indicated .effective July 10, 2024 (the Termination Date) due to breach of agreement for failure to make repairs in accordance with provision 21.C in the Long-Term Care Facility Renal Dialysis Affiliation Agreement. For clarification purposes, Wednesday, July 10, 2024, will be the final day [name of dialysis company] provides renal dialysis services at the SNF [Skilled Nursing Facility] An email notification, from the former dialysis in-house clinic/den, dated 7/5/24, indicated .We have extended our services by 30 days to help give you all more time to place the dialysis patients to outpatient clinics. Our new date we will be ceasing operation is August 9th During an interview, on 8/20/24 at 12:47 P.M., an emergency room (ER) Manager, from the local hospital, indicated Residents E and Resident D were both sent to theER on [DATE]. They both required emergency dialysis treatment, while in the ER and were then admitted to the hospital. The hospital's concern was that the residents were not provided dialysis services at the facility and/or set up with dialysis times according to those residents after the in-house dialysis services ceased. ER Manager indicated Resident F, also from the facility, had been transported to theER on [DATE], due to not having dialysis and was discharged from the hospital on 8/16/24. During an interview, on 8/19/24 at 1:05 P.M., Resident E's sister indicated Resident E was still at the hospital because the facility did not make arrangements for her to have dialysis when they knew the in-house dialysis was closing. She indicated the facility knew for 2 months they were going to close the unit. Resident E had her last had her last in-house dialysis on Friday the 9th. On Monday (8/12), she contacted the facility to find out when Resident E's next dialysis would be or where her sister would be going for dialysis, and they only told her not to worry. On 8/13/24, she was told her sister would be going somewhere in (neighboring city) to have her dialysis three times a week, however the facility would not be able to transport her. Then the facility said they would try a facility in [2 larger cities which were 2-3 hours away] to see if they would accept Resident E. On Wednesday (8/14), her sister indicated she was able to breath and was being sent to a local ER, where she required immediate dialysis and blood transfusion. 1. On 8/20/24 at 2:50 P.M., a review of the clinical record for Resident E was conducted. The resident's diagnoses included, but were not limited to: End Stage Renal Disease (ESRD), dependence on renal dialysis, congestive heart failure and respiratory failure. A Physician Order, dated 3/28/24, indicated, .Hemo-Dialysis 5 [five] times a week (Mondays, Tuesdays, Wednesdays Thursdays, Fridays). In house An Annual Minimum Data Set (MDS) assessment, dated 5/22/24, indicated the resident was alert and oriented, had no cognitive deficits, required dialysis and used oxygen. A current Care Plan, initiated on 5/25/23, and revised 6/2/24, indicated resident required Hemodialysis (in house) related to End Stage Renal Disease. The intervention included but were not limited to: .Dialysis Days: Mondays, Tuesdays, Wednesdays, Thursdays, Fridays . observe for signs of worsening renal insufficiency such as changes in level of consciousness .changes in heart and lung sounds .observe for symptoms of fluid volume excess such as edema, shortness of breath, crackles in lungs, weight gain or hypertension (sic) A current Care Plan, initiated on 5/25/23, and revised on 3/12/24, indicated the resident was at risk for fluid imbalance due to kidney failure, with refusal of dialysis or stopping dialysis early. The interventions included but were not limited to: .observe for signs of fluid overload: Anorexia, Anxiety, Mood/behavioral changes, Confusion, Edema, Nausea/vomiting, Shortness of breath, difficulty breathing (Dyspnea), Increased respirations (Tachypnea), Difficulty breathing when lying flat (Orthopnea), Congestion, Cough, Fatigue, Jugular Venous Distention (JVD), Sudden weight gain. Document and notify MD [Medical Doctor] of abnormal findings (sic) A electronic mail (email) communication , dated 8/12/24, between the previous Administrator and the Regional Director of Operations was provided, on 8/22/24, by the current Administrator. The email indicated chair times for Resident E were written on the email, but did not indicate at what facility she was to have her dialysis treatments. The nursing progress notes, dated 8/12/24 through 8/14/24, did not include documentation to indicate Resident E missed dialysis treatments, staff effectively assessed or monitored for fluid volume overload or for complications of not receiving dialysis in accordance with the physician's order. The notes did not include documentation to indicate staff attempted to secure dialysis services on 8/12/24 or 8/13/24 or to indicate the resident experienced a significant change in condition and was transferred to the hospital. A facility Dialysis Post Communication Record for Resident E, dated 8/14/24 at 4:18 A.M., indicated the resident was admitted to the hospital from dialysis. Addition information indicated .sent to [name of hospital] for abnormal labs (potassium hemoglobin) There were no lab documentation in the chart and Regional Nurse Consultant confirmed there were no lab draws for the resident from 8/12-8/14/24 and she did not know why the nurse completed a PostDialysis Communication Record for Resident E when there was no dialysis center and chair time set up for the resident for 8/14/2024. The next consecutive nursing progress note, dated 8/14/24 at 11:40 A.M., indicated the resident was away from the facility receiving dialysis. There were no nursing progress notes, dated 8/14/24 regarding transfer or discharge forms having been completed for Resident E. An ER Physician Report, dated 8/14/24 at 11:36 A.M., indicated Resident E complained of being short of breath and had missed two dialysis treatments since the previous Friday. Resident E told the physician she typically received dialysis Monday through Friday, however the nursing home where she resided was only able to provide dialysis until Friday (8/9) and she had not received dialysis since 8/12/24. Resident E reported the previous in-house dialysis service stopped and the facility did not ensure she continued receiving dialysis services. The report indicated Resident E suffered from fluid overload from lack of dialysis related to resident not receiving dialysis for five days. She was admitted to the hospital in guarded condition. Lab work at the hospital indicated critical levels of Potassium at 6.5, Creatinine at 10.4 [no normal ranges were provided] and hemoglobin at 6.4 with BUN (Blood Urea Nitrogen level) high at 83. The patient received a blood transfusion of one unit of packed red blood cells due to hemoglobin being less than 7. Hemoglobin is a value assigned to the number of red blood cells that carry oxygen. During an interview, on 8/19/2024 at 1:05 P.M., Resident E's sister indicated Resident E was still at the hospital because the facility did not make arrangements for her to have dialysis when they knew the in-house dialysis center was closing. She indicated the facility knew for two months they were going to close the in-house dialysis unit. Resident E has her last in-house dialysis treatment on 8/9/24. On Monday, 8/12/24, the family member indicated she contacted the facility to find out when Resident E's next dialysis would be or where her sister would be going for dialysis and the facility staff only told her not to worry. On 8/13/24, she was told her sister would be going somewhere in [neighboring city] to have her dialysis three times a week, however, the facility was not able to transport her. The the facility said they would try a facility in [two larger cities which were two - three hours away] to see if they would accept Resident E. On Wednesday (8/14/24) her sister indicated she was not able to breathe and was being sent to a local ER because she required immediate dialysis and a blood transfusion. During an interview, on 8/20/24 at 2:45 P.M., the interim Administrator indicated there were no dialysis centers within a forty-five mile radius, around the facility, that would accept Resident E. The only options suggested to her, were to have her transferred to a facility in [2 larger cities which were 2-3 hours away]. The interim Administrator indicated no documentation could be provided to indicate dialysis services had been secured for Resident E on 8/12/24, 8/13/24 and 8/14/2024. The resident required emergent transfer to the hospital on 8/14/24 During an interview on 8/21/24 at 10:15 A.M., Resident E indicated she had been in the hospital since last Wednesday (8/14/24) and her last day of dialysis, at the facility, was on 8/9/24. On the last day of her dialysis treatment, at the facility, the previous Administrator had told the resident the facility would have dialysis setup for her, by Monday 8/12/24. The Transportation person, Employee 7, had also told the resident the facility was going to make sure she received her dialysis treatment on Monday 8/12/24. On Monday 8/12/24, the resident indicated she did not receive her dialysis treatment and was told by the Interim Administrator they could not find anywhere to send her because she required a Hoyer lift for transport needs. The facility told her she could look for my own dialysis center, which made her angry and she was ready to give up. Resident E indicated she had never received any kind of nursing assessment on Saturday (8/10) through Wednesday (8/14). The resident indicated a nurse had listened to her lungs, on Wednesday, after she complained about not being able to breath and then the nurse decided to send her to the hospital. Resident E indicated she was admitted into the hospital because she needed dialysis. The resident was upset because she was then told she could not go back to the facility because she needed dialysis and the facility would not provide her transportation to a dialysis clinic, because she needed a Hoyer lift for transfers. However, the resident indicated she did not need a Hoyer lift for transfers and the resident indicated the Physical Therapist at the hospital also confirmed she did not require a Hoyer lift for transfer needs. During an interview, on 8/21/24 at 11:32 A.M., Transport Employee 7 indicated she had sent referrals [to local dialysis centers] for all dialysis residents approximately a month ago, prior to the in-facility dialysis center's closure date. However, the previous Administrator had informed Employee 7 she would be working on the referrals, so Employee 7 had no further involvement with the referrals. On Monday 8/12/24, the former Administrator was released from her duties at the facility and Transport Employee 7 was notified that day to start making transportation arrangements for all the residents in the building requiring dialysis. Resident D was referred to [2 different facilities over 1.5 hours away],a facility, both with in-house dialysis. It was Employee 7's understanding the facility would be providing transportation to one of these facilities. Resident E was scheduled to have dialysis on Monday, Wednesday and Friday at a local dialysis center and was scheduled to have her first dialysis treatment there on Wednesday 8/14/2024, however the dialysis center had called on Tuesday, 8/13/24, and informed Employee 7 they could not take Resident E due to her weight and there was no other treatments scheduled for Resident E. Employee 7 indicated no residents had started their dialysis treatments on Monday 8/12/24. Although Employee 7 indicated Resident E was scheduled to receive dialysis treatments 3 times a week, on Monday, Wednesday and Friday at a dialysis center for treatments, there was no physician's order provided to change Resident E's dialysis treatments from a 5 day Monday- Friday schedule to a 3x a week - Monday, Wednesday and Friday schedule. There was no documentation provided regarding to whom Employee 7 had communicated the issues with Resident E's dialysis treatments. During an interview, on 8/21/24 at 3:50 P.M., with alert and oriented Resident K indicated she had been roommates with Resident E for some time. Resident K indicated on Wednesday (8/14/24), last week, both her and Resident E were in the activity room when a staff member came in the room and told Resident E she was going to the ER. Resident K indicated Resident E kept telling her she did not feel well and was worried about not receiving her dialysis treatments due to transportation concerns. Nursing Progress Note for Resident E, dated 8/14/24 at 11:40 A.M., indicated LOA (Leave of Absence) at dialysis. There were no Nursing Notes indicating the resident had been transferred to a local hospital. During an interview, on 8/22/24 at 1:02 P.M., LPN 13 indicated he had written the Progress Note, dated 8/14/24 at 11:40 A.M He indicated he thought Resident E was at an outside dialysis center and when he heard she was in the hospital he assumed she went there from the dialysis center. He was not aware of when or where Resident E's dialysis days at an outside dialysis center had been scheduled. During a interview, on 8/23/24 at 1:33 P.M., an Admission Coordinator (AC) for (multiple local dialysis centers) indicated the facility had contacted and started the admission process for Resident E was receive from the facility, on 7/19/2024. The AC indicated no documentation could be provided to determine dialysis services were scheduled on 8/12/24. In addition, the AC indicated she had never communicated to the facility the need for a bariatric chair for Resident E. The AC indicated no documentation could be provided to indicate communication with the facility occurred between 7/19/24 - 8/19/24 when a second request for dialysis services was received. 2. On 8/21/24 at 3:15 P.M., a review of the clinical record for Resident F was conducted. The resident's diagnoses included, but were not limited to: ESRD ,dependence on renal dialysis, diabetes and hypertension A Quarterly Minimum Data Set (MDS) assessment, dated 6/11/24, indicated the resident was cognitively intact and required dialysis treatments. A current Care Plan, initiated on 3/6/23 and revised on 1/17/24 indicated the resident required Dialysis related to ESRD. The interventions included, but were not limited to: .observe for symptoms of fluid volume excess such as edema, shortness of breath, crackles in lungs, weight gain or hypertension (sic) A current Care Plan, initiated on 3/23/24 and revised 1/17/24, indicated the resident was at risk for fluid imbalance due to ESRD. The interventions included, but were not limited to: .observe for signs of fluid overload: Anorexia, Anxiety, Mood/behavior changes, Confusion, Edema, Nausea/vomiting, Shortness of breath, difficulty breathing (Dyspnea), Increased respirations (Tachypnea), Difficulty breathing when lying flat (Orthopnea), Congestion, Cough, Fatigue, Jugular Venous Distention (JVD), Sudden weight gain. Document and notify MD of abnormal finding (sic) A Physician Order for Resident F, dated 3/27/24, indicated .Hemo-Dialysis five times a week (Mondays, Tuesdays, Wednesdays Thursdays, Fridays). In- house A electronic mail (email) communication , dated 8/12/24, between the previous Administrator and the Regional Director of Operations was provided, on 8/22/24, by the current Administrator. The email indicated chair times for Resident F were written on the email, but did not indicate at what facility he was to have his dialysis treatments A Nursing Progress Note, dated 8/12/24 at 11:00 A.M., indicated the resident was noted to have shortness of breath and an overall decline. The Nurse Practitioner was notified regarding the resident's change of condition and an order was received to send the resident to a local ER. Emergency Medical Staff (EMS) arrived and resident was transported to the ER via an ambulance. It was unclear why the nursing progress note, dated 8/12/24 for Resident F was not completed until 11:00 A.M., after he had been evaluated in the local ER. A un-timed Nurse Practioner (NP) Acute Note, dated 8/12/24, indicated Resident F was short of breath, had a cough, was drowsy and had labored respirations. The note indicated the resident, initially refused to be transferred to the hospital for evaluation of fluid volume overload and dialysis treatment, but then agreed. An ER Physician Report, dated 8/12/24 at 10:45 A.M., indicated Resident F had a medical history of ESRD, on dialysis with last dialysis on Friday (8/9/24) who presented to the Emergency Department with shortness of breath, some congestion, a cough and altered mental status. He was admitted to the hospital's Intensive Care Unit (ICU), in guarded condition with a nephrology consult. Lab work completed in the ER for Resident F included, but was not limited to: high potassium level at 5.4, high BUN at 76 with a critical Creatinine level at 9.42. A Physician's Order, dated 8/13/24, indicated .Dialysis M/W/F @ 11:45 AM [name and address of dialysis center]. Please have ready for transport @10:45 am, one time a day every, Mon, Wed, Fri The order was received while the resident was hospitalized . The resident was discharged from the hospital on 8/16/2024 and returned to the facility. The Physician's order changing the resident's dialysis treatments to three times a week was not received for Resident F until 8/13/24. During an interview on 8/21/24 at 11:47 A.M., Transport Employee 7 indicated Resident F had a medical issue and was sent the hospital. Transport Employee indicated Resident F had an appointment set up for dialysis treatments for Monday (8/12/24) at 11:50 A.M., at the dialysis center, but was sent to the hospital and was admitted on [DATE] prior to the 11:50 A.M. appointment. During an interview, on 8/22/24 at 10:43 A.M., Resident F indicated he was told about the in-house dialysis closure by an aide who worked for the company who provided his dialysis. He indicated arrangements for his dialysis was never done until after the closure. He indicated he went to the hospital on Monday, 8/12/24, and received dialysis while there, but he had no information, prior to his admission to the hospital, regarding an outside dialysis center nor when he would next go to dialysis. After his return from the hospital, he indicated he was informed he would be going to a dialysis center on Mondays, Wednesdays and Fridays for treatments. During an interview, on 8/22/24 at 1:54 P.M., the facility NP indicated the in-house dialysis center had not given the facility much of a notice, maybe two-four weeks prior to their closure. She indicated she had rounded on all the dialysis resident's due to problems with the facility setting up dialysis for those residents requiring dialysis, and would be missing their Monday dialysis. She had instructed Nurse Manager 12 to send residents to a local ER if they had no had dialysis by Wednesday the 14th. She indicated she was contacted about Resident F having some concerns which may or may not have been related to him not having dialysis on his regular scheduled Monday, and had ordered the nurses to send him to theER on [DATE]. There was no documentation provided the NP had notified her supervising MD of the issues regarding missed and/or unscheduled dialysis treatments per orders. During an interview with the Admissions Coordinator (AC) for multiple, local dialysis clinics, on 8/23/2024 at 1:39 P.M. she indicated Resident F had an initial request for dialysis made on 7/19/2024 however, there was no chair time set up for him until after he was hospitalized . His first dialysis treatment at the center was on 8/19/24. 