Every finding on record at Maple Manor Christian Home Inc

Based on observation, interview and record review, the facility failed to ensure a resident (Resident B) was not isolated in her room for 1 of 3 residents reviewed for abuse. Findings include:The clinical record for Resident B was reviewed on 6/8/26 at 9:43 a.m. The resident's diagnoses included, but were not limited to, anxiety disorder (mental health conditions characterized by excessive, persistent, and disproportionate fear or worry about everyday situations) and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrients) with other behavioral disturbance.The incident report, dated 5/15/26, indicated an anonymous visitor notified the Administrator with concerns on how a resident was treated on 5/14/26. It was reported that between approximately 5:30 p.m. and 6:45 p.m., on 5/14/26, the visitor could hear a resident yelling out in the hallway, repeatedly, I need to go, I'm going to s*it my pants, I'm going to s*it my pants if I don't go. The visitor overheard the staff tell the resident she would have to wait because they were bringing other residents back from the dining room. The visitor reported that, after a while, the yelling had become muffled. The visitor walked out into the hallway and realized that the staff had taken the resident into her room and shut the door with no staff members present. The visitor could hear yelling coming from the resident's room which continued for quite some time.On 6/8/26, at 11:22 a.m., the facility video footage was reviewed from 5/14/26 and included the following:-At 6:21 p.m., Resident B was observed sitting up in her high back specialized medical chair across from the nurses' station,-At 6:22 p.m., Certified Nursing Assistant (CNA) 6 (day shift aide) came out from behind the nurse's station and took Resident B into her room,-At 6:23 p.m., CNA 6 exited the room, shut the door to Resident B's room, and went back behind the nurse's station to sit down, and-At 6:44 p.m. CNA 8 (on-coming night shift aide) entered Resident B's room.The video timeline footage from 5/14/26, between 5:41 p.m. and 6:56 p.m., included, but was not limited to, the following:- At 5:50 p.m., Resident B was brought back to the nurse's station from the dining room,- At 5:52 p.m., Licensed Practical Nurse (LPN) 5 moved Resident B next to the medication cart across from the nurse's station,- At 5:54 p.m., CNA 6 and CNA 8 were talking at the nurse's station,- At 5:58 p.m., CNA 8 started checking the residents due to coming on the shift,- At 6:15 p.m., CNA 6 sat down behind the desk at the nurse's station,- At 6:22 p.m., CNA 6 came out from behind the nurse's station and took Resident B into her room,-At 6:23 p.m., CNA 6 exited the room, shut the door to Resident B's room, and went back behind the nurse's station and sat down,-At 6:44 p.m., CNA 8 entered Resident B's room,-At 6:45 p.m., CNA 6 entered Resident B's room,-At 6:47 p.m., CNA 6 exited Resident B's room,-At 6:52 p.m., CNA 6 entered Resident B's room with a bedpan, and-At 6:56 p.m., CNA 6 exited Resident B's room followed by CNA 8 who had bagged linens and trash.The written statement from CNA 6, dated 5/18/26, indicated that shift change was in progress, CNA 6 had given report to CNA 8. All residents were being removed from the dining room during this time. Resident B started yelling that she needed to use the bathroom. The on-coming nurse (LPN 11) told Resident B she would be toileted soon because it was change of shift. CNA 6 told CNA 8 that she would assist with toileting Resident B and needed a bedpan. CNA 6 told CNA 8 that she would be taking Resident B back to her room as CNA 6 went to get a bedpan because Resident B's yelling was a little disruptive during shift change. When CNA 6 returned with the bedpan, CNA 8 was already in the room with Resident B and both CNAs assisted with toileting Resident B.The written statement from LPN 11, dated 5/18/26, indicated on 5/14/26 at approximately 6:00 p.m., Resident B was sitting in the hallway and yelled out that she needed to use the toilet. LPN 11 had never heard Resident B make that request before. LPN 11 was informed by LPN 5 and CNA 6 that Resident B had been fixated on that statement all day and had repeated the statement after being toileted. LPN 11 then engaged in conversation with Resident B, who, at that time, stopped yelling. LPN 11 informed Resident B that it was shift change and someone would toilet her soon. LPN 11 walked away and Resident B began to yell again. Shortly after, CNA 6 stated she was going to take Resident B to her room to avoid disturbing all the other residents with loud yelling. CNA 6 reported she would toilet the resident when the other CNA became available. Resident B was toileted, placed in bed with no other behaviors observed.On 6/9/26 at 1:09 p.m., during a phone interview with CNA 8 they indicated, when CNA 8 had gotten to work on 5/14/26, CNA 6 had talked about putting Resident B on the bed pan. CNA 6 took Resident B to her room. CNA 8 indicated she did not feel that CNA 6 meant to shut the door all the way. Resident B had been screaming and she screamed loudly. Resident B said she needed to go to the bathroom. It took CNA 8 a while to get to Resident B after she received report because she had gotten distracted with other residents. On 6/8/26 at 9:51 a.m., the Quality Assurance Nurse provided a current copy of the document titled Abuse/Neglect/Mistreatment/Exploitation/Misappropriation of Personal Property dated 1/12/2018. It included, but was not limited to, Definitions/Background.Unreasonable Confinement.the separation of a resident from other residents.confinement to his/her room.Policy.The facility strictly prohibits.unreasonable confinement.by employees.The facility will do all that is within its control to assure that resident a free from.unreasonable confinement.This deficient practice was corrected on 5/26/26, prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan which included the following: All staff were educated on resident abuse and resident rights with an emphasis on dignity, neglect, toileting and involuntary seclusion (5/26/26); All alert and oriented residents were interviewed with no negative responses (5/15/26); Skin sweeps were completed on all non-alert residents with no negative findings (5/15/26); Care plans were reviewed and updated on all residents with the potential to be affected (5/15/26). This citation relates to Intake 3016292.410 IAC (Indiana Authorization Code) 16.2-3.1-27(a)(4)

Based on record review and interview, the facility failed to ensure a resident's laboratory work was completed per physician's order for 1 of 12 residents reviewed for physician notification. (Resident 34)Findings include: The record for Resident 34 was reviewed on 2/10/26 at 10:45 a.m. The resident's diagnoses included, but were not limited to, dementia (a decline in cognitive functioning), pain, and severe protein-calorie malnutrition (deficiency of protein and calories).On 6/12/25, the physician gave orders for the resident to have the following lab work drawn every June and December: CBC (complete blood count), TSH (thyroid stimulating hormone) a BMP (basic metabolic panel), and a Urine Micro-Albumin ( protein produced through the liver).A care plan, dated 1/13/26 with a revision date of 2/6/26, indicated the resident had open areas or potential for pressure ulcers due to immobility. The intervention, dated 1/13/26, included, but were not limited to, obtain labs/diagnostic tests as ordered and report results to the physician or NP.A care plan, dated 6/9/25 with a revision date of 1/30/26, indicated the resident had potential and actual impairment to skin integrity - multiple bruised areas. The intervention dated 6/9/25, included, but were not limited to, obtain blood work such as CBC with Differential, Blood Cultures and culture and sensitivity of any open wounds as ordered by the physician.The review of Resident 34's laboratory results section indicated the facility failed to Indicate the lab work had been drawn in December as ordered.In an interview with the Director of Nursing (DON) on 2/11/26 at 10:15 a.m., she indicated that after she checked the resident's orders, she noticed the physician orders for lab work to be drawn in December. The lab orders were never drawn like they were supposed to be. The physician should have been notified that the resident's lab work were not drawn as ordered and checked to see if the physician wanted to re-order them.The facility's current policy on Laboratory Services, included, but was not limited to, .The facility will: .Ensure that the ordering physician is promptly notified of the findings .The facility's current policy on Provider Orders and Management, included, but was not limited to, .3. The process for communicating test results to providers is as follows: .The LPN or RN is to communicate results to the provider via fax or telephone, dependent on criticality of the result .3.1-5(a)(3)