3. Resident D's record review was completed 8/21/2024 at 11:48 A.M. His diagnoses included, but were not limited to: end stage renal disease, dependence on renal dialysis, heart failure, anemia, depression, hemiplegia and hemiparesis. A Physician's order, dated 3/27/2024, indicated Resident D should receive in house dialysis 5 times a week on Monday, Tuesday, Wednesday, Thursday and Friday. A current Care Plan for Resident D, with a revision date of, 4/29/2024, indicated the resident required hemodialysis and at times may refuse dialysis. The goal for the Care Plan was to remain free of complications related to dialysis. Interventions to the Care Plan included, but were not limited to: - Dialysis Days: Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays revised on 4/29/2024. - Observe for symptoms of fluid volume deficit such as hypotension, postural changes in blood pressure, dizziness, thirst, dry oral mucosa, weight loss, nausea or muscle cramps 1/13/2022 - At times, resident will refuse dialysis. Staff to re-approach as needed. If resident continues to refuse, staff to offer education on importance of receiving dialysis as well as inform resident of potential adverse effects. (sic) A Social Services Note, dated 7/30/2024, indicated the Social Service Director had called Facility B, and left a voicemail inquiring about a fax number or email to send a referral for a resident transfer to be closer to his family and other potential dialysis centers. A Quarterly Minimum Data Set (MDS) assessment, dated, 8/1/2024, indicated Resident D had intact cognition, had received dialysis while at the facility and had not rejected any care during the previous seven days. A Social Services Note, dated 8/7/2024, indicated the interim Social Service Employee had sent a referral for Resident D to Facility B and was awaiting acceptance or denial. A Dialysis Hand Off Communication Report, dated 8/9/24, indicated resident had refused treatment from the in-house dialysis, provided at the facility. There was no documentation indicating Resident D had been dialyzed after 8/8/2024. An electronic mail (email) communication, dated 8/12/24, between the the previous Administrator and the Regional Director of Operations, was provided on 8/22/24 by the current Administrator. The email did not include documentation to indicated dialysis services were scheduled for Resident D on 8/12/24. An Acute Note from the Nurse Practitioner, dated 8/12/2024, indicated Resident D had outpatient hemodialysis arranged, and it was ok to wait another day for his outpatient dialysis A Nursing Progress Note, dated 8/14/2024 at 4:34 A.M., indicated Resident D returned from hospital because the hospital could not administer dialysis treatments at night and the resident was to return in the morning for dialysis. A Nursing Progress Note, dated 8/15/2024 at 5:40 A.M., indicated the resident was sent to the hospital for dialysis but was then admitted for pneumonia. An emergency room Admission Note from the Physician on 8/14/2024, indicated Resident D was admitted to the hospital on 8/14/2024 due to not receiving hemodialysis and having the following critical lab levels: -Blood Urea Nitrogen (BUN) 104 mg/dL (normal levels are 6-25 mg/dL) -Creatinine 21.5 mg/dL (normal levels are 0.6-1.5 mg/dL) -Potassium 6.5 mmol/L (normal levels are 3.5-5.2 mmol/L) Resident D's record lacked documentation the Physician had been notified about Resident D not having outpatient dialysis arranged for any future treatments and/or had missed any dialysis treatments. During an interview, on 8/21/24 at 11:32 A.M., Transport Employee 7 indicated Resident D was referred to (2 different facilities over 1.5 hours away) ,a facility, both with in-house dialysis clinics. It was her understanding the facility would be providing transportation to one of these facilities once the resident had been accepted for admission. She indicated no residents were scheduled to start their dialysis treatments on Monday 8/12/24. During an interview on 8/21/24 at 1:45 P.M., Resident D indicated he was sent to the ER because he had not received dialysis since 8/9/24. Resident D had critical BUN, Creatinine and Potassium levels and needed to be dialyzed immediately. The first day he went to the ER for dialysis was on 8/13/2024 and staff had only informed him he needed dialysis; they never told him he was being sent to the ER. The resident indicated he was not assessed on any day since his last dialysis treatment. He was notified at least 30 days in advance of the facility no longer offering dialysis in the facility. He believed the staff was looking for a new place for him to live and were setting up dialysis. Resident D was never made aware by any staff member that the facility was having a hard time finding somewhere for him to go. [name of skilled facility 1.5 hours away], contacted Resident D to inform him he was accepted but needed some papers from the facility. He had told the new Administrator, and she said she would take care of it. During an interview on 8/21/24 at 11:50 AM, an Admission Director (AD) for Facility A indicated an admission referral for Resident D was received, the resident was approved for admission, and more information was requested from the previous Administrator for consideration to be admitted into the hemodialysis program on 8/12/24. The AD for Facility A indicated a response was not received even though her staff had made attempts to contact the resident's residing facility on 8/13/24 and 8/14/24, for additional information. During an interview on 8/21/2024 at 1:45 P.M., Admissions Director (AD) for Facility B (skilled facility approximately 2 hours away) indicated they had not received a referral for Resident D prior to 8/15/24. During an interview on 8/22/2024 10:35 A.M., the Business Office Manager indicated Facility A had called on 8/13/2024 and had inquired about family members' contact information for Resident D. Facility A called again on 8/14/2024 and requested clinical information and the call was transferred to the north nursing unit. During an interview, on 8/22/2024 at 11:23 A.M., QMA 3 indicated Resident D's face was swollen so he was sent out for dialysis because he had not been set up for outpatient dialysis treatments and had not been to dialysis. QMA 3 called a non-emergency transport for both him and Resident B and both residents were sent to the hospital for dialysis. During an interview on 8/22/2024 at 11:25 A.M., the Regional Nurse Consult indicated there was not any transfer or discharge paperwork completed for Resident D on 8/13 or 8/14/2024 when the resident was sent to the hospital for dialysis. During an interview on 8/22/2024 at 12:46 P.M., the Unit Manager indicated Resident D did not have outpatient dialysis setup to start on the week 8/12/2024. On 8/9/2024., the previous Administrator sent her a text message notifying her any resident who did not have a new dialysis center setup should be sent to the hospital on their next dialysis day. The Medical Director and Nurse Practitioner were told all residents had outpatient dialysis setup, but they did not. On 8/13/2024, when the Unit Manager returned to work after being off for 3 days, the Unit Manager was notified Resident D was not looking well. The UM indicated Resident D's face was swollen and it sounded like he had fluid on his lungs. The Nurse Practitioner was notified and gave an order to send Resident D to the hospital. Resident D has never refused dialysis, and she had never been notified he had refused his dialysis treatment. All refusals for any treatment should be documented in the chart and the provider notification of refusal should also be documented. She was not able to provide any notes of why the resident was sent to the hospital in August. On 8/22/2024 at 1:45 P.M., the Regional Nurse Consultant provided a Dialysis Pre/Post Communication Record. The record indicated the resident had refused dialysis on 8/12/2024 at 4:36 A.M. and the Nurse Practitioner was notified. It was unclear why the form indicated the resident had refused a dialysis treatment on 8/12/2024 at 4:36 A.M. when there was no dialysis chair time or appointment set up for the resident on 8/12/2024. During an interview on 8/22/24 at 2:00 P.M., the Nurse Practitioner (NP) indicated Resident D did not have an appointment for dialysis on 8/12/24 because the facility requested she see Resident D due to not having a dialysis appointment on 8/12/24. The facility staff did not contact the NP on 8/9/24 notifying her Resident D refused dialysis. When the NP saw Resident D on 8/12/2024, she told the resident he could miss one more day of dialysis and the resident had no concerns or questions for the NP. During an interview with the Administrator, on 8/22/2024 at 2:12 P.M, from Facility B she denied ever receiving a voicemail referral inquiry or a faxed referral for Resident D from the facility. She indicated she received a referral inquiry for Resident D on 8/15/2024 but was uncertain if the inquiry was from the facility or the hospital During a interview, on 8/23/24 at 1:39 P.M., an Admission Coordinator (AC) for the (multiple local dialysis centers) indicated the facility had contacted had a request for Resident D but it was deleted and another request for services came in on 8/22/24. 4. A record review for Resident R was completed, on 8/23/2024 at 11:12 A.M. Diagnoses included but were not limited to end stage renal disease, type 2 diabetes mellitus with neuropathy, and anemia in chronic kidney disease. A Physician Order,dated 3/28/24, indicated .Hemo-Dialysis 5 times a week (Mondays, Tuesdays, Wednesdays Thursdays, Fridays). In house A current Care Plan problem , initiated on 9/12/2022, indicated Resident R required hemodialysis. Interventions included, but were not limited to, -Dialysis days were Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays. -Observe for fluid volume excess such as edema, shortness of breath, crackles in lungs, weight gain or hypertension. (sic) A Nursing Progress Note, dated 8/12/24 at 8:53 A.M., indicated the resident would not receive dialysis services in accordance with physician orders, on 8/12/24, but dialysis services would resume on 8/13/24. There were no nursing notes and/or assessments from 8 [TRUNCATED]

Based on record review and interview, the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) in accordance with the resident's advanced directives for 1 of 3 residents reviewed for facility discharge. (Resident D) This deficient practice resulted in CPR not being provided immediately when staff found the unresponsive resident and the resident died . The Immediate Jeopardy began, on [DATE] at 5:25 P.M., when staff identified Resident D was unresponsive and failed to immediately initiate CPR. The Administrator and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on [DATE] at 12:46 P.M. The Immediate Jeopardy was removed, on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Finding includes: On [DATE] at 11:13 A.M., a review of the clinical record for Resident D was conducted. The resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, necrotizing fasciitis (flesh eating disease) to a sacral wound, insulin dependent diabetes, End Stage Renal Disease requiring hemodialysis, and a history of a cardiac arrest. A Physician's Order, dated [DATE] at 1:45 P.M., indicated the resident was a Full Code (Medical personnel will do everything possible to save your life in a medical emergency including CPR. A Care Plan, dated [DATE], indicated the resident established advanced directives and wished to be a full code. The interventions included, but were not limited to, .Notify MD [Medical Doctor] and representative of changes in the resident condition/status A Care Plan, dated [DATE], indicated the resident was at risk for complications, related to medical conditions, medications and treatments. The interventions included, but were not limited to, observe for signs/symptoms of complications and assessments as indicated. An Admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated the resident was cognitively intact, had an unstageable wound, and did not have a condition which may have resulted in a life expectancy of less than six months. A MD/NP (Nurse Practitioner) Progress Note, dated [DATE] at 2:30 P.M., indicated the resident was sent to the emergency room (ER) for an evaluation due to persistent hyperkalemia (high potassium levels). The resident refused dialysis and was provided with education. The resident returned to the facility on [DATE]. An Interdisciplinary Team (IDT) Progress Note, dated [DATE] at 12:07 P.M., indicated the resident was at risk for nutritional issues due to weight loss and a wound to her coccyx. The resident triggered for a significant weight loss in the past 30 days, upon return from the hospital, and her wound improved. The resident had been refused dialysis treatments and/or requesting shorter dialysis treatment times. The Medication Administration Record (MAR) for [DATE], indicated the resident was administered Reglan (used for GERD - gastroesophageal reflux disease) 5 mg (milligrams) before meals and at bedtime. The resident accepted the 8:00 A.M., 11:00 A.M and 5:00 P.M. doses, on [DATE]. The resident did not have an order for anti-nausea medication on her MAR. A Nursing Progress Note, dated [DATE] 5:03 P.M., indicated the resident was sent to the emergency room for an evaluation of a lesion near her dialysis port. She returned to the facility the same day. An IDT Progress Note, dated [DATE] at 2:22 P.M., indicated the IDT reviewed Resident D due to multiple lesions noted on her face and slightly above the dialysis port. The resident received topical and oral antibiotic due to cellulitis. The NP reviewed the resident's recent laboratory tests, noted the resident's WBCs (white blood cells) counts were elevated, and gave an order for the resident to be sent to the ER again. There was no nursing progress note to indicate the resident had returned to the facility; however, the resident's census documentation indicated the resident had returned from the hospital on [DATE]. A Nursing Progress Note, dated [DATE] at 5:31 A.M., indicated the resident received IV antibiotic for an infection and did not experience any side effects from the medication. The note also indicated the resident's vital signs were within her normal limits. A Nursing Progress Note, dated [DATE] at 12:00 A.M., indicated the resident experienced an unwitnessed fall. The resident was assessed, the vital signs were checked, range of motion (ROM) was intact, and no injuries were noted. A Neurological Assessment check sheet was initiated. The resident denied pain or discomfort. The physician and the resident's family were notified of the fall. A Nursing Progress Note, dated [DATE] at 6:08 A.M., indicated the resident's vital signs were within normal limits and the resident denied any pain related to the fall and monitoring would continue. A form titled, Neurological Assessment for Resident D indicated the neurological assessments started on [DATE] at 11:45 P.M. and continued until [DATE] at 6:00 A.M. The form indicated the resident did not have her neurological status assessed at 7:00 A.M., 8:00 A.M., 11:00 A.M. and 3:00 P.M., as scheduled for an unwitnessed fall. There were no additional Nursing Progress Notes, on [DATE] until 6:18 P.M., for Resident D. A Nursing Progress Note, dated [DATE] at 6:18 P.M., indicated the resident was found unresponsive at about 5:25 P.M., .by the aide while passing dinner trays. Sternal rub attempted. Res [resident] set on the floor, CPR initiated. 911 called did CPR on the patient for about 25 minutes no pulse or breathing post CPR. EMS did stop CPR, pronounced dead (sic) The resident's family member was present at the time of death. During an interview, on [DATE] at 1:15 P.M., QMA 2 indicated Resident D resided on the North unit. QMA 2 indicated she was assigned to the North unit, on [DATE], during the evening shift. QMA 2 indicated she reported to RN 3 that Resident D complained of stomach pain, vomited phlegm throughout the day, and wanted to go the ER. QMA 2 indicated the resident yelled out most of the day for assistance with the phone and frequent position changes. QMA 2 indicated RN 3 was the only licensed nurse in the facility and was assigned to another unit on [DATE]. QMA 2 indicated RN 3 advised her to administer nausea medication and monitor the resident's response. QMA 2 indicated she checked on Resident D at an unknown time and the resident seemed fine. QMA 2 indicated she overheard the resident say she wanted to wait to go to the ER. QMA 2 indicated the resident's family was updated during the afternoon that the resident's stomach pain continued, the resident asked to be transferred to the ER, and family member wanted staff to wait until their arrival at the facility to send the resident. QMA 2 indicated CNA 4 was passing supper trays and alerted QMA 2 to the resident's yelling. QMA 2 indicated she instructed CNA 4 to continue passing supper trays and QMA 2 would check on Resident D. QMA 2 indicated the resident's family member and QMA 2 entered the resident's room at the same time and found the resident sitting on the side of bed and observed the resident was not breathing. QMA 2 indicated she ran to the nurse's station to determine the resident's code status, instructed CNA 4 to start CPR, and left the North unit to get RN 3 from the South unit. QMA 2 indicated upon her return to the North unit she observed Resident D lying on the floor and CNA 5 was performing CPR. QMA 2 indicated Emergency Medical Services (EMS) staff arrived, the EMS staff took over CPR, and eventually pronounced Resident D deceased . QMA 2 indicated she could not provide a specific timeline of events. During an interview, on [DATE] at 3:17 P.M., RN 3 indicated she was the only licensed nurse in the facility on [DATE]. RN 3 was going about her duties when QMA 2 came to her unit, stating she had called a code. RN 3 indicated she took off running down to the other unit. When she arrived at the resident's room, Resident D was in a sitting position on her bed, without respirations/pulse and had not been receiving CPR. Another staff member helped her position Resident D on the floor so CPR could be initiated. QMA 2 grabbed the crash cart on her way back to the unit. RN 3 indicated QMA 2 told her the resident requested to be sent to ER earlier, but indicated the resident did not exhibit any new symptoms. RN 3 indicated she observed the resident several times throughout the day. RN 3 was told the resident had been visiting with her grandparents and after their visit, was asking again to go to ER. It was RN 3's understanding a non-emergent local transport ambulance and the resident's family member was called. RN3 indicated the resident's family member was in the room when she entered and assessed the resident, brought resident to the floor and had a staff member start CPR. Although RN 3 indicated she observed Resident D several times throughout the day, there was no documentation to support her statement. During an interview, on [DATE] at 3:55 P.M., the Maintenance Director indicated he measured the distance between the North and South nursing station to be 240 feet. During an interview, on [DATE] at 10:14 A.M., CNA 5 indicated he worked the day Resident D passed away but had clocked out for the day at approximately 3:00 P.M. and was not on duty during the evening meal. He indicated the resident told him before lunch she was not feeling well and wanted to go to the ER. He communicated the resident's request to QMA 2. CNA 5 indicated the resident was not using her call light that day and would just call out QMA 2's name repeatedly. He assisted the resident with numerous things during the day. Resident D told CNA 5 she thought the dialysis treatments were making her sick. During an interview, on [DATE] at 10:19 A.M., the Nurse Practitioner indicated she received three phone calls from the facility, on [DATE] regarding Resident D. The NP indicated she was notified of the resident's unwitnessed fall without injury just after midnight, of normal neurologic assessmetns throughout the night at 6:00 A.M., and of the resident's death during the evening. The Nurse Practitioner indicated the facility did not notify that the resident requested to go to the hospital on [DATE]. The Nurse Practitioner indicated Resident D was usually very resistant to go to the hospital. The facility did nott request an order to send the resident to the hospital on [DATE]. During an interview, on [DATE] at 10:32 A.M., CNA 4 indicated she worked, on [DATE] from 7:00 A.M. to 10:00 P.M., on the North unit. Resident D called out several times for assistance and told her she wanted to go to the ER sometime before lunch. CNA 4 indicated she told QMA 2 of the resident's request. Sometime after lunch, the resident's grandparents visited and brought the resident food; however, the resident did not eat much of it. During the evening, while CNA 4 was passing the supper trays, Resident D was yelling out again for assistance. QMA 2 instructed her to continue to pass the meal trays, as QMA 2 would be going into the resident's room shortly. Then CNA 4 observed QMA 2 running out of Resident D's room and told her to call a code blue. CNA 4 indicated she thought she was supposed to call for hel from the other unit because Resident D needed CPR. CNA 4 called the code on the facility overhead paging system, as QMA 2 ran down the hallway towards the South nursing unit. CNA 4 indicated she did not start CPR but followed all the other staff members, when they arrived on the North unit. CNA 4 entered the resident's room, and assisted other staff members to transfer the resident from her bed to the floor to start CPR. She was unable to name the staff member who started CPR. She indicated the ambulance service was at the facility shortly after and they took over CPR on the resident. CNA 4 left the room to continue passing the evening meal trays. During an interview, on [DATE] at 10:42 A.M., the local non-emergency EMS service staff indicated their service received a call, from the facility for an ambulance at 7:11 P.M. The EMS service indicated their dispatcher advised the facility to call 911 for immediate service, and they did not go to the facility on [DATE]. During an interview, on [DATE] at 12:56 P.M., the Interim Director of Nursing (DON) indicated she was the DON, on [DATE], and was on call for any questions/concerns the staff might have. The Interim DON indicated she received a call from RN 3 at 7:21 A.M., indicating Resident D was requesting to go to the ER. The Interim DON indicated she told RN 3 to send the resident to the ER if that was what the resident requested. The Interim DON indicated she did not hear anything further from RN 3, until RN 3 contacted her to tell her they were performing CPR on Resident D. CPR Facts & Stats article was retrieved, on [DATE], from the American Heart Association website at www.cpr.heart.org. The article indicated .CPR is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances for survival On [DATE] the Administrator provided a form titled, An Indiana State Department of Health Certificate of Death The form indicated the date of Resident D's death on [DATE] at 6:00 P.M., and the cause of death was pulseless electrical activity. On [DATE] at 3:28 P.M., the DON provided a policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated Purpose: to ensure the facility provides emergency basic life support immediately when indicated The Immediate Jeopardy that began, on [DATE], was removed, on [DATE], when the facility completed nursing staff education/in-service on CPR-,basic process with emphasis on immediately implementing CPR, in accordance with resident's advanced directive, with one staff member calling the code, while another staff member dials 911 and another staff member documenting code process, mock codes completed for each shift, resident code status and Care plans updated, The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been educated on CPR audits were ongoing to review Progress Notes for a change of condition and/or requests to be sent to ER. This citation relates to Complaint IN00437316. 3XXX,d+[DATE](a)