Based on record review and interview, the facility failed to update the residents' care plans when changes occurred in psychosocial well-being, pain, falls, implementation of intravenous (IV) therapy, and discontinuation of an antibiotic for 3 of 12 residents' care plans reviewed for revisions. (Residents 2, 24, and 5)Findings include:1.The record for Resident 2 was reviewed on 2/6/26 at 12:32 p.m. The resident's diagnoses included, but were not limited to, dementia with mood disturbance (decline in cognitive functioning), anxiety (occasional worry or fear), major depressive disorder (mental condition causing sadness), and post-traumatic stress disorder (mental health condition re-experiencing trauma). The Quarterly Minimum Data Set (MDS) assessment, dated 1/20/26, indicated the resident had significant cognitive impairment and had no mood or behavior issues. A care plan, dated 5/9/24, indicated the resident was at increased risk for grieving and sadness due to recent passing of spouse. The record lacked documentation of the care plan having been updated to reflect improved mood since death of spouse. The review of the Social Work and Psychiatric progress notes between 9/1/25 and 2/10/25, indicated there was no documentation of the resident still grieving her loss. During an interview with the Social Worker, on 2/10/26 at 10:00 a.m., she indicated that initially after the spouse's death in 2024, the resident was grieving for some time but had not voiced missing him in a while. 2. The record for Resident 24 was reviewed on 2/5/26 at 2:00 p.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease ( a form of dementia), difficulty in walking, depression, (feelings of sadness) and age-related osteoporosis (bone deterioration). The Annual MDS assessment, dated 12/10/25, indicated the resident had moderate cognitive issues, had no mood or behavior issues, no impairment in functional range of motion (ROM) bilaterally upper or lower extremities, used a walker or wheelchair, and was independent for mobility with partial assistance and supervision. A new Significant Change in Condition was in the process of being completed. A care plan, dated 9/10/24, indicated the resident was at risk for fall, had a history of falls related to Alzheimer's, psychotropic medications, and osteoporosis. A care plan, dated 8/28/24, indicated the resident was at risk for pain related to history of a fracture. A physician's order, dated 2/20/24, indicated the resident was prescribed two Acetaminophen Oral tablets 325 milligrams (MG) every four hours as needed for pain. The record lacked documentation the resident's pain and falls care plans had been updated to reflect her current status. A nurse note, dated 2/4/26 at 4:53 p.m., indicated the resident was found on the floor in her room on her backside with her legs out in front of her. When she was asked how she fell, or what she was trying to do, the resident indicated she did not remember. The physician and responsible party were notified, and an X-ray of her hip was ordered. A nurse note, dated 2/4/26 at 10:23 p.m., indicated the physician and the Director of Nursing (DON) were notified the right hip X-ray results were that the resident had fractured her pelvis. The review of the nurse's notes, dated between 2/4/26 and 2/6/26, indicated the resident made several requests for pain medication due to her fracture. On 2/6/26 at 11:33 a.m., a new order was received for one Hydrocodone-Acetaminophen 5-325 mg tablet every four hours as needed for pain. The resident's pain level between 2/4/26 and 2/6/26 usually ranged between a pain level of 5 to 8 out of a 0 to 10 scale. (o = no pain to 10 = sever pain) In an interview with the DON on 2/10/26 at 1:50 p.m., she indicated the care plans should have been updated to reflect her recent fall with fracture and the increased pain levels. 3. The record for Resident 5 was reviewed on 2/6/26 at 10:25 a.m. The resident's diagnoses included, but were not limited to, history of urinary tract infections (UTIs) (infection in any part of the urinary system: kidneys, ureters, bladder, and urethra), and the need for assistance with personal care. The care plan, dated 5/18/21, indicated the resident received a prophylactic antibiotic for the history of UTIs. The interventions, dated 5/18/21 and revised 9/4/22, included, but were not limited to: administer medications as ordered by the physician; obtain vital signs; observe for and report as needed signs of adverse effects to the antibiotic: rash, itching, nausea, vomiting, diarrhea; observe for and report as needed signs of infection; obtain lab work as ordered and report results to the physician; encourage fluids with meds, meals and as needed (PRN). The care plans lacked documentation of revisions made in the resident's prophylactic care plan for UTIs and lacked the addition of the midline intravenous catheter to the resident's care plan The Quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident 5 was cognitively intact. The resident had no indwelling catheter, external catheter, ostomy or intermittent catheterization and no urinary program was in place. The resident required supervision with toileting hygiene. A physician's order, dated 1/19/26, indicated the resident was to have Meropenem Intravenous Solution Reconstituted 1 gram (GM) intravenous every 8 hours for 7 days for the diagnosis of Escherichia coli (gram negative bacteria found in the intestines) and extended-spectrum beta-lactamases (ESBL) (bacterial infection producing enzymes resistant to most common antibiotics. A nurse's note, dated 1/19/26 at 9:59 p.m., indicated a peripheral IV, 20 gauge was placed in the resident's left forearm. A physician's order, dated 1/20/26, indicated that the prophylactic oral antibiotic was discontinued, and cranberry capsules 500 milligrams (mg) taken by mouth twice daily were ordered. A physician's order, dated 1/21/26, indicated that the resident was to have a midline peripheral catheter placed to receive the IV antibiotic ordered. During an interview, on 2/10/26 at 1:00 p.m., the DON indicated that the UTI care plan for Resident 5 had been updated to a resolved status since the intravenous treatment was completed and the resident no longer had a UTI. The facility's current policy titled Comprehensive Person-Centered Care Planning, included, but was not limited to, Purpose: To provide guidance to staff on the measures taken to ensure each resident will have a person-centered comprehensive care plan developed and implemented to meet their goals and preferences, and address the resident's medical, physical, mental and psychosocial needs. Care planning drives the type of care and services that a resident receives. If care planning is not complete or is inadequate, the consequences may negatively impact the resident's quality of life, as well as the quality of care and services received .The comprehensive care plan will: .reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments . 3.1-35(d)(2)(B)

Based on observation, record review, and interview, the facility failed to ensure discontinued medications were promptly disposed of during for 1 of 3 residents observed for medication storage. (Resident 54)Findings include:During an observation on [DATE] at 10:31 a.m., of the 200 Hall Medication Room, 2 syringes of heparin (blood thinner used to prevent blood clots) were in the pharmacy return bin in the medication room. The pharmacy label with a physician's order was on the bag of heparin with two syringes inside of the bag for Resident 54. During an interview on [DATE] at 10:35 a.m., Licensed Practical Nurse (LPN) 3 indicated the heparin belonged to Resident 54 and she thought that the resident died after Christmas. The nurse's note, dated [DATE] at 1:31 p.m., indicated Resident 54 passed away. The record for Resident 54 was reviewed on [DATE] at 11:28 a.m. The diagnoses included, but were not limited to, metastatic anal cancer (rectal cancer that had spread to other parts of the body) with a Computed Tomography (CT) implanted port (access to the vein in the upper chest that was power injectable). The physician's order, dated [DATE], indicated to administer 5 milliliters (mL) of heparin intravenously on the 6th of every month for flushing protocol for the CT implanted port to the resident's right chest. The order was discontinued on [DATE]. During an interview on [DATE] at 8:44 a.m., Director of Nursing (DON) indicated the medications were sent back to pharmacy on the computer. There may be some in the medication rooms right now. Once it was in the computer, they would be bagged up and sent to the pharmacy. She could not explain where the heparin for Resident 54 came from. When a resident died, all medications would be taken out and sent back to the pharmacy by mail. The Pharmacy Services policy, reviewed [DATE], included, but was not limited to, . Discontinued, outdated, or deteriorated medication will not be maintained or used in the facility. Medications will be disposed of in compliance with federal, state and local laws. Unopened and unexposed medication may be returned to the issuing pharmacy for credit to the appropriate party. 3.1-25(o)3.1-25(q)