Based on interview and record review the facility failed to supervise a resident, with severe cognitive deficits and wandering behaviors, from exiting the facility resulting in the elopement of Resident J. The immediate jeopardy began on 10/3/23 when the facility failed to ensure supervision was provided to Resident J, who was deemed high risk for an elopement, had a diagnosis of Alzheimer's disease and displayed exit seeking behaviors. As a result, the resident was able to exit the facility unattended. The Interim Administrator, Director of Nursing Services, and Regional Nurses were notified of the immediate jeopardy, at 12:21 P.M. on 10/11/23. The immediate jeopardy was removed, and the deficient practice corrected, on 10/4/23, prior to the start of the survey and was therefore Past Noncompliance Finding includes: On 10/10/23 at 11:21 A.M., a review of the clinical record for Resident J was conducted. The resident's diagnoses included, but were not limited to: Alzheimer's Disease, schizoaffective disorder, anxiety and seizure disorder. An Annual MDS (Minimal Data Set) assessment, dated 9/18/23, indicated the resident had severe dementia, used a wheelchair and no motion sensor or wander elopement alarm. A Quarterly Wandering/Elopement Risk Assessment, dated 8/2/23, indicated the resident's score was 13. A score of 11 or higher indicated resident was a high risk for an elopement. A Psychiatrist Progress Note, dated 8/31/23, indicated the psychiatrist observed the following .adaptive weaknesses, distressing delusions of persecution, e.g., someone is coming to get her, she is pregnant, a significant other is dead, President [NAME] is to blame, etc. Ongoing, agitation, cursing, shouting at staff or reticent to speak, aggression, anxiety, and irritability/lability. At previous placement, resident physical aggression has been reported to cause $20K for repair in destruction of equipment and facility property. At the present encounter, writer observed resident while waiting for lunch as guarded, reactive and defensive, inquired, ?who are you? before writer began introduction. Stated, ?I don?t talk to psychologist! Bye!? Showed oriented to person . Mental status is severely impaired A care plan, dated 4/5/23 and last updated on 7/13/23, indicated the resident had behavioral symptoms of wondering and exit seeking. The interventions included, but were not limited to: identify behavior triggers, reduce exposure to triggers, maintain a safe environment and offer diversional activity. Another care plan, dated 10/20/21 and revised on 7/13/23, indicated the resident exhibited signs of cognitive impairment due to diagnosis of Alzheimer's and Dementia. Interventions included, but were not limited to: provide resident with cues-reminders to assist with decision making and recall. Be alert to non-verbal cues of problems or unmet needs. A Behavior Monitoring form indicated the resident was having Behavior Symptoms of wandering, on 9/9, 9/10, 9/11, 9/24 and 10/3/23 at 10:12 A.M. A self-reported incident #331, dated 10/3/23, regarding Resident J indicated .On 10.3 at approximately 4:00 pm resident wheelchair was observed by staff in the front of the lobby without the resident. Staff member notified the Nurses and a Code [NAME] was initiated. Staff Notified the ED/DNS [Executive Director/Director of Nursing Services] and continued search inside the facility, ED /DNS immediately arrived at the facility and notified police and continues search on the parameter of the facility. The weather outside was clear and warm. The outside search continued without results. A headcount revealed that all residents were accounted for except [name of resident]. [Name of Resident] has last been observed by DNS and Activity Director at 330 pm. She had been sitting outside for fresh air which was her typical behavior. Staff notified ED and DNS an interview with another resident revealed that the resident was observed getting into a Cab and was informed that the resident was taken to the store .3 miles from the facility. The DNS, ED and Activity Director took picture of the resident to the store and the clerk verified that the resident had been at the store. While at the store the DNS received a call from the police that the resident was picked up at the store and taken by EMS to [name of hospital]. ED spoke to nurse at the ER [emergency room ] and the resident was there and had no signs of physical injury after assessment by ER staff. Resident was returned to the facility A typed statement, dated 10/4/23 at 2:48 P.M., signed by the Social Service Director (SSD) indicated she had observed the resident sitting in her wheelchair, outside, and had refused to return, inside the facility. A written statement, undated, by Administrative Assistant, who sits at the main entrance, indicated .On [DATE]rd around lunch time Resident [name of resident] was sitting up here at the desk/lobby area for a hour or 2. She asked to go out, and I nicely told her that I couldn't let her out. She got mad and held the door for 15 secs [seconds] and walked out and went to the sitting area. She was outside for a while and then came back in for her wheelchair. [Name of Resident] then proceeded to go back outside with her wheelchair and sat back down A typed statement by the Director of Nursing Services (DNS), dated 10/3/23 at 5:30 P.M., indicated .Name of Resident J] walked through front after holding door for 15 sec [seconds] sat at the sitting area outside the facility about 11am. This writer and SS [Social Services] attempted to redirect Resident to back in facility Resident declined stating I am trying to get fresh air .Resident continue sitting outside for the rest of the time. At 3:30pm this writer again noted this Resident sitting outside at the same spot During an interview, on 10/10/23 at 11:30 P.M., the Psychiatric Services Nurse Practitioner (NP) indicated she had seen the resident approximately every 2 weeks since July of 2023. She indicated the resident usually sat in a wheelchair, but could walk when she wanted to. The NP indicated the resident sat at the front entrance but had never communicated to her, she wanted to leave the facility. The NP indicated the resident would not have been safe left unattended and by herself outside of the community. The NP indicated the resident had delusions, stating she was seeing people and hearing voices. NP indicated she had to be sent to a psychiatric hospital due to her psychotic state, for stabilization after the elopement incident. During an interview, on 10/10/23 at 1:17 P.M., the SSD, indicated she was with the Resident J while she was sitting outside, in a sitting area, for approximately 1.5 hours. The Front Desk Receptionist sat with the resident afterward. The SSD explained she left the building, at approximately 2:45 P.M., and observed the resident, sitting outside, with the Front Desk Receptionist. As the SSD was leaving the facility the DNS was approaching the area, where the resident was sitting. During an interview, on 10/10/23 at 1:28 P.M., the DNS indicated the resident had exited out of the building, by holding onto the exit door for 15 seconds and the locked door released. The DNS had observed the resident leave the facility. The DNS indicated she, along with the Marketing/Admission Coordinator and the SSD had tried to get the resident to return inside the facility, but the resident declined and went to an area, outside the facility where there were chairs and a table with an umbrella. The DNS indicated she instructed the Marketing/Admission Coordinator to stay with the resident. She had observed the resident, again through the glass door at approximately 3:30 P.M. but didn't notice if anyone was with her. She left the facility at approximately 3:45 P.M., and noticed an empty wheelchair where the resident had been sitting and assumed Resident J had returned inside of the facility. During an interview, on 10/10/23 at 1:42 P.M., the Front desk Receptionist/Administrative Assistance indicated the resident had been sitting at the front entrance for approximately 1-1.5 hours around noon time. The resident then asked to go outside, however she explained to the resident she could not allow her out, so the resident pushed on the door, the alarm sounded, and the door then opened (had an emergency unlock after 15 seconds of pressure on exit door) and the resident wheeled herself out the door. At that time she verbally told the SSD and she went outside with the resident. On 10/10/23 at 1:59 P.M., an interview was conducted with the Administrator, the DNS, the SSD, the Activity Director and the Marketing/Admission Director. The Marketing/Admission Director indicated she went outside to relieve the SSD and sat with the resident for approximately 30 minutes, when the resident was persuaded to return inside the facility for a drink. The Marketing/Admission Director indicated the resident was in her wheelchair and was last observed heading toward the dining room, at approximately 3:00 P.M. The Administrator indicated he was never outside with the resident and was not involved prior to discovery of elopement. The Activity Director indicated, at approximately 3:00 P.M., she had observed the resident, through a glass window, sitting in her wheelchair, at another area, near the gazebo. None of those present, during the interview, had any idea how the resident got out of the facility the second time. During an interview, on 10/10/23 at 2:46 P.M., the Front desk Receptionist/Administrative Assistant indicated she was the person who worked the front desk on 10/3/23 from 8 A.M. through 4:00 P.M. and had not observed the resident and/or Marketing/Admission Director return inside the facility, nor did she observe or hear an alarm indicating the resident had left the building after 3:00 P.M. The SSD indicated, on 10/10/23 at 3:06 P.M., if there were wander seeking behavior notes, they would be in the Progress Notes. She indicated she had not written a progress note regarding the resident's exit seeking behavior that day. During an interview, on 10/10/23 at 3:35 P.M., LPN 2, who worked the resident's unit, indicated she was not aware of Resident J being outside for several hours and not wanting to return to the unit, until the staff were notified of the elopement. During an interview on 10/11/23 at 10:05 A.M., the Administrator indicated the cab company was called and indicated they left the Resident J at the store. The resident told the cab driver she would pay for the cab fare once she got to the store and used an ATM machine. The cab company indicated the resident ran into the store and would not pay the cab fare, so they left her there. He indicated the police notified him the resident had been picked up, at the store, and taken to a local emergency room . An emergency room (ER) Report, dated 10/3/23 at 4:04 P.M., indicated the resident presented to the emergency department with aggressive behavior. Report indicated the resident was found, on the floor, at a smoke shop and 911 was called. The medics evaluated the resident and chose to bring her to the ER for an evaluation. An ER Medical Decision Making Note indicated .Patient presented to the ED [Emergency Department] for an evaluation. She arrived via EMS. It turns out that she resides in a place called [name of facility]. We were able to contact them and they indicated she had eloped from their facility earlier in the day. Apparently she walked from there to a liquor store and the liquor store called 911 and she was subsequently brought in by EMS. In the ED she required sedation .The patient will be transferred back to her facility by the medics On 10/12/23 at 10:27 A.M., the Administrator provided a policy titled, Elopements and Wandering Residents, dated 4/6/19 and revised 9/23, and indicated the policy was the one currently used by the facility. The policy indicated .Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement .4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering .d. Adequate supervision will be provided to help prevent accidents accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly The past noncompliance immediate jeopardy began on 10/3/23. The immediate jeopardy was removed and the deficient practice corrected by 10/4/23 after the facility implemented a systemic plan that included the following actions: all current residents elopement evaluation scores were reviewed, care plans updated, elopement binder reviewed/updated, doors codes changed, wanderguard systems tested , elopement drills and all staff educated on the elopement policy. This Federal tag relates to complaint IN00419004. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure treatments were performed as ordered for 2 of 3 residents reviewed for dressing changes. This resulted in infection, hospitalization , and subsequent amputation for 1 of 3 residents reviewed. (Residents B and G) Findings include: 1. During a interview, on 10/16/21 at 1:00 P.M., Resident B indicated he was a recent [CONDITION(S)] because the previous owners of the facility did not ensure their staff changed his dressings as they were ordered. The clinical record for Resident B was reviewed on 10/18/21 at 10:00 A.M Resident B was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B was admitted to the facility on [DATE]. He was receiving [MEDICATION(S)] (an antibiotic used to treat bacterial infections) daily for [CONDITION(S)]. A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Cleanse bilat [bilateral] heels with wound cleanser, pat dry, Apply skin prep to bilat heels q [every] day at bedtime for wnd [wound] care The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A MAR, dated 9/1/21- 9/30/21, indicated .Cleanse R [right] 1st, 2nd, 3rd, and 4th toes on R foot with wound cleanser, pat dry, apply [MEDICATION(S)], telpha and kerlix q [every] night shift for wnd [wound] care. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] A Progress Note, dated 8/26/21, indicated .MD [Medical Doctor] Progress Note. Nursing has noticed redness of right leg. No fever .Physical Exam: Extremities: Right lower extremity redness noted. Warm to touch. No lymphatic streaks are seen .Assessment and Plan: [CONDITION(S)] try [MEDICATION(S)] [an antibiotic used to treat bacterial infections] 500mg [milligram] 4 times a day for 10 days A Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[CONDITION(S)] of Right leg: Start [MEDICATION(S)] 500 mg 4 times a day for 10 days A Progress Note, dated 9/13/21 indicated .[MEDICATION(S)] 100 mg tab [tablet] Give 1 capusule by mouth two times a day related to [CONDITION(S)] of Right Lower Limb .Not given. Awaiting medication from pharmacy A Progress Note, dated 9/14/21, indicated .ABT [antibiotic] continues for [CONDITION(S)] right foot. Circulation remains poor but does evidence improved color and less [CONDITION(S)] with elevation on wedge in bed. Pain controlled with current med A Progress Note, dated 9/18/21, indicated . Continues of [MEDICATION(S)] for RLE [Right Lower Extremity] [CONDITION(S)]. Color improves with elevation on wedge in bed. 0 adverse effects noted from ABT .Up in electric wheelchair with speciality boots intact A Progress Note, dated 9/22/21, indicated .Assessed right foot. Area to dorsal foot macerated & [and] weeping. Above this area skin is swollen and hot and has tiny water blisters. Toes continue with black eschar surrounded by red skin, signs of arterial wound presentation. Continues on [MEDICATION(S)] for [CONDITION(S)] to this area, but [MEDICATION(S)] was completed 4 days ago. [Name of Physician] is aware. Order received to continuation of [MEDICATION(S)] for 10 more days. Wound treatment will continue with [MEDICATION(S)], [MEDICATION(S)], & kerlix to toes and add abd [abdominal] pad and kerlix for weeping on dorsal foot. A Progress Note, dated 9/22/21 indicated, .Stasis, Serous (Drainage) Moderate (Drainage Amount) No (Odor) 9.5 x 5.2 x 0.1 Red [sic], swollen, hot, and dry with tiny blisters irregular, continue with the [MEDICATION(S)] and restart [MEDICATION(S)] for 10 more days. Treatment order received to the dorsal foot for ABD pad and kerlix QS [every shift]. low air loss mattress heel Suspension/Protection device pressure reducing boots other. Resident has been receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Weeping has started and signs of [CONDITION(S)] have returned this week after completion of [MEDICATION(S)] A Progress Note, dated 9/24/21, indicated .Resident having increased pain bi-lat lower ext [extremity] vascular wounds. temp = 97, biox [a measurement of oxygen in blood] 98 on rm air [room air] b/p [blood pressure] 133/66 pulse = 100 he will be transferred to [name of local hospital] ER [emergency room ] for eval [evaluation] and treatment via 911 ambulance daughter [name] has been notified of his current condition A History and Physical, dated 9/24/21, indicated .[name of local hospital] History of present illness: male with history of severe PVD [[CONDITION(S)]] .Patient was hospitalized in late July 2021 for [CONDITION(S)] of leg and possible infected bypass graft, which was removed .Patient went on to develop several weeks of right foot pain, [CONDITION(S)], and swelling. There is associated weeping of serous fluid. Medical Director at nursing home did trial of [MEDICATION(S)] as well as [MEDICATION(S)] without much effect. also tried [MEDICATION(S)] [ a antibiotic used to treat bacterial infections]. Patient went on to experience progressive pain in the right foot and eventual loss of sensation. There is evidence of foot ischemia. CT [cat scan] of right foot is pending. Vascular surgery was consulted A Progress Note, dated 9/30/21, indicated .Verbal report rec'd [received] from [name of nurse at local hospital] resident had a rt. [right] aka [above the knee amputation] on 9/26/21 During an interview conducted with Corporate Nurse 3, on 10/19/21 at 12:30 P.M., he indicated he could not find any supportive documentation to indicate the [MEDICATION(S)] ordered on 8/26/21 was given as ordered by the resident's physician. During an interview with the Director of Nursing Services, on 10/19/21 at 12:40 P.M., she indicated she was not in charge of wounds at that time and said only that it appeared the treatments were not signed out as done for the dates lacking a electronic signature. 2. A record review was conducted, on 10/15/21 at 11:30 A.M., for Resident G and indicated she was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) assessment, dated 9/27/21, indicated Resident G was cognitively intact and had surgical wound care. A TAR (Treatment Administration Record), dated 9/1/21 - 9/30/21, indicated a treatment order, dated 9/20/21, for L BKA (Left Below Knee Amputation) dressing change every day until healed every night shift for wound care. No documentation of wound dressings being completed on 9/20, 9/23, 9/25, 9/28 and 9/29/21. A TAR (Treatment Administration Record), dated 9/1/21 - 9/30/21, indicated a treatment order, dated 9/20/21, for a wound vac to R AKA (Right Above Knee Amputation) dressing change every 3 days every night shift for wound care. No documentation of wound dressings being completed on 9/20, 9/23, and 9/29/21. A TAR (Treatment Administration Record), dated 10/1/21 - 10/31/21, indicated a treatment order, dated 9/20/21, for L BKA (Left Below Knee Amputation) dressing change every day until healed every night shift for wound care. No documentation of wound dressings being completed on 10/12 and 10/15/21. A TAR (Treatment Administration Record), dated 10/1/21 - 10/31/21, indicated a treatment order, dated 10/11/21, discontinue wound vac and apply Xeroform dressing to site daily to keep moist every night shift for wound vac site. No documentation of wound dressings being completed on 10/14/21. During an interview, on 10/19/21 at 11:20 A.M., the ED indicated if something was not signed off then it is assumed is was not being done. A policy, titled, Skin Management, with a origional date of October 2019, was provided by Corporate Nurse 3 on 10/19/21 at 12:23 P.M., the policy indicated .Procedure for Alterations in Skin Integrity: 4. The wound nurse (licensed nurse assigned responsibility for wounds in the building) will be notified of alterations in skin integrity. a).The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day. 6. IDT Iinterdisciplinary Team] review of new alteration in skin integrity will be completed weekly.7. A plan of care will be initiated to include resident specific risk factors with appropriate interventions A Policy, titled, Administering Medications, with a revision date of April 2019, was provided by Corporate Nurse 3 on 10/19/21 at 12:23 P.M The policy indicated .Medications are administered in a safe and timely manner, and as prescribed This Federal tag is related to Complaints IN 131, IN 903, IN 433, and IN 476. 3.1-37

Based on record review, observation and interview, the facility failed to assess and treat a stage 2 pressure ulcer timely, resulting in the progression of a stage 2 pressure area to an unstagable pressure area, failed to provide interventions to prevent an unstagable pressure area from developing and the facility failed to assess timely and consistently provide interventions to aid in healing and prevent further pressure areas to develop for 3 of 5 residents reviewed for pressure ulcers. (Resident G, T and K) Findings include: 1. A clinical record review for Resident K was completed on 10/8/19 at 4:15 P.M. His current [DIAGNOSES REDACTED]. A current Braden Scale for Predicting Pressure Sore Risk, dated 7/19/19, indicated the resident was at a moderate risk. A weekly skin integrity evaluation, dated 9/17/19, indicated Resident K had a skin alteration of the left trochanter area of redness. No measurement or description was documented. There were no further weekly skin integrity evaluations documented in the medical record. A Wound Management form, dated 10/7/19 at 9:30 P.M., indicated Resident K had a stage 2 pressure ulcer to the left ankle measuring length of 1.2 x 1.1 cm width x 0.1 cm depth. Comments: appears to have been a small blister that opened. Noted approximately 50% brown area under blister pocket and is firm. A Wound Management form, dated 10/7/19 at 9:37 P.M., indicated Resident K had an unstageable pressure area to the left hip measuring 3cm (centimeter) x 3 cm and no depth with 90% of the wound bed covered by eschar/necrotic tissue. A CNA skin care alert sheet, dated 9/18/19, indicated a complete bed bath was given to Resident K with the residents skin section documented as not clear and no documentation of the nurse being notified. Resident K's bathing schedule indicated a complete bed bath was received on the following dates: 9/19, 9/23, 9/24, 9/25, 9/26, 9/28, 9/29, 9/30, 10/1, 10/7 and 10/9/19. There was only 1 Skin monitoring: Comprehensive C.N.A shower review documented for 10/9/19. A nurses note, dated 10/7/19 at 6:28 P.M., indicated a new open area to the resident's left ankle was noted, the physician was notified and new orders were received. On 10/9/19 at 8:30 A.M. the Director of Nursing was observed completing wound measurements on Resident K's wounds. She indicated Resident K had new areas to his left foot of a stage 2 and an unstageable area. Orders for Resident K included: head to toe weekly skin checks ordered on [DATE], skin prep to the left foot base of the great toe 2 times a day and float heels while in bed every shift both ordered on [DATE]. A Wound Management form, dated 10/9/19 at 9:24 A.M., indicated Resident K had an unstagable pressure area to the left big toe (bunion), measuring 0.6 cm length x 1.0 cm width and no depth with 100 % of the wound bed covered by necrotic tissue. A Wound Management form, dated 10/9/19 at 9:26 A.M., indicated Resident K had a stage 2 pressure area to the top of the left foot measuring 0.3 cm length x 0.3 cm width x 0.1 cm depth. During an interview, on 10/10/19 at 10:28 A.M., Certified Nurses Aide 7 indicated the resident was checked and changed every 2 hours and he was to have the booties on PRN (as needed). She indicated the resident had 1 boot on his right foot at the time and there was none on the left foot. During an observation, on 10/10/19 at 10:45 A.M., Resident K was observed laying in bed on his left side with no boot to his left foot. During an interview, on 10:47 A.M., Licensed Practical Nurse 3 indicated the resident should have boots on both feet when in bed. During an interview, on 10/10/19 at 11:41 P.M., the Director of Nursing indicated the Resident should have had his skin assessed weekly. 2. A clinical record review for Resident T was completed on 10/7/19 at 11:49 A.M. Current [DIAGNOSES REDACTED]. An admission assessment, dated 9/17/19, indicated the resident had no skin issues. A Braden Scale for Predicting Pressure Sore Risk, dated 9/17/19, indicated Resident T was at moderate risk for pressure sores. A baseline admission care plan, undated, indicated the resident was at risk for impaired skin related to impaired mobility, communication deficit and incontinence. Interventions included, but were not limited to: weekly skin assessment, report changes in skin status to physician, barrier cream with incontinent care, reposition frequently, monitor for nutritional deficits and dietary consult for decreased appetite. A baseline care plan, undated, indicated the resident had a self care deficit as evidence by s/p (status [REDACTED]. Interventions included, but were not limited to: provide adl care to ensure daily needs are met and total care provided. A nurse's note, dated 9/19/19, indicated Resident T was sent to the hospital for abnormal bleeding. A return admission assessment, dated 9/27/19, indicated the resident had no skin issues. A Braden Scale for Predicting Pressure Sore Risk, dated 9/27/19, indicated Resident T was now at a high risk for pressure sores. A nurse's note, dated 10/5/19 at 6:27 P.M., indicated Resident T had a pressure area on the left foot and a foam dressing was placed for preventative measures. A resident event note, dated 10/6/19 at 5:37 P.M., indicated Resident T had a pressure area to the left heel. The event details were all left blank. A nurse's note, dated 10/6/19 at 10:56 A.M., indicated the resident was turned an repositioned every 2 hours, cushioning done on bilateral heels with foam dressings, and feet floated. A nurse's note, dated 10/6/10 at 11:31 A.M., indicated a treatment order for bilateral heels to prevent breakdown added as ordered. A nurse's note, dated 10/7/19 at 6:41 P.M., indicated discoloration noted to left heel, physician notified, received new order for Prevalon boots. Resident T's current physician's orders [REDACTED]. Prevalon boots to bilateral feet, remove every shift and assess skin ordered on [DATE]. Float heels while in bed ordered 10/7/19. Assess and measure area to left heel and update wound management section ordered 10/8/19. Apply skin prep to bruised area left heel every shift ordered on [DATE]. A current care plan, dated 10/8/19, indicated Resident T had actual alteration in skin as evidence by discolored/ bruised area to the left heel. A Wound Management form, dated 10/8/19 at 3:25 P.M., indicated Resident T had an unstageable- deep tissue pressure area to the left heel measuring 1.6 cm (centimeters) in length x 1.2 cm width, with 90% of the wound bed covered by eschar. Review of the clinical record lacked the documentation to show the weekly head to toe skin checks had been completed. During a continuous observation, on 10/10/19 from 10:30 A.M. to 10:45 A.M., Resident T was sitting in her wheel chair at the nurses station. The resident was observe to have both feet resting on the foot pedals of the wheel chair without having the Prevalon boots on and or a wheel chair cushion to her wheel chair. During an interview, on 10/10/19 at 10:46 A.M., the residents family member indicated she had found the unstageable pressure area to the heel when she had given her mother a bath on Sunday 10/5/19 and reported it to the facility. During an interview, on 10/10/19 at 10:53 A.M., certified nurses aide 8 indicated she was unsure if the resident was to wear the boots at all times and indicated she should have them on at this time. During an interview, on 10/10/19 at 11:40 A.M., the Director of Nursing indicated the resident should have had the boots on and should have been assessed weekly. She indicated the facility did get a new mattress and started to use the Prevalon boots after the resident had the area. 3. A clinical record review for Resident G was completed on 10/9/19 at 8:37 A.M. [DIAGNOSES REDACTED]. An admission observation report, dated 9/6/19, indicated Resident G had a pressure area to her coccyx measuring 0.25 cm (centimeter) circular pinpoint non-blanchable area to sacrum. Small dime size healing area to coccyx area had no drainage noted. A Braden Risk assessment, dated 9/5/19, indicated Resident G was at risk for skin breakdown. A current care plan, dated 9/5/19, indicated the resident had an ADL (activities of daily living) self care deficit: assist with transfers, bed mobility, toileting and dressing as needed related to fractures. Interventions included, but were not limited to: provide the amount of assistance/supervision to meet the residents needs, assist with transfers,and encourage resident to participate in ADL's as able. A current care plan, dated 9/5/19, indicated the resident had a surgical wound to the left hip and a fractured left arm. Interventions included, but were not limited to: monitor for pain, weight bearing as tolerated left arm and leg and assess condition of surrounding skin and report emergence of skin excoriation. A current care plan, dated 9/12/19, indicated the resident was at risk for skin breakdown related to recent fractures, pain, assist with bed mobility, transfers, [MEDICAL CONDITION], incontinence and current wounds. Interventions included, but were not limited to: assist PRN (as needed) to reposition/ shift weight to relieve pressure, complete weekly skin review, observe for any new areas of skin breakdown, provide pressure relieving device, pressure relieving mattress and chair cushion. A Wound Management record, dated 9/11/19 at 12:19 P.M., indicated the resident was observed to have a small pinpoint size area to the coccyx measuring 0.25 cm x 0.25 cm with no depth documented. Wound was covered with 100% granulation tissue. A care plan, dated 9/12/19, indicated the resident had a pressure ulcer to coccyx. Interventions included, but were not limited to: complete weekly Wound Assessment in wound Management. Review of current physician orders, dated 9/6/19, indicated the resident was to have head to toe skin checks weekly and complete non-pressure observations or a Wound Management form if appropriate. The orders also indicated to assess and measure pressure area to coccyx and follow up with documentation in Wound Management weekly on Wednesday. The Wound management documentation for the coccyx wound dated for 9/18, 9/25 and 10/3/19 was requested on 10/9/19 but no documentation was provided. A Wound Management record, dated 10/8/19 at 1:03 A.M., indicated the coccyx area was documented as an unstageable-slough and/or eschar pressure area measuring 0.7 cm x 0.5 cm no depth documented. A care plan, dated 10/7/19, indicated Resident G had a stage 2 pressure ulcer to her coccyx. Interventions included, but were not limited to: apply [MEDICATION NAME] cream, apply dressing per physician order, cleanse open area to coccyx with normal saline, pat dry, apply therahoney and cover with [MEDICATION NAME] every evening until slough in the wound bed is resolved. During an observation, on 10/09/19 at 3:16 P.M. Resident G was observed to have pinpoint blackened area to the coccyx area. No pressure relieving cushion was observed in the recliner chair the resident had been sitting in. During an interview, on 10/9/19 at 3:17 P.M., the Clinical Liaison indicated the resident did not like to sit on the cushion and it was care planned. She indicated it was added to the care plan as of 10/8/19. During an interview, on 10/10/19 the Director of Nursing indicated the weekly skin assessments had not been completed for Resident G and her area had worsened. On 10/10/19 the Corporate Nursing staff provided the policy titled, Pressure Ulcer (injury) Risk Evaluation, dated 7/24/18, and indicated the policy was the one currently used by the facility. The policy indicated .1. Risk Evaluation. A Braden scale will be completed upon admission, re-admission, and then weekly times 1, with significant changes, and then quarterly. 2. Skin Evaluation. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently, if indicated. 3. Monitoring: a. Staff will perform routine skin inspections(with daily care). b. Nurses are to be notified to inspect the skin, if changes are identified. c. Nurses will conduct skin evaluations at least weekly to identify changes. 4. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers This deficiency was cited on 8/16/19. This facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-40(a) 3.1-40(b)

Based on record review, observation and interview, the facility failed to assess and treat a stage 2 pressure ulcer timely, resulting in the progression of a stage 2 pressure area to an unstagable pressure area, failed to provide interventions to prevent an unstagable pressure area from developing and the facility failed to assess timely and consistently provide interventions to aid in healing and prevent further pressure areas to develop for 3 of 5 residents reviewed for pressure ulcers. (Resident G, T and K) Findings include: 1. A clinical record review for Resident K was completed on 10/8/19 at 4:15 P.M. His current [DIAGNOSES REDACTED]. A current Braden Scale for Predicting Pressure Sore Risk, dated 7/19/19, indicated the resident was at a moderate risk. A weekly skin integrity evaluation, dated 9/17/19, indicated Resident K had a skin alteration of the left trochanter area of redness. No measurement or description was documented. There were no further weekly skin integrity evaluations documented in the medical record. A Wound Management form, dated 10/7/19 at 9:30 P.M., indicated Resident K had a stage 2 pressure ulcer to the left ankle measuring length of 1.2 x 1.1 cm width x 0.1 cm depth. Comments: appears to have been a small blister that opened. Noted approximately 50% brown area under blister pocket and is firm. A Wound Management form, dated 10/7/19 at 9:37 P.M., indicated Resident K had an unstageable pressure area to the left hip measuring 3cm (centimeter) x 3 cm and no depth with 90% of the wound bed covered by eschar/necrotic tissue. A CNA skin care alert sheet, dated 9/18/19, indicated a complete bed bath was given to Resident K with the residents skin section documented as not clear and no documentation of the nurse being notified. Resident K's bathing schedule indicated a complete bed bath was received on the following dates: 9/19, 9/23, 9/24, 9/25, 9/26, 9/28, 9/29, 9/30, 10/1, 10/7 and 10/9/19. There was only 1 Skin monitoring: Comprehensive C.N.A shower review documented for 10/9/19. A nurses note, dated 10/7/19 at 6:28 P.M., indicated a new open area to the resident's left ankle was noted, the physician was notified and new orders were received. On 10/9/19 at 8:30 [NAME]M. the Director of Nursing was observed completing wound measurements on Resident K's wounds. She indicated Resident K had new areas to his left foot of a stage 2 and an unstageable area. Orders for Resident K included: head to toe weekly skin checks ordered on [DATE], skin prep to the left foot base of the great toe 2 times a day and float heels while in bed every shift both ordered on [DATE]. A Wound Management form, dated 10/9/19 at 9:24 [NAME]M., indicated Resident K had an unstagable pressure area to the left big toe (bunion), measuring 0.6 cm length x 1.0 cm width and no depth with 100 % of the wound bed covered by necrotic tissue. A Wound Management form, dated 10/9/19 at 9:26 [NAME]M., indicated Resident K had a stage 2 pressure area to the top of the left foot measuring 0.3 cm length x 0.3 cm width x 0.1 cm depth. During an interview, on 10/10/19 at 10:28 [NAME]M., Certified Nurses Aide 7 indicated the resident was checked and changed every 2 hours and he was to have the booties on PRN (as needed). She indicated the resident had 1 boot on his right foot at the time and there was none on the left foot. During an observation, on 10/10/19 at 10:45 [NAME]M., Resident K was observed laying in bed on his left side with no boot to his left foot. During an interview, on 10:47 [NAME]M., Licensed Practical Nurse 3 indicated the resident should have boots on both feet when in bed. During an interview, on 10/10/19 at 11:41 P.M., the Director of Nursing indicated the Resident should have had his skin assessed weekly. 2. A clinical record review for Resident T was completed on 10/7/19 at 11:49 [NAME]M. Current [DIAGNOSES REDACTED]. An admission assessment, dated 9/17/19, indicated the resident had no skin issues. A Braden Scale for Predicting Pressure Sore Risk, dated 9/17/19, indicated Resident T was at moderate risk for pressure sores. A baseline admission care plan, undated, indicated the resident was at risk for impaired skin related to impaired mobility, communication deficit and incontinence. Interventions included, but were not limited to: weekly skin assessment, report changes in skin status to physician, barrier cream with incontinent care, reposition frequently, monitor for nutritional deficits and dietary consult for decreased appetite. A baseline care plan, undated, indicated the resident had a self care deficit as evidence by s/p (status [REDACTED]. Interventions included, but were not limited to: provide adl care to ensure daily needs are met and total care provided. A nurse's note, dated 9/19/19, indicated Resident T was sent to the hospital for abnormal bleeding. A return admission assessment, dated 9/27/19, indicated the resident had no skin issues. A Braden Scale for Predicting Pressure Sore Risk, dated 9/27/19, indicated Resident T was now at a high risk for pressure sores. A nurse's note, dated 10/5/19 at 6:27 P.M., indicated Resident T had a pressure area on the left foot and a foam dressing was placed for preventative measures. A resident event note, dated 10/6/19 at 5:37 P.M., indicated Resident T had a pressure area to the left heel. The event details were all left blank. A nurse's note, dated 10/6/19 at 10:56 [NAME]M., indicated the resident was turned an repositioned every 2 hours, cushioning done on bilateral heels with foam dressings, and feet floated. A nurse's note, dated 10/6/10 at 11:31 [NAME]M., indicated a treatment order for bilateral heels to prevent breakdown added as ordered. A nurse's note, dated 10/7/19 at 6:41 P.M., indicated discoloration noted to left heel, physician notified, received new order for Prevalon boots. Resident T's current physician's orders [REDACTED]. Prevalon boots to bilateral feet, remove every shift and assess skin ordered on [DATE]. Float heels while in bed ordered 10/7/19. Assess and measure area to left heel and update wound management section ordered 10/8/19. Apply skin prep to bruised area left heel every shift ordered on [DATE]. A current care plan, dated 10/8/19, indicated Resident T had actual alteration in skin as evidence by discolored/ bruised area to the left heel. A Wound Management form, dated 10/8/19 at 3:25 P.M., indicated Resident T had an unstageable- deep tissue pressure area to the left heel measuring 1.6 cm (centimeters) in length x 1.2 cm width, with 90% of the wound bed covered by eschar. Review of the clinical record lacked the documentation to show the weekly head to toe skin checks had been completed. During a continuous observation, on 10/10/19 from 10:30 [NAME]M. to 10:45 [NAME]M., Resident T was sitting in her wheel chair at the nurses station. The resident was observe to have both feet resting on the foot pedals of the wheel chair without having the Prevalon boots on and or a wheel chair cushion to her wheel chair. During an interview, on 10/10/19 at 10:46 [NAME]M., the residents family member indicated she had found the unstageable pressure area to the heel when she had given her mother a bath on Sunday 10/5/19 and reported it to the facility. During an interview, on 10/10/19 at 10:53 [NAME]M., certified nurses aide 8 indicated she was unsure if the resident was to wear the boots at all times and indicated she should have them on at this time. During an interview, on 10/10/19 at 11:40 [NAME]M., the Director of Nursing indicated the resident should have had the boots on and should have been assessed weekly. She indicated the facility did get a new mattress and started to use the Prevalon boots after the resident had the area. 3. A clinical record review for Resident G was completed on 10/9/19 at 8:37 [NAME]M. [DIAGNOSES REDACTED]. An admission observation report, dated 9/6/19, indicated Resident G had a pressure area to her coccyx measuring 0.25 cm (centimeter) circular pinpoint non-blanchable area to sacrum. Small dime size healing area to coccyx area had no drainage noted. A Braden Risk assessment, dated 9/5/19, indicated Resident G was at risk for skin breakdown. A current care plan, dated 9/5/19, indicated the resident had an ADL (activities of daily living) self care deficit: assist with transfers, bed mobility, toileting and dressing as needed related to fractures. Interventions included, but were not limited to: provide the amount of assistance/supervision to meet the residents needs, assist with transfers,and encourage resident to participate in ADL's as able. A current care plan, dated 9/5/19, indicated the resident had a surgical wound to the left hip and a fractured left arm. Interventions included, but were not limited to: monitor for pain, weight bearing as tolerated left arm and leg and assess condition of surrounding skin and report emergence of skin excoriation. A current care plan, dated 9/12/19, indicated the resident was at risk for skin breakdown related to recent fractures, pain, assist with bed mobility, transfers, [MEDICAL CONDITION], incontinence and current wounds. Interventions included, but were not limited to: assist PRN (as needed) to reposition/ shift weight to relieve pressure, complete weekly skin review, observe for any new areas of skin breakdown, provide pressure relieving device, pressure relieving mattress and chair cushion. A Wound Management record, dated 9/11/19 at 12:19 P.M., indicated the resident was observed to have a small pinpoint size area to the coccyx measuring 0.25 cm x 0.25 cm with no depth documented. Wound was covered with 100% granulation tissue. A care plan, dated 9/12/19, indicated the resident had a pressure ulcer to coccyx. Interventions included, but were not limited to: complete weekly Wound Assessment in wound Management. Review of current physician orders, dated 9/6/19, indicated the resident was to have head to toe skin checks weekly and complete non-pressure observations or a Wound Management form if appropriate. The orders also indicated to assess and measure pressure area to coccyx and follow up with documentation in Wound Management weekly on Wednesday. The Wound management documentation for the coccyx wound dated for 9/18, 9/25 and 10/3/19 was requested on 10/9/19 but no documentation was provided. A Wound Management record, dated 10/8/19 at 1:03 [NAME]M., indicated the coccyx area was documented as an unstageable-slough and/or eschar pressure area measuring 0.7 cm x 0.5 cm no depth documented. A care plan, dated 10/7/19, indicated Resident G had a stage 2 pressure ulcer to her coccyx. Interventions included, but were not limited to: apply [MEDICATION NAME] cream, apply dressing per physician order, cleanse open area to coccyx with normal saline, pat dry, apply therahoney and cover with [MEDICATION NAME] every evening until slough in the wound bed is resolved. During an observation, on 10/09/19 at 3:16 P.M. Resident G was observed to have pinpoint blackened area to the coccyx area. No pressure relieving cushion was observed in the recliner chair the resident had been sitting in. During an interview, on 10/9/19 at 3:17 P.M., the Clinical Liaison indicated the resident did not like to sit on the cushion and it was care planned. She indicated it was added to the care plan as of 10/8/19. During an interview, on 10/10/19 the Director of Nursing indicated the weekly skin assessments had not been completed for Resident G and her area had worsened. On 10/10/19 the Corporate Nursing staff provided the policy titled, Pressure Ulcer (injury) Risk Evaluation, dated 7/24/18, and indicated the policy was the one currently used by the facility. The policy indicated .1. Risk Evaluation. A Braden scale will be completed upon admission, re-admission, and then weekly times 1, with significant changes, and then quarterly. 