Based on record review and interview, the facility failed to ensure physician orders for laboratory work were drawn as ordered for 1 of 12 residents reviewed for laboratory services. (Resident 34)Findings include:The record for Resident 34 was reviewed on 2/10/26 at 10:45 a.m. The diagnoses included, but were not limited to, dementia (a decline in cognitive functioning), pain, and severe protein-calorie malnutrition (deficiency of protein and calories).The physician's order, dated 6/12/25, indicated Resident 34 was to have the following labs drawn every June and December: CBC (complete blood count), TSH (thyroid stimulating hormone) a BMP (basic metabolic panel), and a Urine Micro-Albumin. The review of the resident's laboratory results indicated the facility failed to draw the December laboratory test as ordered. The resident's clinical laboratory record indicated the resident's last lab values were drawn on the following dates: TSH-3 on 7/30/25; T 4 on 6/18/25; BMP on 6/13/25; and A Urine Micro-Albumin test on 7/9/25. During an interview with the Director of Nursing (DON) on 2/11/26 at 10:15 a.m., she indicated the resident's laboratory orders for the TSH, BMP and Urine Micro-Albumin were not completed as ordered in December. The facility's current policy on Laboratory Services, included, but was not limited to, Policy: The facility will provide laboratory services to meet the needs of the resident. The facility will be responsible for the quality and timeliness of the services .The facility will: Provide or obtain laboratory services only when ordered by the attending physician. Ensure that the ordering physician is promptly notified of the findings .3.1-49(a)3.1-49(f)(1)

Based on observation, record review, and interview, the facility failed to follow documentation procedures of dispensed medications on the Controlled Drug Record of administered narcotics for 5 of 24 residents observed for pharmacy services. (Residents 16, 15, 13, 49, and 50) Findings include: During an observation on 1/8/25 at 1:42 p.m., of the 300 Hall medication cart, the following concerns were identified: 1. Resident 16's Viberzi had a count of 14 tablets left on the Controlled Drug Record. The resident's medication card contained 13 tablets of Viberzi. The Controlled Drug Record indicated no tablets of Viberzi had been signed out. The physician's order, dated 7/2/24, indicated the nurse was to administer 100 mg (milligrams) of Viberzi one time a day for Irritated Bowel Syndrome (IBS). The January 2025 Medication Administration Record (MAR) indicated the Viberzi was last administered on 1/8/25 between 8:00 a.m. and 11:00 a.m., by Licensed Practical Nurse (LPN) 5. 2. Resident 15's Gabapentin had a count of 14 capsules left on the Controlled Drug Record. The resident's medication card contained 12 capsules of the Gabapentin. The LPN indicated that she had administered two capsules to the resident. The Controlled Drug Record indicated the last dose was administered on 1/7/25 at 9:32 p.m., by LPN 4. The physician's order, dated 11/17/24, indicated the nurse was to administer two capsules of 600 mg Gabapentin three times daily for type 2 diabetes mellitus with diabetic neuropathy. The January 2025 MAR indicated the Gabapentin capsules were last administered on 1/8/25 between 8:00 a.m. and 11:00 a.m., by LPN 5. 3. Resident 13's Gabapentin had a count of 17 capsules left on the Controlled Drug Record. The resident's medication card contained 16 capsules of the Gabapentin. The Controlled Drug Record indicated the last dose was administered on 1/7/25 at 8:18 p.m., by LPN 4. The physician's order, dated 1/13/24, indicated the nurse was to administer one capsule three times daily for pain. The January 2025 MAR indicated the Gabapentin capsule was last administered on 1/8/25 between 8:00 a.m. and 11:00 a.m., by LPN 5. 4. Resident 49's Tramadol had a count of 16 tablets left on the Controlled Drug Record. The resident's medication card contained 15 tablets of the Tramadol. The Controlled Drug Record indicated the last dose was administered on 1/7/25 at 8:17 p.m., by LPN 4. The physician's order, dated 4/3/24, indicated the nurse was to administer one tablet two times daily for chronic pain. The January 2025 MAR indicated the Tramadol tablet was last administered on 1/8/25 between 8:00 a.m. and 11:00 a.m., by LPN 5. 5. Resident 50's Gabapentin had a count of 29 capsules left on the Controlled Drug Record. The resident's medication card contained 27 capsules of the Gabapentin. The Controlled Drug Record indicated the last dose was administered 1/7/25 at 8:20 p.m., by LPN 4. LPN 5 indicated there were two different times that the medication was given during the day. The physician's order, dated 8/28/24, indicated the nurse was to administer one capsule three times daily for pain. The January 2025 MAR indicated the Gabapentin capsule was last administered on 1/8/25 between 8:00 a.m. and 11:00 a.m., and on 1/8/25 between 2:00 p.m. and 4:00 p.m., by LPN 5. During an interview on 1/8/25 at 1:51 p.m., LPN 5 indicated she had not signed out the narcotics because she didn't have a pen. She should have signed them out at the time of administration. The Controlled Substance Monitoring and Administration policy and procedure, last reviewed on 9/3/24, included, but was not limited to, .18. Controlled substances in solid form are to be withdrawn from the area/container they are stored, counted, and recorded on the Narcotic Sign-out Sheet with each administration . Documentation All documentation the Narcotic Sign-out Sheet and MAR/eMAR [electronic Medication Administration Record] are to be legible and clear . 2. When documenting withdrawal of medications from the locked narcotic drawer or medication locker in the refrigerator, the actual date and actual time of the withdrawal is to be documented on the Narcotic Sign-out Sheet . 3.1-25(b)(1)(c)

Based on observation, interview and record review, the facility failed to ensure a resident (Resident B) was not restrained in place for 1 of 3 residents reviewed for abuse. Findings include: The clinical record for Resident B was reviewed on 11/21/24 at 12:16 p.m. The resident's diagnoses included, but were not limited to, dementia, abnormality of the gait and cognitive communication deficit. On 11/21/24 at 12:50 p.m., the resident was observed sitting up on the side of her bed. She was well groomed and pleasantly confused with no signs of any psychosocial distress. On 11/21/24 at 11:45 a.m., the facility video footage, from 10/28/24 between 5:48 a.m. and 5:55 a.m., was observed with the following: On 10/28/24 at 5:48 a.m., CNA (Certified Nursing Aide) 5 was observed to propel Resident B across from the nurse's station and backed the wheelchair up against the wall. Resident B had attempted to propel her wheelchair forward. CNA 5 moved the resident's wheelchair back up against the wall, locked the brakes to the wheelchair and leaned over the resident. CNA 5 had turned to walk away from the resident. The resident placed her hands down towards the wheelchair wheels, at which time, CNA 5 turned back around, walked back towards the resident, and then had placed the residents arms and hands across the resident's chest. The resident placed her right arm back down toward the wheelchair wheel and CNA 5 placed the resident's right arm back crossed the resident's chest. CNA 5 was standing to the right of the resident and the resident then had attempted to scoot forward to move the wheelchair and placed her arms back down on the wheelchair wheels. CNA 5 again, had moved both of the resident's arms back crossed the resident's chest. CNA 5 then checked to ensure wheelchair brakes were locked. The CNA had turned and looked to the right at which time the resident attempted to move her wheelchair. CNA 5 was bent over the resident which obstructed the view of the resident and then CNA 5 had turned and leaned back against the wall. The resident placed her right arm down toward the wheelchair wheel at which time CNA 5 had placed the resident's right arm back across the resident's chest. The resident moved her legs, put both her arms down and unlocked her wheelchair. CNA 5, again, had placed the residents arms back across the resident's chest and locked both brakes on the wheelchair. The resident placed her right arm down towards the wheelchair wheel and CNA 5 had placed the resident's right arm across the resident's chest. The resident moved her body and legs, at which time, CNA 5 locked the left wheelchair brake and checked the right brake to make sure it was still locked. The resident attempted to propel herself and could not due to the wheelchair brakes had been locked. The resident had continued to try to propel herself multiple times. CNA 5 was observed to place her right hand on the resident's right shoulder area to get the resident to sit back in