2. Skin Evaluation. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently, if indicated. 3. Monitoring: a. Staff will perform routine skin inspections(with daily care). b. Nurses are to be notified to inspect the skin, if changes are identified. c. Nurses will conduct skin evaluations at least weekly to identify changes. 4. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers This deficiency was cited on 8/16/19. This facility failed to implement a systemic plan of correction to prevent recurrence. 3.1-40(a) 3.1-40(b)

Based on interview, observation and record review, the facility failed to ensure that peritoneal [MEDICAL TREATMENT] care was provided to 2 of 2 residents by not following physician orders, not following infection control standards and by not having trained staff to provide peritoneal [MEDICAL TREATMENT] care resulting in symptoms of decreased level of consciousness, weakness, diarrhea, low blood pressure and pain requiring transfer and admission to the hospital. (Resident 29 & 91) The immediate jeopardy began on 9/25/18 when the facility failed to provide appropriate care to 2 of 2 residents receiving peritoneal [MEDICAL TREATMENT] who were then sent to the hospital. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy at 3:42 P.M. on 9/26/18. The immediate jeopardy was removed on 9/28/18, but noncompliance remained at the lower scope and severity of isolated, no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. During an interview, on 9/24/18 at 12:05 P.M., Resident 29 indicated she was concerned with cleanliness of her peritoneal [MEDICAL TREATMENT] treatments because some staff members were not using masks and gloves while they connected and disconnected her from the [MEDICAL TREATMENT] cycler. She indicated some staff had not been trained on how to connect and disconnect her. She indicated she was really upset because she was suppose to be disconnected at 9:00 A.M. from the cycler and she was still connected at time of interview and she indicated this occurred often. Resident 29 was observed at this time with her peritoneal [MEDICAL TREATMENT] catheter still connected to the [MEDICAL TREATMENT] machine. The clinical record for Resident 29 was reviewed on 9/26/18 at 10:43 A.M. The [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 8/9/18, indicated Resident 29 had a BIMS (Brief Interview of Mental Status) score of 13, cognitively intact and was receiving [MEDICAL TREATMENT] services in the facility. A care plan for at risk for [MEDICAL TREATMENT] related complications (peritoneal [MEDICAL TREATMENT]) included interventions, but were not limited to, observe and report to physician complications related to [MEDICAL CONDITIONS]/fluid overload, respiratory difficulty, increased weakness, changes in mental status, changes in vital signs, nausea and vomiting,and weigh resident as ordered. A care plan, dated 8/3/18, for risk of actual fluid imbalance related to diuretic use and peritoneal [MEDICAL TREATMENT] (as evidenced by [MEDICAL CONDITION], respiratory difficulties, lung sounds and increased confusion) included interventions, but were not limited to, observe and report any signs and symptoms of fluid imbalance to the physician. The Orders for Extended Care Facility from the [MEDICAL TREATMENT] center, dated 8/1/18, indicated Resident 29 was to be 1. weighed twice a day (once a night prior to going on the cycler and once in the morning after she came off the cycler), 2. a BP (blood pressure) was to taken before the resident was put on the cycler at night and after the resident was taken off the cycler in the morning, 3. resident was to be placed on the cycler nightly, 4. if systolic BP was less than 90, notify the Home [MEDICAL TREATMENT] Department, 5. if the BP was greater than 180, notify the Home [MEDICAL TREATMENT] Department, 6. if weight was greater that 64 kg (kilograms)/140 lbs (pounds) or less than 56 kg/123 lbs, notify the Home [MEDICAL TREATMENT] Department, 7. routine exit site care was to be done daily by washing the exit site with antibacterial pump soap, 4 x 4 gauze, rinse well with water, dry thoroughly and apply thin layer of [MEDICATION NAME] cream to exit site and cover site with 2 x 2 dressing. 8. Securely tape catheter to abdomen to prevent tugging or pulling on the catheter, do not tape too tightly as that could cause irritation and lead to infection, check that catheter is taped with every patient interaction. 9. Notify the Home [MEDICAL TREATMENT] Department for the following: a. drainage, redness, pain/tenderness, bleeding or trauma to or around the exit site, b. cloudy or hazy effluent in the drain bag, c. resident weight outside the above guidelines, d. any contamination of the cycler or tubing system, e. any contamination to the resident's transfer set, f. [MEDICATION NAME] in the drain bag that was causing the [MEDICAL TREATMENT] solution to drain slowly or g. [MEDICATION NAME] in the catheter that was occluding tubing. 10. Please send flow sheets, current medication list and labs drawn at your facility to each physician clinic appointment, 11. Arrange transportation to appointments, 12. make sure weights and BPs (blood pressure) were legible on flow sheets and that flow sheets were signed by a nurse, 13. check cycler every hour to make sure it was functioning properly. The guidelines for determining the percentage of dialystate to use: a. if weight was less than 60 - 62 kg and/or SBP (systolic blood pressure) was 100-130, use two bags of 1.5% (one 3 L (liter) and one 5 liter), b. if weight was 62 - 64 kg and/or SBP was 131-150, use one bag of 1.5% (3 liter) and one bag of 2.5% (5 liter), c. if weight was 64 kg or above and/or SBP was 151-180, use two bags of 2.5% (one 3 liter and one 5 liter) and d. if blood sugar was above 250 use only 1.5% solution. The Cycler Flow sheet, dated 8/2/18, indicated Resident 29 weighed 133 lbs (60 kg) and had a SBP of 125 and 2 bags of 2.5% were used, start time was 11:30 P.M. The cycler was disconnected at 9:30 A.M. the next morning. There was no weight documented. The Cycler Flow sheet, dated 8/3/18, indicated Resident 29 weighed 131.6 lbs (59.6 kg) and had a SBP of 121 and 2 bags of 2.5 % were used, the start time was 11:45 P.M. The cycler was disconnected at 9:35 A.M. the next morning. There was no weight documented. The Cycler Flow sheet, dated 8/4/18, indicated Resident 29 weighed 129.8 lbs (59 kg) and had a SBP of 117 and one bag of 1.5% and one bag of 2.5% were used, the start time was 11:00 P.M. There was no documentation available for when the cycler was disconnected. The Cycler Flow sheet, dated 8/5/18, indicated Resident 29 weighed 130 lbs (59 kg) and had a SBP of 120 and one bag of 1.5% and one bag of 2.5 % were used, the start time was 11:30 P.M. There was no documentation available for when the cycler was disconnected. The Cycler Flow sheet, dated 8/6/18, indicated Resident 29 weighed 131.8 lbs (59.9 kg) and had a SBP of 138, 2 bags of 1.5 % were used, the start time was 10:13 P.M. and resident was disconnected the next morning at 9:30 A.M. A Complaint/Grievance Report, dated 8/6/18, indicated Resident 29 and her husband had filed a concern the cap to the PD (peritoneal [MEDICAL TREATMENT]) was not in place and staff was not following the treatments properly. The findings to the investigation indicated the cap to the PD was not in place following the PD treatment. The PD catheter was cleaned, run off was observed to be clear and cap was replaced. The plan to resolve complaint was further training of nursing licensed staff to be scheduled, the [MEDICAL TREATMENT] center was notified and the physician. The Cycler Flow sheet, dated 8/8/18, indicated Resident 29 weighed 130.4 lbs (59.3 kg) and had a SBP of 102, 2 bags of 1.5% were used, the start time was 10:10 P.M. There was no documentation available for when the cycler was disconnected. The Clinical Notes Report from [MEDICAL TREATMENT] center, dated 8/10/18 at 3:00 P.M., indicated Resident 29's husband had reported that nurses were not using the [MEDICATION NAME] required for connection. The [MEDICAL TREATMENT] had called the facility to request flow sheets. Resident 29 had complaints regarding the ECF (extended care facility) staff set up of the cycler, they had been given orders to follow and have not been following them. Staff was scheduled the next week to get trained for new employees. Resident 29 was really frustrated with difference from her personal training and staff set up of cycler. New order was called to facility to hold [MEDICATION NAME] (blood pressure medication), and use 1.5% solutions when the resident was feeling dizzy or light headed. The Orders for Extended Care Facility, dated 8/24/18, indicated guidelines for determining the percentage of dialystate to use: a. if weight was less than 65 - 67 kg and/or SBP (systolic blood pressure) was 100-130, use two bags of 1.5% (one 3 L (liter) and one 5 liter), b. if weight was 67 - 69 kg and/or SPB was 131-150, use one bag of 1.5% (3 liter) and one bag of 2.5% (5 liter), c. if weight was 69 kg or above and/or SBP was 151-180, use two bags of 2.5% (one 3 liter and one 5 liter) and d. if blood sugar was above 250 use only 1.5% solution. The Cycler Flow sheet, dated 8/24/18, indicated Resident 29 weighed 143 lbs (65 kg) and had a SBP of 118, 4 bags of 1.5% were used with a start time of 10:50 P.M. The cycler was disconnected at 9:30 A.M. on 8/25/18, there was no weight available. The Cycler Flow sheet, dated 8/25/18, indicated Resident 29 weighed 135.1 lbs (59.8 kg) and had a SBP of 90, there was no documentation present for the type of bags used or the number. The cycler was disconnected the next morning at 9:30 A.M., there was no weight available. The was no documentation of physician notification available for SBP of 90. The Cycler Flow sheet, dated 8/26/18, indicated Resident 29 weighed 149 lbs (67.7 kg) and had a SBP of 126, 2 bags of 1.5 % were used. The cycler was disconnected the next morning at 10:00 A.M., there was no weight available. The Cycler Flow sheet, dated 8/27/18, indicated Resident 29 weighed 133.5 lbs (60.6 kg) and had a SBP of 102, 1.5 % bags were used, there was no indication of how many bags. The cycler was disconnected the next morning at 9:48 A.M. The was no other information or nurse signature for the disconnect after [MEDICAL TREATMENT]. A Complaint/Grievance Report, dated 8/27/18, indicated Resident 29's husband was concerned with [MEDICAL TREATMENT] nurse had appeared frustrated and spilled fluid on the floor and the 2nd nurse had never done the [MEDICAL TREATMENT] cycler before. The complainant remarks indicated I just worry about infection. The Assessment Report, dated 8/28/18 at 5:05 P.M., indicated Resident 29 had presented with +3 [MEDICAL CONDITION] to bilateral lower extremities, she expressed multiple frustrations with the ECF and that the facility had orders to send flow sheets with resident to every clinic visit and clinic had to call and request sheets and sheets were not completed as ordered. The supplies sent with resident were masks, sanitizer, [MEDICATION NAME] holder and [MEDICATION NAME]. The review of flow sheets indicated average BP was 120/60 and average weight was 59 kg. It was noted the facility was not completing all blanks on flow sheet on post flow sheet and ECF staff was informed all blanks need to be completed. Orders were sent to the facility reinforcing guidelines exchange set up, check modem for transmitting and proper hygiene. There were no orders present on MAR (Medication Administration Record) to reflect the orders from 8/28/18. The Patient Instruction Sheet, dated 8/28/18, indicated Resident 29 had physician orders [REDACTED]. The Cycler Flow sheet, dated 8/29/18, indicated no there was no documented information from 8/28/18, on 8/29/18 one bag of 1.5 and one bag of 2.5 were used and on 8/30/18, 2 bags of 1.5 were used and blood pressures were in parameter. The Physical Therapy, PT Evaluation & Plan of Treatment, dated 9/14/18 at 6:50 P.M., indicated Resident 29 exhibited new onset of decrease in strength, decrease in functional mobility, and reporting having difficulty breathing while resting in her recliner, oxygen saturation was 93-96 percent. The complaint of difficulty breathing was communicated to nursing. There was no physician notification available for complaint of difficulty breathing. A Clinical Notes Report from [MEDICAL TREATMENT] Center, dated 9/18/18 at 7:45 A.M., indicated RN 5 had called the [MEDICAL TREATMENT] center to report that Resident 29 was feeling full with abdominal distention and the resident was requesting a drain and that the facility did not have any one available that could do that now and indicated the resident was currently attached to cycler. The Cycler Flow sheet, dated 9/18/18, indicated Resident 29 weighed 121.5 lbs and had a SBP of 100, 1.5% bags were used with no indication of how many bags. The cycler was disconnected at 8:45 A.M. the next morning. The Cycler Flow sheet, dated 9/19/18, indicated resident 29 weighed 120.8 lbs and had a SBP of 104, 1.5% bags were used with no indication of how many. There was no documentation available of when cycler was disconnected. The Progress Note, dated 9/19/18 at 4:43 A.M., indicated Resident 29 had become more confused lately, and was confused on this shift. There was no physician notification available for new complaint of confusion. The Clinical Notes Report from the [MEDICAL TREATMENT] center, dated 9/20/18 at 6:14 P.M., indicated RN during home visit at facility she discussed with resident and husband that resident has to remind staff of steps they are missing. She indicated she reminded staff masks need to be the first thing done prior to hand washing and staff members reported the resident reminds them of steps. She indicated she taped to the wall by resident to mask, wash, and sanitize prior to any resident care related to [MEDICAL TREATMENT] and that instructions for solution selection was brought to the attention and reminders to complete all blanks on the flow sheets. The Clinical Notes Report from the [MEDICAL TREATMENT] center, dated 9/20/18 at 6:40 P.M., indicated the flow sheets had been reviewed and noted to have multiple banks and no physician notification for SBP less than 100. The Cycler Flow sheet, dated 9/20/18, indicated resident 29 weighed 122.7 lbs and had a SBP of 106, 2 bags of 1.5% were used, the start time was 11:00 P.M. There was no documentation available of when cycler was disconnected. The Clinical Notes Report from the [MEDICAL TREATMENT] center, dated 9/21/18 at 6:05 P.M., indicated the physician at the clinic had been informed of the Resident 29's concern about treatment and care at the facility and the [MEDICAL TREATMENT], she indicated the staff doesn't always want to listen or care for her. The Cycler Flow sheet, dated 9/21/18, indicated resident 29 weighed 123.1 lbs and had a SBP of 102, 2 bags of 1.5% were used, the start time was 11:00 P.M The cycler was disconnected at 9:00 A.M. the next morning. The Cycler Flow sheet, dated 9/23/18, indicated resident 29 weighed 124.3 lbs and had a SBP of 142, 2 bags of 1.5% were used, the start time was 11:00 P.M. There was no documentation available of when cycler was disconnected. A Hematology Report, dated 9/24/18, indicated Resident 29 had a WBC (white blood cell) count of 18.68 (reference range 4.00-11.00). There was no physician notification available for elevated WBC count. During an interview, on 9/25/18 at 10:06 A.M., Resident 29's husband indicated that Resident 29 had decreased level of consciousness since yesterday and that she had diarrhea since 4:00 A.M. with nausea and that no staff had been in to assess the resident yet that day. There was no documentation of assessment or notification to physician for change of condition. The SBAR Communication Form, dated 9/25/18 at 11:50 P.M., indicated Resident 29 presented with weakness, lethargy, elevated temperature and crackles to lung sounds. Her vital signs were 99.6 temperature, 122 pulse and biox 88% on oxygen. She had decreased level of consciousness and increased confusion. Resident 29 was sent to the local emergency roiagnom on [DATE]. The Emergency Department Physician Evaluation, dated 9/25/18, indicated Resident 29 had a complaint of weakness and diarrhea. she had increased generalized weakness. She initially had significant [MEDICAL CONDITION] with a blood pressure of 78/64 and a pulse of 116. Her WBC count was 24,580 and glucose of 44. The diagnostic impression was septic shock (a severe infection). The History & Physical from local hospital, dated 9/25/18, indicated Resident 29's chief complaint was a malaise and shortness of breath over the past 2-3 days and diarrhea that started on 9/24/18. During an interview, on 9/26/18 at 11:37 A.M., the supervisor from the [MEDICAL TREATMENT] center indicated she was aware that Resident 29 and her husband had concerns with timing of care and attention that the resident had been receiving in the ECF and they had instructed resident to talk with administration in the facility. During an interview, on 9/27/18 at 12:06 P.M., the DON (Director of Nursing) indicated there is no documentation available for why wrong percentages of dialystate solution was administered through the cycler in regards to SBP and weights. During an interview, on 9/28/18 at 11:48 A.M., the Medical Director indicated the facility had not made him aware of Resident 29's change of condition or the laboratory results from 9/24/18 with a white blood cell count of 18.68. He indicate he was not aware that the facility had not been following the orders related to the percentage of dialystate in regards to SBP and weight. 