the wheelchair. At 5:53 a.m., the resident tried to propel herself and could not due to the locked wheelchair brakes. CNA 5, again, placed her left hand on the resident's right should area to sit her back in the wheelchair. CNA 5 had assisted Resident B to put her hearing aides in and walked away from the resident. At 5:55 a.m., the resident unlocked her wheelchair brakes and propelled herself around the nurse's station. During an interview on 11/22/24 at 11:38, the Executive Director indicated Resident B wanted to go back to her room and CNA 5 was trying to keep her from going to her room so she would not fall. During an interview on 11/22/24 at 11:41 a.m., Staff Member 6 indicated it was not appropriate to lock a resident's wheelchair to prevent them from moving. On 11/21/24 at 1:20 p.m., the Director of Nursing provided a current copy of the undated document titled If You See Something Say Something. It included, but was not limited to, employees are required to report .all .occurrences of .unreasonable confinement .What constitutes abuse .Physical .Restraints .It is prohibited to .unnecessarily inhibit a resident's freedom of movement or activity The Past noncompliance began on 10/28/24 at 5:48 a.m. The deficient practice was corrected by 10/29/24 after the facility implemented a systemic plan that included the following actions: All staff were interviewed and educated on abuse and neglect which included involuntary seclusion and physical/chemical restraints (10/29/24); Resident interviews and facility wide skin assessments were conducted with no findings (10/28/24). 3.1-3(w) This Citation relates to Complaint IN00446181

Based on observation, interview and record review, the facility failed to ensure staff to resident abuse did not occur for 1 of 3 residents reviewed for abuse. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/3/24 at 9:48 a.m. The resident's diagnoses included, but were not limited to, dementia with behavioral disturbance and mood disorder. The care plan, dated 1/24/24, indicated the resident was at risk for mood changes and verbal aggression. The interventions included, but were not limited to, allow the resident to vent feelings and frustrations, change care givers, ensure the resident's safety and observe from a distance and to leave resident alone to calm down. During an interview on 6/3/24 at 9:13 a.m., LPN (Licensed Practical Nurse) 3 indicated on 5/12/24, CNA (Certified Nursing Aide) 5 reported to her that CNA 9 had spoken inappropriately to Resident B and pointed her finger at him. She did not witness the incident but immediately reported to the Director of Nursing. During an interview on 6/3/24 at 10:25 a.m., the Director of Nursing (DON) indicated after she watched the video, you could tell CNA 9 pointed her finger at the resident and poked him in the chest. The staff member was terminated. The progress note, dated 5/12/24 at 8:45 p.m., indicated it was reported that CNA 9 and Resident B had an altercation in the hallway around 6:00 p.m. after Resident B was removed from another resident's room. Resident B called CNA 9 a bitch and told her to go to hell. CNA 9 responded verbally with her finger pointed at the resident. The resident sat in the hallway for a few minutes and then wheeled himself back to his room. The resident did not display any adverse effects from the interaction. All notifications had been made. On 6/3/24 at 10:45 a.m. , during a video of the incident on 5/12/24 at 6:04 p.m., with the Director of Nursing present, the following was observed: On 5/12/24 at 6:04 p.m., CNA 9 was observed to wheel Resident B out of a resident's room on the left of the hallway. CNA 9 was observed to walk up to the nurse's station and then abruptly stopped, turned around and walked back down the hall towards Resident B. CNA 9 was standing next to Resident B, in conversation and then poked Resident B in the chest area with her finger and then walked back up towards the nurse's station. A conversation was exchanged between CNA 9 and CNA 5 and then CNA 9 exited the camera view. The written statement from CNA 5, dated 5/12/24 and untimed, indicated she was headed to the dining room but then remembered something and turned around and went back towards the nurse's station. CNA 5 heard Resident B yell you can go to hell, she looked down the hall. CNA 9 had walked past Resident B, immediately turned around and approached him. CNA 9 pointed her finger at Resident B and said in a deep, harsh voice, you don't talk to me like that. Resident B asked CNA 9 , what did I say. CNA 9, had her finger pointed at Resident B and scolding him by saying you told me to go down there. On 6/3/24 at 9:18 a.m., a current copy of the document titled Abuse/Neglect/Mistreatment/Exploitation/Misappropriation of Personal Property dated 1/12/18 was provided. It included, but was not limited to, Policy .The facility strictly prohibits resident abuse .physical abuse .includes, but is not limited to, hitting slapping, pinching .mistreatment .inappropriate treatment The Past noncompliance began on 5/12/24 at 6:04 p.m. The deficient practice was corrected by 5/30/24 after the facility implemented a systemic plan that included the following actions: All staff were interview, educated on abuse and neglect and post tests on abuse completed (5/30/24); Resident interviews/assessments were conducted with no findings (5/13/24). This Citation relates to Complaint IN00434474 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to ensure staff immediately responded when a resident (Resident B) fell and a full body assessment completed at the time of the fall for 1 of 3 residents reviewed for neglect. Findings include: The clinical record for Resident B was reviewed on 2/1/24 at 1:29 p.m. The diagnoses included, but were not limited to, metabolic encephalopathy, osteoarthritis and vascular dementia. The baseline care plan, dated 12/9/23, indicated the resident was a fall risk and the resident was to have a PSA (personal safety alarm) to her bed and chair at all times. During an interview on 2/1/24 at 12:20 p.m., CNA (Certified Nursing Aide) 8 indicated on 12/19/23, she was coming up the 200 hallway and heard a loud thump. RN 4 told her Resident B had just put herself on the floor. She went around the nurse's station and saw the resident on the floor. She told RN 4 it looked like the resident had fallen. Resident B was hollering out and she tried to keep her calm. She asked RN 4 to help her with the resident because she could not move her until RN 4 assessed the resident. RN 4 just sat there. She heard RN 4 call the DON (Director of Nursing) to let her know Resident B had put herself on the floor. RN 4 finally got up to help assist Resident B back up into her wheelchair. RN 4 told Resident B, look what that got you. RN 4 did not even assess Resident B for any injury. Resident B asked RN 4 to call her daughters to let them know she had fallen. RN 4 responded no, you ran them all off as well.CNA 8 looked Resident B over and did not see anything, however she was not allowed to assess the resident since she was a CNA. RN 4 then went outside for a break and she reported the incident to the DON. The progress note from RN 4, dated 12/19/23 at 2:22 p.m., indicated the resident had sat herself down on the floor at the nurse's station. The resident had reported over and over throughout the day that she would put herself on the floor. Her alarm sounded at the nurse's desk and she had put herself on the floor at the foot of her wheelchair. The resident was assessed and no injury found. The progress note, dated 12/19/23 at 5:08 p.m., indicated that upon video review of Resident B's fall at approximately 2:30 p.m., it was observed that the resident was sitting in her wheelchair at the nurse's station. The resident continued to scoot closer and closer to the edge of her wheelchair. The resident fell forward onto the floor and hit the wheel of another resident's wheelchair in front of her. Upon assessment by LPN (Licensed Practical Nurse) 3, there were no injuries or physical concerns observed. Nursing would continue to observe and monitor neurological status. On 2/1/24 at 1:46 p.m., the video of the incident, dated 12/19/23 at 2:18 p.m., was observed with the Executive Director present. The following was observed in the video: On 12/19/23 at 2:18 p.m., Resident B was observed sitting at the nurse's station. RN 4 was observed sitting at the desk behind the nurse's station. Resident B scooted forward towards the edge of her chair. At 2:19 p.m., RN 4 turned her head towards the direction of Resident B. Resident B then fell forward out of the wheelchair and onto the floor, striking her head on the wheel of another residents' wheelchair. RN 4 remained sitting behind the nurse's station and did not look up. At 2:20 p.m., CNA 8 came around the nurse's station and saw Resident B on the floor at which time RN 4 picked up the facility phone to make a call. CNA 8 went behind Resident B's wheelchair and turned off Resident