2. During an observation, on 9/24/18 at 11:01 A.M., LPN (Licensed Practical Nurse) 2 answered the call light in Resident 91's room, the resident and mother in law requested to have resident disconnected from cycler and expressed they had been waiting 45 minutes already. LPN 2 refused to disconnect resident at that time, indicating she could not do it at that time due to family in the room. Mother- in-law indicated she was not happy about the refusal. During an interview, on 9/24/18 at 11:14 A.M., Resident 91 indicated the facility staff regularly did not disconnect her timely and no one in the facility knew what they were doing with the machine. She indicated she had pain in abdomen region and lower ribs that hurt when she coughed, she rated the pain at a 10 out of 10. During an observation, on 9/24/18 at 11:20 A.M., LPN 2 was observed to enter Resident 91's room and wash her hands for 12 seconds. She set up supplies on bed side table on a towel, no disinfection of the table was noted. She placed on gloves and then mask applied to face by placing straps around her ears. She applied alcohol gel to gloves, moved table over by [MEDICAL TREATMENT] machine and then grabbed pole from across and placed by bed. She removed gloves and washed her hands for 10 seconds, reapplied gloves (non sterile), attached cap to pole, then applied alcohol gel to gloves. She proceeded disconnect catheter from tubing and wiped off then end of the catheter tubing. During an interview, on 9/24/18 at 11:30 A.M., Resident 91 indicated she did have concerns with the cleanliness of the Peritoneal [MEDICAL TREATMENT] process because some staff does not wear gloves or mask, some would lay the tubing on the bed or on clothing, and that some staff had not been trained by the [MEDICAL TREATMENT] center. During an interview, on 9/25/18 at 10:15 A.M., Resident 91 indicated she was sick and been up vomiting last night, she complained of pain rated at 10 and stated she has the chills. She indicated her pain was in ribs and abdominal area and it was worse than the day before. The clinical record for Resident 91 was reviewed on 9/27/18 at 9:05 A.M. The [DIAGNOSES REDACTED]. The resident was able to answer all screening questions and complete interview with appropriate answers. Resident 91 was admitted to the facility on [DATE]. There was no care plan for peritoneal [MEDICAL TREATMENT] documented. A Progress Note, dated 9/20/18 at 8:10 P.M., indicated Resident 91's husband had informed nursing staff that resident's [MEDICAL TREATMENT] needs to be hooked up tonight and the nursing staff had informed resident's husband there was no order for [MEDICAL TREATMENT] for this shift and they passed it on to day shift to clarify resident's [MEDICAL TREATMENT] orders. A Progress Note, dated 9/22/18 at 4:34 P.M., indicated Resident 91 had periods of increased confusion and had stated she was too weak to transfer. There was no physician notification available for this change in condition. A Progress Note, dated 9/25/18 at 3:00 P.M., indicated Resident 91 had an unwitnessed fall in room and she was found on her bottom beside her bad. Resident 91 had indicated she was attempting to transfer self and was just too tired to stand. During an interview, on 9/26/18 at 11:37 A.M., the RN (Registered Nurse) supervisor from the [MEDICAL TREATMENT] center indicated only staff trained by the [MEDICAL TREATMENT] center should work with the peritoneal [MEDICAL TREATMENT]. She indicated the training and validation train to train staff was under contract with with the facility. She indicated she was validated on hand washing and skills check off for the peritoneal [MEDICAL TREATMENT] and that using hand sanitizer on gloves was not part of the skills check off. During an interview, on 9/26/18 at 2:00 P.M., Resident 91 indicated she had a headache, right shoulder pain, upper and lower back pain and she was tired. She indicated the facility had a hard time getting her temperature. She stated I just don't feel good and she had hallucinations over the past couple of days. She denied any pain relief from Tylenol provided over one hour ago and complained of nausea. LPN 3 was present during interview. During an observation, on 9/26/18 at 2:10 P.M., LPN 3 placed gloves on to assist Resident 91 to bed. There was no hand washing noted prior to assisting resident. LPN 3 removed gloves and applied new ones, no hand washing was noted at this time. She proceeded to wash the bedside table with gel bleach and 4 x 4 gauze, she missed cleaning approximately a fifth of the table in the center, and cleaned the IV pole with the same 4 x 4 gauze that was used to clean the table. She removed the [MEDICATION NAME] from the [MEDICAL TREATMENT] machine and place it on the pole and wiped off [MEDICATION NAME] with same 4 x 4 gauze that was used to clean the table and pole. She then gathered the bag of fluid directly from the storage box, opened it and placed on table. There was no warming of the bag noted. There was a ring from a cup and splatters of unknown substance present on the table. She placed bag on the IV pole and hooked tubing to [MEDICATION NAME], moved the pole by resident's bedside and then placed a towel and fluid drainage bag on the floor. She then removed her gloves. She pulled up her own pants, and then pulled the resident's access catheter from inside the resident's pants and hooked to [MEDICATION NAME]. There was no hand washing and no glove use observed, and did not cleanse the end of the resident's [MEDICAL TREATMENT] catheter. She then washed her hands for 15 seconds from the time the water was turned on to the time she dried her hands, applied clean gloves and provided mask to resident and others present in the room. She applied hand sanitizer to her gloves and rubbed hands for 8 seconds. She placed on mask and continued to rub wet gloves form previous hand sanitizer for 18 seconds. She the reapplied hand sanitizer to gloves and rubbed hands together for 12 seconds. She then moved the resident's access catheter to the center notch on the [MEDICATION NAME], which drained fluid. The [MEDICATION NAME] had been wiped off with the same gauze that was used to clean the table and the pole. She applied hand sanitizer to gloves and rubbed for 6 seconds. She then turned on the cycler, drainage went directly from bag that was hung on the pole and drainage bag on the floor. LPN 3 indicated at this time, I did that wrong and RN (Registered Nurse) 4 indicated to just start over. LPN 3 disconnected resident's access site from [MEDICATION NAME] and placed on bed, there was no cap placed on the end of the resident's access catheter. She changed her gloves, no hand washing noted at this time. She cleaned the resident's emesis from the resident's access catheter, by using bleach solution and 4 x 4 by rubbing the tubing with up and down motions. She placed new cap on the [MEDICATION NAME], grabbed a new bag of solution from box on floor, opened bag and placed on table. No second cleaning of the table was noted. She changed gloves, no hand washing noted and no warming of the second bag noted. Applied new gloves and applied hand sanitizer to gloves and rubbed hands for 45 seconds, reapplied hand sanitizer and rubbed again for 15 seconds. She weighed new bag and placed on pole, and attached tubing to [MEDICATION NAME]. She cleaned the [MEDICATION NAME] again, and removed her gloves, washed hands for 20 seconds and applied new gloves. She picked up the resident's access catheter from bed and attached it to [MEDICATION NAME]. There was no cleaning of the resident's [MEDICAL TREATMENT] observed. She applied hand sanitizer to gloves and rubbed hands or 10 seconds and then made some adjustments to the [MEDICATION NAME] and started the cycler. A Progress Note, dated 9/26/18 at 4:55 P.M., indicated Resident 91 had a blood pressure of 80/56 and heart rate of 74. She had reported nausea and vomiting recently but medications had been administered and were effective. An SBAR Communication Form, dated 9/26/18 at 5:39 P.M., indicated Resident 91 was unable to turn with out assistance or sit up in bed, and she complained of feeling fatigued. She had complained of generalized pain rated at a 4. She had a non productive cough that resident had stated had been present all day. There was no physician notification to [MEDICAL TREATMENT] center for blood pressure of 80/56 documented. A Progress Note, dated 9/26/18 at 11:18 P.M., indicated Resident 91 had a vitals taken at 10:28 P.M. that were blood pressure 78/48, temperature of 97.9 F and plus one [MEDICAL CONDITION] (swelling) to bilateral lower extremities. Nephrology center was notified and advised to start IV (intravenous fluids) or send to local emergency room . A second nurse had checked resident's blood pressure and it was 86/50. Resident was sent to local emergency room . The ER (emergency room ) Note, dated 9/26/18 at 11:52 P.M., indicated Resident 91 had been sent to the ER because of a blood pressure of 70/40 and that her blood pressures had been running 80/50 for the last 5 days. Resident had indicated she had nausea, vomiting and diarrhea, as well as a productive cough. The procedure indicated the high probability of sudden, clinically significant deterioration in the resident's condition required the physician's highest level of preparedness to intervene urgently. The services provided to the resident were to treat and/or prevent clinically significant deterioration that could result in vital organ system failure. Resident 91's pressure was 87/58 after the EMS (Emergency Medical Service) had given one liter of fluids IV. Resident was diagnosed with [REDACTED]. During an interview, on 9/27/18 at 9:13 A.M., the DON (Director of Nursing) indicated the facility used to do peritoneal [MEDICAL TREATMENT] and the facility used to have issues with doing it. She indicated Resident 29 was the first [MEDICAL TREATMENT] resident the facility has had in a while. She indicated she had some old staff that were trained in building for peritoneal [MEDICAL TREATMENT] and had to get new employees trained. She indicated she has not had any training on peritoneal [MEDICAL TREATMENT] yet and that the ADON (Assistant Director of Nursing) had just received training on 9/24/18. She indicated that Resident 29 and 91 have been receiving peritoneal [MEDICAL TREATMENT] for a long time at home and they were both very versed in the procedures. During an interview, on 9/27/18 at 3:14 P.M., the DON indicated LPN 2 had not received a refresher course on peritoneal [MEDICAL TREATMENT]. Her last recorded date of training was 8/31/16. She indicated daily skilled nurse's note should have been completed daily since admission of 9/20/18. During an interview, on 9/27/18 at 3:26 P.M., the RN ( Registered Nurse) supervisor from the [MEDICAL TREATMENT] center indicated that the administration of the wrong time type [MEDICATION NAME] could potentially cause resident 's weight to go down, [MEDICAL CONDITION], weakness and light-headedness. During an interview, on 9/27/18 at 3:30 P.M., RN 4 indicated she was in the room on 9/26/18 during care and that Resident 91 did complain pain and discomfort. She indicated the resident did complain of nausea and of course vomited, and resident complained of not feeling well. She indicated All [MEDICAL TREATMENT] residents complain of not feeling well before start of exchange. She indicated she was aware that the nurse had given the resident Tylenol an hour before with no reported from resident relief, She resident had indicated not a lot of relief and that she did not specifically ask the pain scale of the resident. She indicated that the resident was given [MEDICATION NAME] for nausea and vomiting and that she did not notify the physician of the the nausea because it had resolved. She indicated she was unaware if LPN 3 had notified the physician of the resident's complaint of pain and not feeling well. During an interview, on 9/28/18 at 9:05 A.M., LPN 2 indicated she did not notify the physician regarding the pain that resident was having on 9/24/18. She indicated she had notified in regards to low blood pressure for a few days to request medication. During an interview, on 9/28/18 at 10:24 A.M., LPN 3 indicated there was no documentation available for physician notification for the complaints of nausea, vomiting, increased pain and not feeling well in 9/26/18. During an interview, on 9/28/18 at 11:48 A.M., the Medical Director indicated it was his understanding and expectation that the staff in the facility would received training on new hires and refresher training on previous staff prior to accepting the peritoneal [MEDICAL TREATMENT] residents. On 9/26/18 at 3:00 P.M., the DON provided the Peritoneal [MEDICAL TREATMENT] policy, dated 6/21/18, and indicated this was the policy currently being used by the facility. The policy indicated the initiation and maintenance of peritoneal [MEDICAL TREATMENT] would be performed by a Licensed Nurse who had been trained in CAPD (continuous ambulatory peritoneal [MEDICAL TREATMENT]). Residents may participate in their own PD under the direction of the registered nurse. The system would be maintained using aseptic technique and according to the written order of the physician. On 10/2/18 at 11:00 A.M., the ED (Executive Director) provided the Change of Condition policy, dated 7/10/18, and indicated this was the policy currently being used by the facility. The policy indicate the facility would evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay evaluation information to physician and to document actions to include but limited to the following: a significant change in the resident's physical, mental or psychosocial status, a need to alter treatment . 1. Licensed Nurse will evaluate any change in condition through direct observation, physical examination and vital signs at the onset of the change and as ordered by the physician . A policy for laboratory notification was present, no policy was provided. The CAPD Exchange Procedure, dated 2010, indicated with this and all peritoneal [MEDICAL TREATMENT] procedures, always maintain aseptic technique. 1. Clean the work surface and gather the supplies needed for the exchange (mask, warmed PD solution, stay safe cap and stay safe [MEDICATION NAME]). 2. Retrieve catheter and close your extension set clamp. Put on mask. Everyone in the room must also put on a mask. Wash your hands. Open the solution bag by tearing from notched edge of the package overlap. wipe off any moisture on the bag surface. 3. Check the solution (strength, clarity, amount, leaks and expiration). 4. Pick up the stay safe disc with it colored plastic cover. Turn the blue dial on the disc counterclockwise until it fits into the c

Based on interview and record review, the facility failed to protect a resident from abuse after an allegation had been made of a staff member retaliating against a resident. This resulted in the resident crying and expressing fear of retaliation in 1 of 4 residents reviewed for abuse. (Resident 2) Findings include: During the Resident Council Meeting, on 9/26/18 at 1:30 P.M., Resident 2 had indicated she was afraid to retaliation by staff members if any of the residents reported them for care concerns based on the fact that the staff members fight and yell amongst each other in front to the residents. She indicated that if they (the staff) treat each other that way, could you imagine how they would treat us. During an interview, on 10/1/18 at 9:45 A.M., Resident 2 was upset and crying and indicated that she felt she was being retaliated against by LPN (Licensed Practical Nurse) 6 since the Resident Council Meeting held on 9/26/18. She indicated she knew she had the [DIAGNOSES REDACTED]. who said anything to LPN 6 because no names were mentioned in the Resident Council meeting. She indicated she knew something was different in how LPN 6 was treating her, because the nurse always gave her her medications between 7:00 and 7:30 P.M., and when she asked her medications on 9/26/28 in the evening, the nurse told her she had to wait. She indicated that the staff knows her pain gets really bad if she doesn't get her medications at the time she's used to. She indicated she did not get her medications until around 10:00 P.M., and when the nurse brought them she slammed the cup down on the table. Resident 2 indicated she had noticed that LPN 6 had the insulin pen in her hand when she came in the room, so she pulled her sleeve up to prepare for her injection. She indicated LPN 6 proceeded to stab her in the arm with the insulin pen hard enough to make the resident jump back and say ouch, the nurse then proceeded to remove the needle and stab her in the arm a second time. Resident 2 indicated she had asked LPN 6, Did you do that on purpose? and the LPN just looked at her. Resident 2 indicated her roommate had observed the incident. She indicated LPN 6 never explained what she was going to do, nor did she pinch the skin up to give the insulin injection. She indicated she was really upset because she felt the nurse was retaliating against her but she didn't understand why because she had never said anything about that specific nurse. Resident 2 indicated she reported the incident to the shower aide the next morning, and the shower aide had explained she had to report it because LPN did her wrong. She indicated she had talked to the DON (Director of Nursing) and ED (Executive Director) on Thursday in regards to the incident but they had told her that maybe she was being too sensitive about incident and because she had [MEDICAL CONDITION], maybe she wasn't remembering the incident correctly. She indicated that LPN 6 worked 9/27/18 again and treated her differently. She indicated she did not get her medications until around 10:00 P.M. on 9/27/18 and that the LPN would not talk to her or look at her. She indicated she had asked LPN 6, Why are doing this to me? and the LPN responded that she didn't have to tell her anything and that wasn't going to be around her if didn't have another CNA (certified nurse aide) with her since didn't want to accused of anything. Resident 2 stated after that comment that she had told LPN 6 not to come into her room anymore if that was how she was going to treat her. Resident 2 indicated that RN (Registered Nurse) brought her medications around 10, however LPN 6 kept coming into her room to give the roommates medications. Resident 2 indicated she was a paranoid [MEDICAL CONDITION] and the way that LPN 6 was treating her was only making it worse. She indicated she did not get hardly any sleep on Thursday night, that she tried to call the local state agency and the ombudsman over the weekend with no answer and that she had a meeting with the Resident Council president in regards to how she was being treated. She indicated that staff members in the facility had tried to talk her out of reporting it to the state surveyors that were currently in the building. The clinical record for Resident 2 was reviewed on 10/2/18 at 12:51 P.M., the [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 7/16/18, indicated Resident had a BIMS score of 12, mild cognitive impairment. A care plan, dated 7/17/18, for at risk for anxiety for [DIAGNOSES REDACTED]. A care plan, dated 7/17/18, for at risk for mood related issues related to [DIAGNOSES REDACTED]. During an interview, on 10/1/18 at 10:10 A.M., Resident 191 (Resident 2's roommate) indicated that she did witness LPN 6 come into the resident's room and when Resident 2 pulled up her sleeve, LPN stabbed her in the arm hard enough to make Resident 2 jump in her chair and say ouch, LPN 6 then proceed to stab Resident 2 in the arm again with the insulin pen. She indicated she knew how insulin injections were suppose to given, the skin was supposed to be pinched up and then place the needle in the arm. She indicated when Resident 2 asked it that was done on purpose, LPN 6 just looked at her. She also indicated she was present when Resident 2 had asked for her medications earlier and was told she would have to wait. During an interview, on 10/1/18 at 10:20 A.M., LPN 2 indicated she was aware of the incident that occurred on Wednesday, 9/26/18. She indicated that CNA 8 had reported to her directly that Resident 2 was very upset during her shower because LPN 6 had stabbed her while administering her insulin injection last night twice. She indicated she was aware the resident felt like she was being retaliated on. She indicated the ADON (Assistant Director of Nursing) was present when CNA was reporting to her the incident and she told the ADON to listen. She indicated she knew it was a reportable incident and that also made the SSD aware of the incident and SSD had went down and talked to Resident 2. She did also indicate she was aware that LPN 6 had worked the following night and she was surprised. During an interview, on 10/1/18 at 10:30 A.M., the ED indicated she became aware of the incident that occurred on 9/26/18 in the evening, in the morning of 9/27/18 but she did not report it until Friday morning, 9/28/18, when she realized Resident 2 was really devastated. She had said because of the resident's [MEDICAL CONDITION], the resident felt that her mind was messing with her and to just leave it alone and not say anything. She indicated no documentation on investigations completed was available. She indicated that LPN 6 did work the night of 9/27/18. During an interview, on 10/1/18 at 12:32 P.M., CNA 8 indicated Resident 2 was really upset and fearful about any further retaliation during her shower on 9/27/18 in the morning. She indicated she had reported the incident to LPN 2, and the ADON was present. CNA provided a statement of the following: On the morning of (MONTH) 27th, (YEAR), I (staff name) was giving a shower to (Resident 2's name). While giving her a shower, I noticed she was a little down so I asked her what was wrong. (Resident 2) looked at me and said, well, can I tell you something. I said sure you can always talk to me. (Resident 2) told me that the night before she felt like the (LPN 6) had stabbed her while giving her her insulin shot. I asked if she was sure and she said yes, I am sure she stabbed me and when I pulled my arm back she shoved it in. (Resident 2) continued to say she looked at (LPN 6) and asked her if she did that on purpose, she said the (LPN 6) did not answer her and just looked at her, so I asked her again if she just stabbed me on purpose. She said she just looked at me and just walked out of the room. (Resident 2) asked me not to tell anyone. I then told (Resident 2) that I was sorry but I have to report this situation. Once we were done I walked (Resident 2) back to her room, and went to the nurses station and reported to my nurse at the time. During an interview, on 10/1/18 at 12:32 P.M., the ADON indicated she aware of the incident. She had heard Resident 2 talking about insulin being given too rough and she did not report it because the DON and ED had already talked to the resident. During an interview, on 10/1/18 at 1:00 P.M., the SSD (Social Service Director) indicated LPN 2 had made her aware of the incident and that she did report it to the ED on 9/27/18. She indicated Resident 2 was a newer admission into the facility and that she was alerted and oriented. The SSD provided the following statement: On 9/27/18 (nurse name) informed SSD that (resident name) had a problem with a nurse. SSD went to speak to resident. She stated that last night, (Nurse name) gave me my meds. I was upset because I like to get my meds between 7 and 7:30. I didn't get my meds until 10. She gave me my shot and I jumped. She had to stick me again. I said that hurt fans she didn't say anything. Not I'm sorry. She did say, she is not into the routine. It would of made me feel better if she had said sorry. SSD informed the CEO and DON of resident's statements and they went to speak with the resident. A Progress Note, dated 9/27/18 at 8:51 P.M., indicated Resident 2 had requested medication from LPN 6 and LPN 6 responded she would be with her when she got a CNA for a witness. Resident 2 wanted to know why a witness was needed and the nurse advised she would feel more comfortable with if interactions were witnessed. Resident 2 became angry and stated if a witness is needed then she would like to have another nurse to care for her. Resident 2 came down to the common area threatening to report the nurse to the state in the morning as well as administration. A Progress Note, dated 9/27/18 at 9:26 P.M., indicated Resident 2 was very agitated and she threw her phone as the nurse approached her. Resident 2 asked the nurse if she was upset and the nurse indicated she was going to give her medications. The Resident had been talking very loud about people targeting her for bad treatment. The State Report, dated 9/28/18, indicated Resident 2 had notified the ED and DON on 9/28/18 at approximately that she felt pointed out from LPN 6 the night before when the nurse said that she needed witness to provide care. The time of the incident was 9/27/18 at 10:01 P.M. A statement, dated 9/28/18, indicated after receiving the concern from Resident 2, LPN 6 was suspended that was signed by the DON. During an interview, on 10/02/18 at 5:06 PM, the ED indicated she should have reported the incident on Thursday, but she was unaware of the portion of statement from CNA 8. She indicated no statements have received from witnesses or other staff as of yet. She indicated when she was in the facility on Sunday, 9/30/18, Resident 2 was really upset and crying about the incident. On 9/25/18 at 10:00 P.M., the ED provided the Abuse, Neglect, Exploitation and Misappropriation of Property Policy, no date, and indicated this was the policy currently being used by the facility. The policy indicated it was prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property, and to assure that all alleged violations of federal or State laws which involve abuse, neglect, exploitation, injuries of unknown origin and misappropriation are investigated, and reported immediately to the Facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. Every Stakeholder, contractor and volunteer immediately shall report any allegation of abuse, injury of unknown origin, or suspicion of crime. If the suspected perpetrator is a Stakeholder, the charge nurse immediately will the Stakeholder for the resident care areas and suspend him/her while the matter is investigated. 3.1-27(a)(1) 3.1-27(b)

Based on interview and record review, the facility failed to ensure a resident with a right heel wound, which developed an infection, was treated to prevent deterioration of the wound and untreated infection (Resident 37) and failed to adequately assess pain and respiratory status prior to a hospitalization related to a [MEDICAL CONDITION] embolism (Resident 21) for 2 of 14 residents reviewed for quality of care. Findings Include: 1. A clinical record review was conducted, on 09/27/18 at 9:04 AM, for Resident 37 and indicated an admission date of [DATE]. Her [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment, dated 02/26/18, indicated a BIMS (Brief Interview for Mental Status) score of 15, cognitively intact. The assessment indicated no unhealed pressure ulcers, no infections, and no use of antibiotics. No venous or arterial ulcers were indicated as being present. A [MEDICAL CONDITION] was indicated as present. The MDS assessment, dated 06/01/18, indicated no pressure areas, foot wounds, or infections present. A care plan was in place related to an arterial ulcer of the right heel, osteo[DIAGNOSES REDACTED], and toe amputation. Wound documentation indicated a right heel wound on admission. First pressure wound record completed for the area was on 02/22/18. Additional right heel documentation began again on 06/11/18, referring to the area as non-pressure, with progressive worsening of the area up to the time the osteo[DIAGNOSES REDACTED] was diagnosed . On 06/20/18, the area was reclassified as a pressure area. Wound documentation began on 07/30/18 for non-pressure wounds to the right 2nd and 3rd toes. No documentation was present related to the right 4th toe wound. A Pressure Wound Tracking report indicated, 04/26/18, the right heel wound was classified as unstageable with measurements of 6cm x 5cm x 0cm and foul odor drainage. Physician orders [REDACTED]./39/18 to 08/31/18, 08/31/18 to 09/08/18, 09/08/18 to 09/28/18, and 09/08/18 to current. No orders were indicated for the time periods of 05/21/18 to 06/11/18 and 06/18/18 to 06/28/18. No orders for treatments related to the toe wounds were indicated. TAR (Treatment Administration Record) documentation indicated no wound treatments from 05/20/18 to 06/12/18. Multiple days during (MONTH) and (MONTH) where no wound care documentation was indicated. No wound care documentation was indicated for toe wounds to the right foot. A wound culture was indicated on 02/24/18 with moderate gram positive rods and cocci, suggestive of diphtheroids/coryneform. No notes related to physician notification were indicated. No antibiotics were ordered at this time. A physician visit note, dated 07/20/18, indicated all wound labs and the MRI would be repeated. A physician order, dated 07/20/18, indicated the labs and MRI were to be completed. A wound culture was completed on 07/23/18 with many gram positive rods, suggestive of diphtheroids/coryneform. No antibiotics orders were started. No MRI results were available for review. A physician order, dated 08/10/18, indicated the resident was to be sent to the emergency room for evaluation and admission related to the right foot arterial flow concern/issues. An operative report, dated 08/27/18, indicated a surgical debridement of the right heel wound and amputation of the 2nd, 3rd, and 4th toes were amputated on the right foot. A pathology report, dated 08/27/18, indicated osteo[DIAGNOSES REDACTED] and gangrenous necrosis were present. A wound culture, dated 08/27/18, indicated many coryneform gram positive bacillus. During an interview, on 10/01/18 at 9:19 AM, the DON (Director of Nursing) indicated wound assessments were to be completed weekly. During an interview, on 10/01/18 at 12:04 PM, LPN (Licensed Practical Nurse) indicated the resident was not started on any antibiotic after the wound culture because it was not considered an infection. No note was available to indicate the physician was notified. During an interview, on 10/02/18 at 3:28 PM, LPN indicated they were unable to locate a result for the MRI ordered on [DATE] and could not determine if it had been completed. 2. During an interview on, 9/26/18 at 10:29 A.M., Resident 21 indicated around 4/13/18 she began having pain on her left side in her rib cage area. She indicated she reported the pain to the DON (Director of Nursing) at the time and the nurses about the pain. After a few days, the resident indicated to the ADON (Assistant Director of Nursing), at the time, that she was having extreme pain on her left side. The ADON indicated to the resident she didn't look like she was in pain, but she was going to call the doctor. Resident 21 indicated she did not want to wait for the doctor's phone call as she had been complaining about the pain for a couple days, so she called 911 herself. A record review was conducted on, 9/26/18 at 11:33 AM, for Resident 21. Her [DIAGNOSES REDACTED]. An operative note, dated 2/13/18, indicated Resident 21 had bilateral below knee amputations on 2/13/18 and admitted to the facility on [MEDICATION NAME] (a blood thinner) 40 mg (milligrams) daily on 2/26/18. The quarterly MDS (Minimum Data Set) assessment, dated 8/14/18, indicated her BIMS (Brief Interview Mental Status) score was 13, cognitively intact. Resident 21 was able to answer cognitive screening questions appropriately and facility staff indicated she was alert and oriented. The MDS, dated [DATE], indicated she was receiving anticoagulants for 7 days for the look back period on the admission MDS. The progress notes, dated 4/13/18 at 4:10 P.M., indicated at 10:00 A.M. Resident 21 complained of severe pain to right side and upper back with shortness of breath with lung sounds diminished bibasilar. The resident's pain was not relieved with medication. The resident was informed she would be seen by her doctor on rounds. Resident waited until nurse left room and called 911. She was sent to hospital emergency room for evaluation. There is no documentation the physician was notified of her unrelieved pain. The hospital transfer sheet, dated 4/14/18, indicated Resident 21 had a left sided [MEDICAL CONDITION] embolism. She returned on Xarelto (a blood thinner) 15 mg twice daily. The care plan, dated 4/25/18, indicated she would tolerate her current pain management and the interventions included receiving education for pain management, be receptive when disciplines are providing education material to her, be able to recall educational information provided to her, and medications as ordered. The care plan, dated 7/11/18, indicated she was at risk for abnormal bleeding due to the use of an anticoagulant medication. The interventions indicated administering medications as ordered, monitor for abnormal signs and symptoms of bleeding, and labs as ordered. The MAR (Medication Administering Record) for April, July, (MONTH) or (MONTH) (YEAR) indicated no documentation for monitoring pain on a daily basis. Pain was only monitored when an as needed pain medication was administered. A Pain Evaluation assessment completed on 5/4/18, 7/21/18 and 7/25/18, indicated she was in pain. No Pain Evaluation assessments completed prior to 5/4/18. During an interview on, 9/27/18 at 2:58 P.M., the DON (Director of Nursing) indicated on 4/13/18 she was not aware of what was in place at that time for unrelieved pain, but as of this time if she did not have relief from pain after the as needed pain medication they should notify the physician. On 102/18 at 11:00 A.M., the ED (Executive Director) provided the policy Change of Condition, dated 7/10/18, and indicated the policy was the one currently being used by the facility. The policy indicated the facility will evaluate and document changes in a resident's health, mental or psychosocial status in an efficient and effective manner; to relay evaluation information to the physician and do document actions to include but not limited to the following: a significant change in the resident's physical, mental, or psychosocial status. Update the care plan and Minimum Data Set (MDS) as needed. 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure a resident was provided, and monitored for, adequate fluid intake that resulted in multiple hospital stays for urinary tract infections, acute [MEDICAL CONDITION] and dehydration in 1 of 1 residents reviewed for hydration. (Resident 93) Finding includes: During an observation, 9/25/18 at 9:40 A.M., Resident 93 was observed laying in bed and his skin appeared very dry and lips were dry and cracked. The clinical review for Resident 93 was reviewed, on 10/1/18 at 9:59 A.M., the [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated 7/27/18, indicated Resident 93 was not cognitively intact, required extensive assist for eating, and and was frequently incontinent of urine and bowel. A care plan, dated 1/2/18, for at risk for fluid volume deficit because I require assistance with intake and [DIAGNOSES REDACTED]. The interventions included staff will watch for and report any physical signs and symptoms of dehydration and/or abnormal lab values, staff will provide and monitor intake of diet/fluids and staff will encourage fluid intake with and between meals and report to nurse any signs and symptoms of dehydration. A Progress Note, dated 10/21/18 at 11:35 P.M., indicated Resident 93 presented with elevated temperature of 100.8. At 8:00 P.M., his temperature was 102.9 and resident was shakey and lethargic. Resident was sent to local emergency room at 9:30 P.M. The History and Physical Exam, dated 10/22/17, indicated Resident 93 presented with chief complaint of fever and per the staff at the facility, he was more lethargic than normal and had tremors. His vitals signs included a temperature of 104.3 and a of pulse 139. The laboratory tests included a WBC (white blood cell count) of 12,600 (normal range 4,000-10,800) . The [DIAGNOSES REDACTED]. A Progress Note, dated 3/25/18 at 3:21 P.M., Resident 93 was drooling and not responding appropriately and was transferred to the local emergency room . The hospital Discharge Summary, dated 3/31/18, indicated Resident 83 was admitted with acute stroke with history of chronic stroke with residual right [MEDICAL CONDITION] and [MEDICAL CONDITION] and urinary tract infection that presented with extended spectrum beta lactamse Enterbacter cloacae, present on admission versus colonization. The laboratory values for BUN (blood urea nitrogen) was 24 (reference range 8-23) and Creatinine was 1.39 (reference range 0.70-1.20), sodium 146 (reference range 136-145) and chloride 109 (reference range 98-107), indicative of dehydration. The emergency room Report, dated 5/7/18, indicated the resident had a WBC of 9,300 and did have a urinary tract infection on (MONTH) that grew out [MEDICATION NAME] species that was sensitive to Cipro. Resident was started back on Cipro. The emergency room Report, dated 8/20/18, indicated the diagnostic impression was a urinary tract infection from [MEDICATION NAME] cloacae complex and proteus species and resident was discharged back to facility. The Physician Note, dated 9/3/18, indicated Resident 93 had a history of [REDACTED]. The [DIAGNOSES REDACTED]. The History and Physical, dated 9/11/18, indicated Resident 93 presented to the ER with a temperature of 100.3, pulse of 100 and blood pressure of 112/57. The resident's history was pertinent for [MEDICAL CONDITION] residual right [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident had recently had urine cultures positive for [MEDICATION NAME] cloacae 10/2017, 3/2018 and 8/2018. The laboratory values were WBC 12.21, Sodium 148, BUN 25, Creatinine 2.31. The physical assessment indicated the resident's mouth appeared very dry. [DIAGNOSES REDACTED]. Resident was rehydrated with fluids. The Infection Control Consultation, dated 9/17/18, indicated Resident had 3 episodes of UTI (urinary tract infection) with [MEDICATION NAME] as the offending organism this year alone. In fact, he had 2 different strains of [MEDICATION NAME] cloacae growing in the urine, including a multidrug resistant strain which was treated in 3/2018. The Physician Summary & Transfer Orders to ECF, dated 9/19/18, indicated a physician order [REDACTED]. There was no documentation available that laboratory results were drawn as ordered. The Discharge Summary, dated 9/20/18, indicated Resident 93 had some acute [MEDICAL CONDITION] as well as [MEDICAL CONDITION] (high sodium in blood) and dehydration [MEDICAL CONDITION] on admission. The Medical Nutrition Review, dated 9/20/18 at 11:53 A.M., indicated Resident 93's hydration need was 1590-1900 ml (milliters) daily. The Meal Report, dated 3/13/18 through 9/27/18, indicated Resident 93's recorded fluid intake. The average fluid intake daily was lowest 540 ml and highest 1381 ml. The week of 9/4/18 through 9/10/18, the average daily fluid intake was 540 ml and the week of 9/20/18 to 9/26/18, the average daily fluid intake was 748 ml. The History and Physical, dated 9/27/18, indicated resident presented to the local emergency room with dry mucous membranes. The laboratory values were WBC 11.97 and Creatinine of 1.35, and critical calcium of 15.9. The [DIAGNOSES REDACTED]. The ER Physician Report, dated 9/27/18, indicated Resident 93 appeared dehydrated. The Dietitian Note, dated 9/27/18, indicated Resident 93 had poor dentition, but was eating and drinking well at the ECF based on H&P reports (reported that the patient said he was eating well). I am doubtful of the accuracy of his reports of good PO (by mouth intake) intake d/t (due to) chronic [MEDICAL CONDITION] with PMH (past medical history)-especially with his weight loss since previous admission and that he could not previously answer my questions during my assessment. She indicated weight loss could reflect his dehydrated status. Resident 93 had a 4.6 percent severe weight loss in 16 days since last admission on 9/11/18. During an interview, on 10/2/18 at 4:09 P.M., the SCC (Signature Care Coordinator) indicated he was unaware of where they dietician collected her information for hydration requirements and that residents with risk for dehydration should be monitored more closely. The dietician was a consultant and was unavailable for interview and it was not the facility's policy to record intakes. On 10/2/18 at 2:00 P.M., the ED (Executive Director) provided the Hydration policy, dated 6/27/18, and indicated this was the policy currently being used by the facility. The policy indicated residents would receive sufficient amounts of fluid to maintain proper hydration . The dietitian would assess all residents for hydration adequacy at least quarterly, and more often as necessary as per resident need . Change in hydration should be assessed by nurse. 3.1-46(b)