B's alarm. CNA 8 then moved another resident from out of in front of Resident B and bended over the resident. During this time, RN 4 hung up the facility phone and then pulled out her cell phone to make another call. CNA 8 walked down the hall towards the front doors. At 2:20 p.m., CNA 8 walked back down toward Resident B, at which time RN 4 had gotten up from her seat and walked out from behind the nurse station. RN 4 stared at Resident B while she was on the floor. At 2:21 p.m., RN 4 and CNA 8 assisted Resident B up from the floor and placed her back into the wheelchair. RN 4 did not assess Resident B for injury prior to moving her. RN 4 then went back behind the nurse's station, sat down, and picked up the facility phone where she remained until 2:24 p.m. At 2:24 p.m., RN 4 got up and exited out from behind the nurse's station, walked down the hall and exited out the side door. During an interview on 2/1/24 at 1:50 p.m., the Executive Director indicated the nurse in the video was an RN, Resident B's alarm was sounding and RN 4 did not move. RN 4 was no longer employed by the next day. On 2/1/24 at 12:29 p.m., the Director of Nursing provided a current copy of the document titled Abuse/Neglect/Mistreatment/Exploitation/Misappropriation of Personal Property dated 1/12/18. It included, but was not limited to, Abuse .Abuse also includes the deprivation by an individual .of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Prevention .The facility strictly prohibits .neglect .by employees Neglect .the willful failure of the facility .employees .to provide goods and services that are necessary to avoid physical harm, mental anguish, or emotional distress The Past noncompliance began on 12/19/23. The deficient practice was corrected by 12/21/23 after the facility implemented a systemic plan that included the following actions: All nurses were educated on the importance of fall assessments to include completing the assessment prior to moving a resident; All licensed staff were educated on abuse and neglect, which included providing services necessary to avoid physical harm, mental anguish and emotional distress. This Citation relates to Complaint IN00424481 3.1-27(a)(3)

Based on interview and record review, the facility failed to ensure a resident admitted with a history of diabetes received blood sugar level cheeks and insulin timely for 1 of 3 residents reviewed for quality of care. (Resident B) Findings include: An Incident Report, dated 8/24/23 at 8:20 p.m., indicated Resident B arrived at the facility on the evening of 8/23/23 around 6:30 p.m. The resident's insulin orders were not put into the system. An Admission MDS (Minimum Data Set) assessment, dated 8/24/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited, to diabetes mellitus Type 1 with ketoacidosis and coma, dementia, and cognitive communication deficit. A Hospital Discharge Summary, dated 8/23/23, indicated the resident's discharge medications included, but were not limited to, the following: - Toujeo (a long acting insulin medication), staff were to administer 15 units daily. - Humalog (a fast acting insulin medication), staff were to administer 5 units, three times a day with meals. The August EMAR (Electronic Medication Administration Record) lacked documentation the resident received her insulin (Toujeo 15 units) or accu check (blood sugar level) on 8/23/23 and the resident had not received the fast acting Humalog insulin with breakfast or lunch the following day on 8/24/23. A Progress Note, dated 8/24/23 at 4:10 p.m., indicated the physician saw the resident for the initial admission assessment. All previous records from the hospital were reviewed. New orders were received to discontinue the routine Lispro (insulin medication) and start accu checks with a sliding scale Lispro. A Progress Note, dated 8/24/23 at 4:24 p.m., indicated the resident vomited twice during the shift, approximately 3 hours after a meal. A Progress Note, dated 8/24/23 at 5:17 p.m., indicated staff administered 12 units of Humalog and the nurse was waiting for a call from the physician. A Progress Note, dated 8/24/23 at 6:25 p.m., indicated the resident's family member was notified of the resident vomiting twice and a high accu check reading of 600 mg/dl (normal adult range of blood sugar levels was 80 mg/dl to 120 mg/dl). A Progress Noted, dated 8/24/23 at 7:18 p.m., indicated the resident's accu check reading was high at 600 mg/dl. Staff administered 32 units of Humalog STAT (immediately) per the physician's order. A Progress Note, dated 8/24/23 at 8:00 p.m., indicated the nurse attempted to give the resident her night time medication and the resident was unresponsive. Her blood sugar reading was 600 mg/dl. The physician was contacted and a new order was received to send the resident to the hospital. During an interview on 9/11/23 at 7:42 p.m., RN 2 indicated when there was a new admission to the facility she would get an admission packet, with a hospital discharge summary. She would verify the resident's vitals, complete a head-to-toe assessment, and if they were diabetic, she would obtain blood sugar on them. There was a night shift agency nurse, and she was the one that completed the resident's admission. The night shift nurse should have noted that the resident was diabetic, and reviewed and entered the orders into the system. When she returned the next morning, she only had time to read the resident's history and physical before the administration staff took the chart to finish up the admission. There were no accu checks or insulin orders in the system for the resident. The resident was a diabetic and had not received insulin the night before. There were no accu checks or insulin orders in the system on 8/24/23 until 4:00 p.m. At that time, the RN did get an accu check on Resident B and it was high. The RN gave the ordered dose of insulin and called the physician. The physician gave the order of 20 units STAT and to recheck the blood sugar in 2 to 3 hours. The resident was not cognitively aware but could not answer questions appropriately. During an interview on 9/11/23 at 8:04 p.m., the Director of Nursing (DON) indicated, on 8/23/23, the night shift nurse was an agency nurse. The DON had talked to her prior to leaving the building and instructed her, that if she had any issues, she was to call the DON. That nurse did not call her. The agency nurse did input some medication orders but did not input the insulin or accu check orders. She indicated she did not know how. The system was asking for parameters but there were no parameters given. There were no parameters because the insulin was scheduled. The next morning upon her arrival she retrieved the resident's chart to review the orders with the physician. She did not get all the clarifications and orders inputted until around 1:30 p.m. on 8/24/23. She thought the resident had only been nauseated before dinner and she was aware the resident had received Zofran. The day shift RN told her that the night shift nurse did not put in insulin orders because she did not know the parameters. She had reviewed the hospital EMAR and Resident B had received the Toujeo the night before on 8/22/23. It would be a nursing measure to obtain an accu check on a known diabetic and did not necessarily need a physician order. She had asked the agency nurse if she had taken Resident B's blood sugar and the agency nurse stated she did and it was 101, but she did not know where to document it in the record. The nurse could have documented under progress notes, vitals, or on the admission assessment. The EMAR, dated 8/24/23 at 7:00 p.m., indicated the nurse had administered the resident's Humalog 20-units STAT. The EMAR, dated 8/24/23 at 7:18 p.m., indicated the nurse had administered the resident's Humalog 32-units STAT. During an interview on 9/12/23 at 9:00 a.m., the DON indicated the RN did not go into the system and document the actual times given. The progress notes indicated the 7:00 p.m. dose was given at 5:00 p.m. The DON had started education for staff evolved and had not educated the agency staff that generally work at the facility. The current plan was for her to review all new admission orders the next working day. The current facility policy, titled Abuse/Neglect/Mistreatment/Exploitation/Misappropriation of Personal Property, with a reviewed date of 1/18/2023, was provided by the DON on 9/11/23 at 7:16 p.m. The policy indicated, .2. To ensure that the facility personnel are trained during orientation, and at periodic intervals .Definitions/Background: .Neglect: the willful failure of the facility, its employees, or service providers to provide goods and services that are necessary to avoid physical harm . The current facility policy, titled Admission Policy, with a reviewed date of 2/25/2023, was provided by the DON on 9/12/23 at 12:13 p.m. The policy indicated, .The purpose of this facility policy .to establish uniform guidelines for facility staff to following in admitting residents . The current facility policy, titled Admission Orders, with a reviewed date of 2/25/2023, was provided by the DON on 9/12/23 at 12:13 p.m. The policy indicated, .The purpose of this policy .to ensure that each resident receives necessary care and services upon admission to the facility .At the time a reside is admitted , the facility will have physician's orders for the resident's immediate care .Procedure: Admission orders will be obtained from .discharge summary .Admission orders will, at a minimum, .include .medications .and routine care to maintain .the resident's functional abilities .The physician/provider will be notified of the resident's admission, orders will be verified for continuation . The current facility policy, titled Documentation in the Resident's Medical Record, with a reviewed date of 2/8/2023, was provided by the DON on 9/12/23 at 12:13 p.m. The policy indicated, .The purpose of this policy is to ensure accurate, clear, and concise record of the care a resident receives, status of health conditions, .1. The resident's medical record should be .accurate, .and consistent .3. Documentation should be within a timely manner .to enable providers to make informed decision about .continuity of care . The current facility policy, titled Diabetic Care, with a reviewed date of 2/25/2023, was provided by the DON on 9/12/23 at 12:13 p.m. The policy indicated, .The purpose of this policy is to ensure that the facility monitors and provides appropriate care for diabetic residents .A blood glucose check will be performed as a nursing measure . This Federal tag relates to Complaint IN00416292. 3.1-37(a)

Based on record review and interview, the facility failed to ensure timely revision of a resident's care plan to reflect new pressure wound interventions for 1 of 13 residents whose care plans were reviewed. (Resident 33) Findings include: The clinical record for Resident 33 was reviewed on 11/3/22 at 11:15 a.m., the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 9/19/22, indicated the resident was severely cognitively impaired. She required extensive assistance of two staff members for ADL's (Activities of Daily Living). She was at risk for developing pressure wounds. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, dated 3/14/18 and revised on 11/1/22, indicated the resident was at risk for skin breakdown. The interventions included, but were not limited to, assist with repositioning (dated 3/14/18), and pressure redistribution mattress in place to the bed (dated 11/1/22). The resident's care plan, dated 8/18/19 and revised on 10/12/22, indicated the resident had the potential for skin integrity breakdown due to a history of chronically picking at her arms and had dry fragile skin. The resident had a Stage 3 pressure wound versus trauma area to her left buttock. The interventions included, but were not limited to, alternating air mattress (dated 11/1/22), complete treatments as ordered (dated 8/18/19), encourage good nutrition (dated 8/18/19) and hydration to promote healthier skin, encourage her to avoid scratching (dated 8/18/19), assist with keeping hands clean and fingernails short (dated 8/18/19), keep her skin clean and dry and use lotion on dry skin. Place pool noodle pieces to her wheelchair to keep her from her hitting legs (dated 9/8/22). The clinical record lacked documentation of any revision to the care plan with the interventions for a Stage 3 pressure wound. The Weekly Skin and [CONDITION(S)] assessment, dated 10/10/22, indicated the resident had an abrasion to her left calf. The nurse's note, dated 10/12/22 at 4:21 p.m., indicated while completing incontinent care an area was observed to be open on the resident's left buttock that was pressure versus trauma area and measuring 2 cm (centimeters) x 2 cm x 1 cm. She had no pain, no drainage, no signs, or symptoms of infection. The surrounding area was normal skin tone. The new orders were received and noted to cleanse the wound with wound cleanser, pat dry and apply a [MEDICATION(S)] dressing daily and prn (as needed) for soilage or dislodgement. The Wound Assessment Form, dated 10/12/22 at 4:00 p.m., indicated the left buttock pressure wound measured 2 cm by 2 cm by 1 cm and at a Stage 3. No exudate, and the surrounding skin was intact. The Wound Assessment Form, dated 10/27/22, indicated the left buttock pressure wound measured 1 cm by 1 cm by 0.2 cm and was a Stage 3. A scant amount of serous drainage, the wound bed was pink, and the surrounding tissue was intact. During an interview on 11/3/22 at 11:00 a.m., the Wound Nurse indicated when an issue like a pressure wound was identified she would be notified by the staff and interventions would be added at that time. The care plan would be updated or the issue would be added at that time with interventions. If the current interventions were not working, she would reassess the wound and add new interventions. The Wound Management Program policy, dated 8/1/2018, was provided by the DON (Director of Nursing) on 11/1/22 at 10:00 a.m. The policy included, but was not limited to, . F. Documentation and Care Planning 1. The wound management program documentation requirements include: a. Identification of the location and frequency of wound documentation. b. Identification of forms used and format for reporting. c. Required comprehensive description of pressure ulcer weekly, at a minimum. d. Delineation of 'in-house' documentation required (for example, weekly reports to the Director of Nurses) and by whom. e. Goals of the wound care plan collaboratively determined with the resident, family, and interdisciplinary team. f. Assigned responsibility/accountability for the initial care plan and for subsequent updating. g. Determined facility time frames for care plan updating . 3.1-35(d)(2)(B)

Based on record review, observation, and interview, the facility failed to ensure thorough skin assessments were conducted to identify pressure wounds prior to the development of a Stage 3 and unstagable pressure ulcer and failed to ensure proper procedures were followed for an assistive device which resulted in a suspected deep tissue injury for 3 of 3 residents reviewed for pressure wounds. (Residents 33, 6, and 4) Findings include: 1. The clinical record for Resident 33 was reviewed on 10/31/22 at 10:50 a.m. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Minimum Data Set) assessment, dated 9/19/22, indicated the resident was severely cognitively impaired. She required extensive physical assistance of two staff members for ADLs (Activities of Daily Living). She was at risk for developing pressure wounds. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, dated 3/14/18 and revised 8/18/19, indicated the resident was at risk for skin breakdown. The interventions included, but were not limited to, assist with repositioning and pressure redistribution mattress in place to the bed. The resident's care plan, dated 8/18/19 and revised on 10/12/22, indicated the resident had the potential for skin integrity breakdown due to a history of chronically picking at her arms and had dry fragile skin. The resident had a stage III pressure wound versus trauma area to her left buttock. Interventions included, but were not limited to, alternating air mattress, complete treatments as order, encourage good nutrition and hydration to promote healthier skin, encourage her to avoid scratching, assist with keeping hands clean and fingernails short, keep her skin clean and dry and use lotion on dry skin, and place pool noodle pieces to her wheelchair to keep her from her hitting legs. The Weekly Skin and [CONDITION(S)] assessment, dated 10/10/22, indicated the resident had an abrasion to her left calf. The Wound Assessment Form, dated 10/12/22 at 4:00 p.m., indicated the left buttock pressure wound measured 2 cm by 2 cm by 1 cm and at a stage III. No exudate, and the surrounding skin was intact. The nurse's note, dated 10/12/22 at 4:21 p.m., indicated while completing incontinent care an area was observed to be open on the resident's left buttock that was a pressure versus trauma area and measuring 2 cm (centimeters) by 2 cm by 1 cm. She had no pain, no drainage, no signs, and symptoms of infection. The surrounding area was normal skin tone. New orders were received and noted to cleanse the wound with wound cleanser, pat dry and apply a [MEDICATION(S)] dressing daily and prn for soilage or dislodgement. The nurse's note, dated 10/17/22 at 1:31 p.m., indicated the treatment to her left buttock was continued and tolerated well. The area showed some improvement with zero signs or symptoms of infection, zero drainage or active bleeding. The Wound Assessment Form, dated 10/19/22, indicated the left buttock pressure wound measured 1.4 cm by 1 cm by 0.2 cm at a stage III. A scant amount of serous drainage, and the surrounding skin was intact. The nurse's note, dated 10/26/22 at 1:38 p.m., indicated the treatment continued to the resident's left buttock with zero signs or symptoms of infection, zero