Based on observation, interview and record review, the facility failed to recognize, evaluate, develope and implement interventions to manage pain for 2 of 3 residents reviewed for pain. Resident #112 experienced pain from incontinence care and a Stage III pressure ulcer. Resident #75, a hospice resident, experienced pain during repositioning. Findings include: 1. On 9/20/16 at 9:56 A.M., an interview was conducted with Resident #112 and a family member. The family member indicated sometime during the night shift, this past Saturday/Sunday (9/17 & 9/18) a CNA washed the resident's bottom too hard with a washcloth. The resident indicated he asked the CNA to stop and she told him to shut up and continued to rub his bottom. The resident's brother indicated the resident had a pressure ulcer on his bottom and the area was sore and painful. The family member indicated when he arrived at the facility on Sunday morning the resident was yelling at him to get him out of the facility. The family member indicated the resident was very distraught and upset most of the day and had complained of left shoulder pain. The resident indicated his bottom was sore, but did not complain of pain in his shoulder. On 9/20/16 at 11:08 A.M., a review of the clinical record for Resident # 112 was conducted. The record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The admission orders [REDACTED]. Another order indicated to administer [MEDICATION NAME] (Tylenol - pain medication) 500 mg per peg tube (PGT - feeding tube)) every 4 hours as needed-may order liquid form 160 mg/5 ml (milliliters) - give 15.6 milliliters = 500 mg (not to exceed 4 GM in 24 hours). The [MEDICATION NAME] was discontinued on 9/12/16 due to order was written on 9/7/16 and was good for 5 days, therefore discontinued on 9/12/16. An admission pain assessment, dated 9/8/16, indicated the resident had been assessed for pain and scored a 5 (no indication on assessment what a score of 5 meant). The assessment indicated the resident had normal breathing, occasional moan or groan, had facial grimacing, and his body language was tense/distressed/fidgeting. The assessment instructions indicated .Interventions should be immediately implemented and documented on the care plan The 5 day Admission Minimum Data Set (MDS) Assessment, dated 9/15/16, indicated the resident's BIMS (Brief Interview Mental Status) score was 9 (moderate dementia). The assessment indicated the resident was frequently incontinent of bladder and always incontinent of bowel. The assessment indicated the resident occasionally had pain and rated his pain a 6 on a 0-10 pain scale. The assessment indicated the resident had a Stage lll pressure ulcer (Full thickness tissue loss) which was present upon admission. A care plan, dated 9/20/16, indicated the resident had the potential for complications related to incontinence of bowel and bladder. The interventions included but were not limited to: report any changes to peri area/skin to physician, maintain privacy/dignity when checking resident for incontinent episodes, and apply topical barrier creams as ordered. Another care plan, dated 9/12/16, indicated resident had a pressure ulcer with interventions to: report changes in skin status, provide pressure relieving/reducing mattress and position with pillows to maintain body alignment. The current care plan and Interim admission care plan did not address the problem of pain. During an interview, on 9/20/16 at 2:35 P.M., LPN (Licensed Practical Nurse) #23 indicated she worked the day shift on Sunday (9/18/16). When she came on her shift she observed the Resident #112 in his room and resident was screaming. LPN #23 indicated she observed the resident to have his brief off and the resident's bottom was blood red and resident was thrashing about in his bed. LPN #23 did not indicate she provided pain medication after she observed the resident. The Medication Administration Record (MAR) for September 2016 indicated the resident was monitored for pain every 12 hours using the following pain scale: 0 = no pain, 1-2 = mild, 3-4 = moderate pain, 6-6 = severe pain, 7-8 = very severe pain, 9-10 most severe pain. The following results were recorded on the MAR: on 9/10 thru 9/18 the day shift nurses (6a-6p) assessed the resident's pain as 0 no pain. The 6p-6a shift recorded the following results: -9/10-pain rated as a 5 -9/11-pain rated as an 8 -9/12-pain rated as a 6 -9/13-pain rated as an 8 -9/14 pain rated as an 8 -9/15 pain rated as a 4 -9/16 & 9/17 rate a 0 -9/18 rated pain as a 4 -9/19 rated pain as a 5 The MAR (Medication Administration Record) indicated the resident received the following pain medications: -on 9/11/16, a [MEDICATION NAME] tablet (5/325 mg) was administered per [DEVICE] at 8:49 P.M., with good effect. -on 9/17 a Tylenol (500 mg) was administered per [DEVICE] at 7:13 P.M., with good effect. The MAR indicated the 9/11 [MEDICATION NAME] was given for fracture site and the Tylenol on 9/17 was given for general aches. On 9/21/16 at 4:04 A.M., LPN #24 was contacted at the facility for an interview. LPN #24 indicated he worked this past weekend on the North Unit and had been Resident #112's nurse. LPN #24 indicated the resident yelled out for a nurse, his brother and a neighbor (resident across the hall) throughout the night. LPN #24 indicated he had medicated the resident Saturday evening with Tylenol. He indicated he had accessed the resident's pain level during his shift from 6 pm-6am and indicated he had documented the resident's pain was assessed at an 8 but he couldn't tell what time the assessment was entered into the MAR. LPN #24 indicated Resident #112 was hard to assess for pain, but indicated the resident had a sore bottom from diarrhea and he wasn't sure if pain medication (Tylenol) was helping the resident or not. LPN #24 indicated he had not contacted the physician regarding the resident's pain or diarrhea. On 9/21/16 at 10:25 A.M., an observation of a wound dressing change for Resident #112 was conducted with LPN #26. LPN #26 removed the old dressing from the resident's bottom/coccyx area. The wound was cleansed, by LPN #26, with wound cleanser and gauze. The resident was observed to flinch at times when the area was touched by the gauze. The peri-anal area was observed to be beefy red. LPN #26 was observed to place a piece of alginate with [MEDICATION NAME] into the coccyx wound and covered the wound with a boarder gauze. LPN #26 then applied chalet cream to the peri-anal area. LPN #26 did not assess the resident for pain before or after his wound care. During an interview, on 9/21/16 at 2:50 P.M., the DON (Director of Nursing) indicated the nurses were assessing the resident's pain each shift. The DON indicated when a nurse monitored and or assessed a resident's pain she would expect the nurse to administer pain medications as ordered or document other means the pain was relieved. The DON indicated there was no pain plan of care initiated for the resident on the Interim Admission Care Plan or on the comprehensive care plan initiated on 9/12/16. The DON indicated the care plan for pain should of been initiated, and the facility was still within the time frame to put one in place. During an interview on 9/21/16 at 3:07 P.M., the resident's physician indicated he had received no calls from the facility in regards to the resident having pain. The physician indicated he was surprised the facility didn't call because the pain medication-[MEDICATION NAME] had been ordered for 5 days and no one had called him to reorder the medication. The physician indicated he was planning on writing a new order for [MEDICATION NAME], as needed, for the resident's pain today. On 9/20/16 at 3:20 P.M., the Nurse Consult provided a policy titled Pain Management, dated 6/1/15, and indicated the policy was the one currently used by the facility. The policy indicated .Each resident identified with pain will have ongoing assessments, a monitoring system and a specific plan of care to address these issues The policy indicated .4. e. If diversional activity provided no relief .consider the use of PRN medications The policy indicated .8. Whenever the results of pain assessments reveal that the resident's pain is not under control, the attending MD (Medical Doctor) should be notified 2. A clinical record review was completed on 09/21/2016 at 1:26 P.M., and indicated Resident #75 was admitted on [DATE]. [DIAGNOSES REDACTED]. A physician order [REDACTED].#75 was ordered to have [MEDICATION NAME] 5-325 mg three times a day for pain and [MEDICATION NAME] 5-325 mg every four hours PRN for pain. A care plan, dated 9/7/2016, indicated Administer and observe for effectiveness and for possible side effects from: Routine pain medication and PRN pain medication. Resident #75's MAR indicated Resident #75 had not received any [MEDICATION NAME] 5-325 mg for the month of September 2016. During an observation on 9/21/2016 at 1:55 P.M., Resident #75 was observed to grimace and voice ouch ouch when LPN (Licensed Practical Nurse) #29 assisted her to roll over in bed. LPN #29 indicated Resident #75 frequently voices and shows physical signs of pain when she is assisted to reposition in bed. During an observation on 9/21/2016 at 3:46 P.M., the DON and LPN #11 assisted Resident #75 to roll over in her bed. Resident #75 was observed grimacing in pain when the repositioning took place. LPN #11 indicated Resident #75 frequently shows signs of pain when she is repositioned. During an interview on 9/21/2016 at 3:46 P.M., the DON indicated Resident #75 shows signs of pain and verbalizes pain when she is repositioned every two hours. During an interview on 09/22/2016 at 12:17 P.M., the DON (Director of Nursing) indicated Resident #75 had not received any PRN [MEDICATION NAME] or PRN Tylenol this month. She further indicated all of Resident #75's ordered medications were listed on her MAR. During an interview on 9/22/2016 at 2:40 P.M., the DON indicated Resident #75 should have better pain control than what she has been receiving. She indicated Resident #75 is a hospice patient and should not have pain when she is turned and repositioned. She further indicated Resident #75 current pain management was not effective. During an interview on 9/23/2016 at 9:48 A.M., CNA #3 indicated Resident #75 shows signs of pain or voices pain every time she is repositioned in bed. A policy was provided by the DON on 09/23/2016 at 10:30 A.M., titled Pain Management dated 06/01/2015, and indicated this was the policy currently used by the facility. The policy indicated .When pain medication is ineffective evaluate the pain and communicate to the physician using SBAR.(Situation, Background, Assessment, and Recommendation) and .When treating pain, start with drugs appropriate to the resident's current level of pain and progress by increasing the dose of that drug until maximum benefit is obtained 3.1-37(a)

Based on interview and record review, the facility failed to ensure a CNA followed proper protocol while transferring a resident with a Hoyer lift which resulted in injury and transportation to the Emergency Department for treatment of [REDACTED]. Resident # D Findings include: The clinical record for Resident # D was reviewed on 5/3/12 at 10:30 A.M. This resident's [DIAGNOSES REDACTED]. Review of a SBAR (Situation-Background-Assessment-Recommendation) Physician...Communication and Progress Note dated 9/20/11, indicated, "...swelling noted to R (right) shin & leg/foot turned out...send to...ER for xray...CNA was getting ready to give resident a shower when she noticed that her R shin was swollen. I assessed shin & found swelling noted to area. No trauma noted. Skin of normal color, no redness, warmth noted. R leg laying on bed c (with) foot turned out...." Review of a "Facility Incident Reporting Form" dated 9/20/11, indicated, "...(Resident # D) was observed by staff to be laying in bed. Her right lower leg appeared deformed....Interviews reveal (Resident # D) had been laid down for bed per Hoyer lift 20-30 minutes prior to discovery. CNA caring for (Resident # D) states she was unaware of injury. (Resident # D's) care plan listed Hoyer lift for transfers. No other staff observed anyone else in (Resident # D's) room in the interim between transfer to bed and discovery. Re-enactment of the transfer revealed that 1 CNA performed the transfer. (Resident # D) returned from ER with splinted right lower leg...." Review of a Radiology Report dated 9/20/11, indicated, "...There is an acute oblique fracture through the distal tibial shaft...Minimally anterolaterally displaced spiral fracture of the distal fibular metadiaphysis..." Review of an undated internal facility reenactment with CNA # 12, indicated, "...I did not have assistance with the transfer...." Review of a "Performance Improvement Form" dated 9/23/11, indicated, "...(CNA # 12)...Failure to follow procedure for Hoyer transfers: transfer of residents on 9/19/11 without assistance. This failure may have lead to injury of (Resident # D): fracture to tibia and fibula...." Review of Resident #D's care plan titled "...Assist with all ADL's (activities of daily living)"..." dated 8/30/11, indicated, "...Hoyer lift for all transfers...." Resident # D's Significant change MDS (Minimum Data Set) assessment dated [DATE] indicated her cognition was severely impaired. She needed total assistance with 2 staff assistance with transfers and bathing. The MDS indicated she required a mechanical lift with 2 staff assistance for transfers. The MDS indicated the resident did not have a history of falls. Review of a facility policy titled "Mechanical Lift (Sling Lift)" revised 3/6/12, indicated, "...Obtain assistance from another staff member for transfer as necessary. Two people are required when using the Mechanical Lift..." Review of a facility policy titled "Accidents and Supervision to Prevent Accidents" revised 4/28/11, indicated, "...Center provides appropriate assistive devices to reduce the risk and/or prevent accidents. Ways to reduce risk and/or prevent risk are: Education of the staff in using assistive devices properly...Patient who becomes frightened during transfer in a mechanical lift may exhibit resistance movements that result in avoidable accidents...." This Federal tag relates to Complaint IN 648. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a CNA demonstrated competency and followed proper protocol while transferring a resident with a Hoyer lift, which resulted in a fracture requiring emergency room treatment, for 1 of 6 residents reviewed for proper use of a mechanical lift in a sample of 22. Resident # D Findings include: 1. The clinical record for Resident # D was reviewed on 5/3/12 at 10:30 A.M. This resident's [DIAGNOSES REDACTED]. Resident # D's Significant change MDS (Minimum Data Set) assessment dated 8/30/11 indicated her cognition was severely impaired. She needed total assistance with 2 staff assistance with transfers and bathing. The MDS indicated she required a mechanical lift with 2 staff assistance for transfers. The MDS indicated the resident did not have a history of falls. Review of Resident # D's care plan titled "...Assist with all ADL's (activities of daily living)..." dated 8/30/11, indicated, "...Hoyer lift for all transfers...." Review of a "Facility Incident Reporting Form" dated 9/20/11, indicated, "...(Resident # D) was observed by staff to be laying in bed. Her right lower leg appeared deformed....Interviews reveal (Resident # D) had been laid down for bed per Hoyer lift 20-30 minutes prior to discovery. CNA caring for (Resident # D) states she was unaware of injury. (Resident # D's) care plan listed Hoyer lift for transfers. No other staff observed anyone else in (Resident # D's) room in the interim between transfer to bed and discovery. Re-enactment of the transfer revealed that 1 CNA performed the transfer. (Resident # D) returned from ER with splinted right lower leg...." Review of a Radiology Report dated 9/20/11, indicated, "...Acute [MEDICAL CONDITION] tibia and fibula..." Review of a facility investigation/interview dated 9/20/11, indicated, "...(CNA # 12) took care of (Resident # D) today 9/20/11 from 6 A.M. - 2 P.M. States she transferred resident by herself c (with) Hoyer lift. She did not ask the nurses or (UM) (unit manager) myself for assistance. States resident did not hit legs on bed & showed no pain...." Review of an undated internal facility reenactment with CNA # 12, indicated, "...I did not have assistance with the transfer...." Review of a "Performance Improvement Form" dated 9/23/11, indicated, "...(CNA # 12)...Failure to follow procedure for Hoyer transfers: transfer of residents on 9/19/11 without assistance. This failure may have lead to injury of (Resident # D): fracture to tibia and fibula...." Review of CNA # 12's personnel file indicated she received training and education related to mechanical lifts on 1/28/11. Review of a facility policy titled "Mechanical Lift (Sling Lift)" revised 3/6/12, indicated, "...Obtain assistance from another staff member for transfer as necessary. Two people are required when using the Mechanical Lift..." This Federal tag relates to Complaint IN 648. 3.1-14(i)

Based on observation, interview, and record review, the facility failed to evaluate and analyze causative factors related to falls and develop appropriate interventions to prevent a fall which resulted in a facial laceration, large contusion, transportation to the Emergency Department and three sutures above the right eye (Resident # 3). The facility also failed to ensure the bed height of a seizure resident was in the lowest position to prevent the risk of possible injury (Resident # 31). This deficient practice affected 2 of 12 residents reviewed for falls in a sample of 24. Findings include: 1. During initial tour of the North Unit of the facility on 1/30/11 at 3:30 P.M., while accompanied by RN # 5, Resident # 3 was observed with a large purplish brown bruise to his right eye. Above the right eye were visible sutures to a scabbed laceration. The clinical record of Resident # 3 was reviewed on 2/06/11 at 9:30 A.M. and indicated [DIAGNOSES REDACTED]. Resident # 3 incurred 8 falls between 10/08/10 and 2/05/11. Review of Nurse's Notes indicated the following falls: 10/08/10 at 6:00 P.M.-"Called to room. Resident on floor on R (right) side @ bedside. ROM (range of motion) to all extremities (sic). Assist 2 to B.R. (bathroom) toileted...." 10/08/10 at 6:40 P.M.- "Called to room. Res (resident) on floor bed-side (sic) bed. Legs in front of him. No injury noted...." 11/21/10 "late entry for 6:30 P.M.-Resident was observed on his Rt (right) side @ end of bed. Resident states he was 'going to BR (bathroom)...tab alarm not sounded. Resident assisted back to bed. Tab alarm replaced. Resident says 'Don't put that on it makes noise.' Resident put tab alarm back in place to silence alarm...." 12/24/10 at 7:30 A.M.-"Note alarm sounding. Upon entry into residents room observe resident to be siting on bottom with legs extended outward...Resident states 'I wanted to sit in my chair'...call light attached to bed resident is able to identify function of device and knows to call for assist...discussed with resident cause of event...." 1/09/11 at 11:00 A.M.-"Resident found sitting on fall matt (sic) at bedside in upright position. No alarm sounding-found unclipped on bed...." 1/19/11 at 7:20 P.M.-"Pt (patient) found on floor, sitting on buttocks, back against bed. Pt sitting on mat, placed bedside for safety purposes...while sitting on floor, Pt announced 'I need to pee'...." 1/25/11 at 3:40 A.M.-"While assisting resident in rm (room) (number) CNA (certified nursing aide) notified this nurse that resident on floor. Immediately assessed resident who I found lying on floor in his room, lying on his right side...noted bleeding from laceration to right forehead above right eye...2 cm (centimeters) long and 1 cm wide 1.5 cm deep. Resident stated he did not recall what happened, and why he attempted to ambulate. This nurse had checked on resident at 3:20 A.M. who at that time was resting in bed, low bed, floor mat and call lite was in place...." 1/25/11 at 5:00 A.M.-"Notified (Name) ambulance for resident transfer to ER (emergency room )...." 1/25/11 at 9:35 A.M.-"Pt (patient) came back from ER...3 sutures to R (right) eye and hematoma to R eye that is swollen...." 2/05/11 at 7:30 A.M.-"Resident found with legs on fall mat. Shoulders and head on bed. Alarm intact. Assisted to return to bed...bed alarm attached...." Resident # 3's most recent quarterly MDS (Minimum Data Set) assessment, dated 1/25/11, indicated he needed extensive assistance of one person for transferring and ambulation. It also indicated his mental status was severely impaired. Review of Resident # 3's Care Plan, dated 8/10/10 and updated 2/01/11, indicated, "Problem: (Resident # 3) is at risk for falls R/T (related to) decreased mobility...Interventions: ...08. Assist with transfers as needed...11. Falling Star Program...13. Check resident more frequently. 14. Check resident for incontinence Q (every) hour. 15. 15 minute checks." During interview with the Director of Nursing on 2/10/11 at 3:40 P.M., she indicated she could not determine which interventions were put in place after each fall "because it's not documented." "We don't even show the alarm as an intervention. I don't know when that was put into place." 2. The clinical record of Resident # 31 was reviewed on 2/07/11 at 2:00 P.M. and indicated [DIAGNOSES REDACTED]. Resident # 31 was observed lying in his bed on 1/31/11 at 10:30 A.M. His bed was elevated to waist height, approximately three feet up from the floor. A padded fall mat was observed lying on the floor on the east side of his bed. Resident # 31 was observed to have a tracheostomy and unable to verbalize his needs. When queried if he had adjusted his bed to the observed height, he nodded in a negative manner. Resident # 31's bed remained at waist height during the following additional observations on 1/31/11: 12:25 P.M., 2:50 P.M. and 5:20 P.M. The bed height concern was brought to the attention of the Corporate Consultant on 1/31/11 at 5:30 P.M. Upon entering Resident # 31's room, she attempted to lower his bed by pushing the down arrow mounted on the foot-board of the bed. It failed to lower and it was determined at that time that the bed had been unplugged from the electrical outlet at some point during the day. The bed was plugged into an electrical outlet and lowered to the lowest position. During interview with the Corporate Consultant at the time of the 5:30 P.M. observation, she indicated maintenance would need to add an additional outlet to Resident # 31's room to accommodate his needs (Intravenous pump, suction machine, nebulizer, bed, etc.). The most recent quarterly MDS (Minimum Data Set) assessment, dated 1/31/11, indicated Resident # 31 needed an extensive assist of two staff tor transfers, dressing, eating, and bathing. A Care Plan, dated 11/03/10, indicated, "Problem: (Resident # 31) is at risk for falls R/T (related to) Hx (history) of falls, seizure disorder, compulsive behaviors...Approach: ...06. Mat at bedside when he is in bed, make sure pad overlaps bedside table for safety...08. Low bed and bed alarm...13. Falling Star Program...." A Nurse's Note, dated 2/3/11 at 1:50 P.M., indicated, "Upon entry into room writer notes resident legs extended partially lying on floor with upper torso being held off floor by CNA. Per (3) lifted to bed...CNA (certified nursing aide) states that she was starting to transfer resident. Instructed him to wait but he continued got foot caught on feeding pole...." A facility policy titled "Falling Stars," revised 10/31/08, indicated, "Rationale: Falling Stars are used for residents identified at high risk for falls and/or with a history of falls (past or current). It establishes a common method of communication to remind staff to monitor these residents for fall prevention. It alerts staff to residents at risk for falls and who have approaches or interventions on their care plans to reduce and/or prevent repeat falls...Procedure: ...3. Update and/or implement Falling Stars interventions if the resident is identified at high risk or has a history of fall (past or current)...." 3.1-45(a)(1) 3.1-45(a)(2)