drainage or active bleeding. Pillows were placed to relieve pressure. No signs or symptoms of pain. The Wound Assessment Form, dated 10/27/22, indicated the left buttock pressure wound measured 1 cm x 1 cm x 0.2 cm and was a Stage 3. A scant amount of serous drainage, the wound bed was pink, and the surrounding tissue was intact During an interview on 11/3/22 at 8:35 a.m., LPN (Licensed Practical Nurse) 1 indicated nurses did weekly skin checks usually when the resident received a shower. A pressure wound should have been identified before it was a stage III. The skin should be monitored for redness, [CONDITION(S)], pain, no blanchable skin, and breaks in the skin. The residents should be turned and repositioned every 2 hours, low air mattress and float the heels. During an interview on 11/3/22 at 10:00 a.m., the Wound Nurse indicated the resident's wound was facility acquired. Interventions for prevention include a alternating air mattress, pressure reduction cushion to the resident's wheelchair, float the heels with a pillow, turn and reposition every 2 hours and as needed, and dietary consult for nutrition. If a resident developed a pressure area the staff would inform her. The skin assessments were done weekly. A pressure wound should be found before it reached a stage III. There would be signs and symptoms before the wound reached a stage III. She would stage the wound, but staff could and if the wound was staged wrong she wound assess the wound and change the staging. A wound care consultant would come in monthly to assess the wounds. She could them anytime a wound developed or worsened. She would monitor the wounds weekly. During an observation on 11/7/22 at 11:00 a.m., Resident 33's wound was observed. The wound bed had improved with a thin layer of bright pink skin. 2. The clinical record for Resident 6 was reviewed on 11/1/22 at 9:35 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 7/26/22, indicated the resident was cognitively intact with the need for cues for recall and temporal orientation to day of week and month; had no mood or behavior issues; required supervision with one staff member's assistance for bed mobility and transfers; needed limited assistance of one staff for ambulation on/off the unit with a walker; was not steady in balance and required staff assist to stabilize; had no impairment in functional ROM (range of motion); had no present pressure ulcer, and was not at risk for development of a pressure ulcer. The Annual MDS assessment, dated 10/17/22, indicated the resident remained the same, except she currently had a Stage 3 pressure ulcer that was not healed. She remained not at risk for development of a pressure ulcer. On 6/5/22, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Weekly Skin and [CONDITION(S)] assessment, dated 8/4/22, indicated the resident's skin integrity was intact with unbroken skin. The resident had no skin issues. The Pressure Ulcer Assessment, dated 8/5/22, indicated the resident had a Stage 3 right heel ulcer which measured 1.4 cm by 1.0 cm by 0.2 cm. Appeared as if it had been blistered and then ruptured. Treatment ordered. Upon discovering the Stage 3 pressure ulcer, the following new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - encourage the resident to turn and reposition every 2 to 3 hours or float heels every day and night shift. - Liquid Protein Supplement two times a day for the wound to the right heel 30 ml (milliliters) each administration - 60 ml total. - cleanse wound to the right heel with wound cleanser or soap and water, pat dry. Mix collagen powder with wound gel to make a paste. Apply paste to wound on the right heel and cover with foam dressing at bed time (night). - A multivitamin daily. The Pressure Ulcer Assessment, dated 8/11/22, indicated the right heel measured 1.2 cm by 0.9 cm by 0.2 cm and was a Stage 3. A Nutrition/Dietary Note, dated 8/16/22 at 3:36 p.m., indicated the resident was going to be added to the Nutrition At Risk (NAR) program related to the Stage 3 pressure injury to the left heel. The Pressure Ulcer Assessment, dated 8/18/22, indicated the right heel measured 1.0 cm by 1.0 cm by 0.2 cm and was a Stage 3. The resident was non cooperative with elevating her heel off the bed. She was educated multiple times and encouraged to float her heel with pillows. She independently moved in bed, and in and out of bed. A nursing note, dated 8/23/22 at 12:01 a.m.,. indicated the wound to the right heel continued. The wound bed was yellow with a scant amount yellow drainage. Staff continued to encourage the resident to her float heels to prevent worsening to the area. The Pressure Ulcer Assessment, dated 8/25/22, indicated the wound to the right heel measured 1.0 cm by 1.0 cm by 0 cm and was unstageable. The wound bed had > (greater than) 85% slough. A new treatment ordered due to the presentation of slough to the wound bed. On 8/25/22, a new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply Santyl to the wound bed and cover with a border gauze dressing. A nursing note, dated 8/27/22 at 11:34 p.m., indicated there was no improvement noted to the heel wound. A scant amount yellow/brown drainage was observed on the previous dressing. The resident continued to complain of pain with pressure to the area. No odor was detected . A nursing note, dated 8/30/22 at 1:18 a.m., indicated no changes to the heel wound were noted. The wound bed was yellow with white tissue to the surrounding wound edges with a scant amount yellow drainage. The resident indicated the area only hurt when pressure was applied. A Nutrition/Dietary note, dated 8/30/22 at 2:51 p.m., indicated the resident was to continue to receive liquid protein and multivitamin. The note corrected the previous entry on 8/16/22 to reflect the right heel was impaired, not the left. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intakes of food and fluid were good. No new recommendations. Continue to follow on NAR for stability. The Pressure Ulcer Assessments, dated 9/1/22 and 9/8/22, indicated the right heel measured 1.0 cm by 1.0 cm by 0 cm and was unstageable. The wound bed was approximately 50 % (percent) slough to 50 % red beefy tissue. The resident not cooperative with floating her heels. The resident was independent with mobility in bed and with transfers. The resident was educated and provided pillows and/or wedge to prop her heels up off the bed. A nurses note, dated 9/4/22 at 11:01 p.m., indicated treatment continued to right heel pressure area. The wound bed was pale yellow; skin around the edges was white with scant amount yellow drainage on the previous dressing. Santyl was applied to wound bed as directed. The resident stated the area was painful only when pressure was applied. The nursing notes, dated 9/5/22 at 10:50 p.m. and the 9/12/22 at 12:56 a.m., both indicated the pressure area to the right heel appeared much the same with no improvement noted. The wound bed was pale yellow and skin at the edges was white with scant or no amount of yellow drainage on the dressing. The resident continued to require frequent reminders to elevate her heels off the mattress. The Pressure Ulcer Assessment, dated 9/15/22, indicated the right heel had the same measurements as last week's assessment, but the wound bed now had 70 % red tissue and 30 % yellow slough. The resident remained non cooperative with floating her heel off the bed. The nursing note, dated 9/22/22 at 5:15 p.m., indicated a new order was received today to change the treatment to the right heel wound. The wound consultant was here today for a monthly visit and recommended to discontinue the Santyl. The wound bed was pink and improving. The Wound Care note, dated 9/22/22, indicated a new order to continue to use Composite to cover the wound and provide bacterial barrier. Daily dressing changes were required due to difficult location due to friction and sheer from the sheets, and clothes that dislodged the dressing within 24 hours. The Pressure Ulcer Assessments, dated 9/22/22 and 9/29/22, indicated the right heel measured 1.0 cm by 1.0 cm by 0.2 cm and was now a Stage 3. The resident continued to be non cooperative with floating her heel. The nursing note, dated 10/1/22 at 2:18 a.m., indicated the area to right heel was closed at this time. The nursing note, dated 10/2/22 at 12:13 a.m., indicated the treatment continued to the right heel. The area was scabbed and surrounding skin area was red with no drainage. The Pressure Ulcer Assessment, dated 10/5/22, indicated the right heel measured 1.0 cm by 1.0 cm by 0.2 cm and was now a Stage 3. The resident continued to be non cooperative with floating her heel. The Pressure Ulcer Assessments, dated 10/12/22 and 10/19/22, both indicated the right heel measured 0.8 cm by 0.8 cm by 0.2 cm and was a Stage 3. The Pressure Ulcer Assessment, dated 10/25/22, indicated the right heel measured 0.7 cm by 0.8 cm by 0 cm and was unstageable due to a scab being present. The new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If scab comes off and the area re-opens, staff would need to change treatment to the area. A care plan, dated 4/26/21 with a revision date of 8/5/22, indicated the resident had the potential for impaired skin integrity due to a Stage 3 left heel which developed on 8/5/22. The interventions included, but were not limited to, alternating air mattress to bed (dated 8/9/22); document the skin status at least weekly (dated 4/26/21); encourage good nutrition and hydration in order to promote healthier skin (dated 4/26/21); encourage meds/supplements as ordered (dated 8/8/22); encourage to keep the skin clean and dry (dated 8/9/22); encourage to turn side to side and/or float heels (dated 8/9/22); observe skin impairment for delayed healing or signs or symptoms of infection and notify MD/NP (Medical Doctor/Nurse practitioner) as needed (dated 4/26/21); and treatment as ordered (dated 4/26/21). The clinical record indicated the pressure wound was on the right heel, not the left. During a wound observation and interview on 11/3/22 at 11:20 a.m., the Wound Nurse indicated the right heel wound was thought to have started out as a blister and then it broke and was now scabbed over. Staff continued to treat the scab as it was unknown as to what was underneath the scab. She was very surprised when it was discovered as the resident was mobile and although she spent majority of time in bed, she did get up to the bathroom and moved about in her room. The wound consultant informed staff the blister should be coded as a Stage 3. The resident did not always keep her feet elevated like she should. The resident indicated that she forgot sometimes to elevate her feet. During an interview with the Director of Nursing (DON) on 11/3/22 at 2:45 p.m., she indicated nursing debated between the resident's wound being slough or a Stage 3 and it was decided to go with the higher staging of a Stage 3 due to the scab. 3. The clinical record for Resident 4 was reviewed on 11/1/22 at 10:03 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 10/13/22, indicated the resident was severely cognitively impaired. The resident required limited assistance of one staff for transfers and bed mobility. She required extensive assistance of one staff for walking in her room and corridor, locomotion on and off unit, dressing, and toileting. She required supervision for eating and personal hygiene. The care plan, dated 5/4/22 and last revised on 8/3/22, indicated the resident was at risk for falls related to a history of falls, poor safety awareness and decision making related to dementia. She would turn off or take off alarms and try to get up unassisted as times. The interventions included, but were not limited to ask therapy for a recommendation on an appropriate helmet (dated 9/23 and 9/24). A helmet was received (starting 9/27/22), and would implement use upon return (starting 10/11/22). The care plan, dated 5/8/22 and last revised on 10/31/22, indicated the resident was at risk for skin breakdown and [CONDITION(S)] (urinary tract infections) due to impaired cognition, incontinence of bowel and bladder and requiring assistance and reminders to turn and reposition. On 10/29/22, the care plan was updated for the Risk for skin breakdown related to the safety helmet and the suspected deep tissue injury of the right outer ear. The interventions included, but were not limited to observe the ears, chin, and jawline every shift for signs of breakdown (starting 10/31/22), observe the skin daily with care and notify the nurse, contact the MD/NP as needed for areas of concern, and document on the skin at least weekly (starting 5/8/22). The clinical record lacked documentation of the monitoring for skin impairment related to the soft helmet prior to the discovery of the deep tissue injury. The clinical record lacked documentation of therapy notes related to an evaluation for the soft helmet size. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Initial Pressure Wound Assessment, dated 10/29/22, indicated a suspected deep tissue injury to the right outer ear, which measured 0.3 cm long by 0.2 cm wide. The treatment initiated was for the application of skin prep. The nursing staff were to monitor the skin integrity to the ears, jawline, and neck every shift related to the wearing of the soft helmet. A potential supply of another style of helmet was to be looked into, if available. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify the physician of any changes in the skin condition every day and night shift for skin integrity. During an interview on 11/7/22 at 9:27 a.m., the Rehabilitation Manager indicated the facility asked her to measure for the soft helmet. She had to guess on the size, because the resident was in the hospital at that time. She just found a resident with a similar sized head and used that as a guide for the helmet fit. She was not told of the rubbing of the soft helmet on the resident's ear. The facility had not asked her to find a different helmet. To properly fit a helmet, she would follow the guide book for ordering a helmet. She would measure the circumference of the head usually. During an interview on 11/7/22 at 9:52 a.m., the Wound Nurse indicated nursing staff would do the daily skin assessments. She was told by a nurse of the discovery of the suspected deep tissue injury to the ear. Therapy was consulted for the soft helmet to prevent further head injuries. The resident was very demented and was unable to follow directions, and they had exhausted all interventions. She had assumed that therapy had fitted the helmet. She didn't feel the helmet was tight on the resident. The helmet had a strap under the chin. The order was for the resident to wear the helmet all of the time. The nurse or CNA (certified nurse aide) could put the helmet on the resident. She was unsure if another helmet would be ordered. The Wound Management Program policy, dated 8/1/2018, was provided by the DON (Director of Nursing) on 11/1/22 at 10:00 a.m. The policy included, but was not limited to, . A. Accountability 1. The Wound Management Program identifies staff participation and accountability to include: a. Persona responsible for program oversight and coordination. b. Staff involved in prevention and treatment (and their roles) c. Expectation of all caregivers to observe resident skin integrity during the daily provision of the resident's personal care during the daily provision of the resident's personal care . 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure weekly skin assessments accurately reflected the residents current skin status and therapy evaluation for a helmet assessment were document for 2 of 13 residents reviewed for skin impairments. (Residents 6 and 4) Findings include: 1. During an observation of wound care for Resident 6 on 11/3/22 at 11:20 a.m., the Wound Nurse indicated the resident had a scabbed area to the back of her right heel which was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] The clinical record for Resident 6 was reviewed on 11/1/22 at 9:35 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Weekly Skin and [CONDITION(S)] assessments between August and October 2022 indicated the following assessments were not coded correctly: The Weekly Skin and [CONDITION(S)] assessment, dated 8/4/22, indicated the resident's skin integrity was intact/unbroken skin. Resident had no skin issues. The Pressure Wound assessment, dated 8/5/22, indicated the resident had a right heel pressure ulcer, length 1.4 cm (centimeters) by 1 cm by 0.2 cm Stage 3. The Weekly Skin & [CONDITION(S)] assessment, dated 8/11/22, indicated the resident had intact/unbroken skin. Staff were to continue with treatment to the left heel and [MEDICATION(S)] powder under the abdominal folds. The Weekly Skin & [CONDITION(S)] assessment, dated 8/18/22, indicated the resident had intact/unbroken skin. The resident's right heel treatment was in place to the resident's heel related to skin breakdown. The Weekly Skin & [CONDITION(S)] assessment, dated 8/25/22, indicated the resident had intact/unbroken skin. Staff were to apply [MEDICATION(S)] powder under the abdominal folds, facility barrier cream to the buttocks, treatment to the right heel continued. The Weekly Skin & [CONDITION(S)] assessment, dated 9/1/22, indicated the resident had intact/unbroken skin. Staff were to apply [MEDICATION(S)] powder under the abdominal folds, facility barrier cream to the buttocks, treatment to the right heel continues. The Weekly Skin & [CONDITION(S)] assessment, dated 9/8/22, indicated the resident had intact/unbroken skin. Staff were to continue with treatment to the right heel. The Weekly Skin & [CONDITION(S)] assessment, dated 9/15/22, indicated the resident had intact/unbroken skin. Treatment continued to the resident's right heel. The Weekly Skin & [CONDITION(S)] assessment, dated 9/22/22, indicated the resident had intact/unbroken skin. Staff were to continue to apply [MEDICATION(S)] powder under the resident's abdominal folds. The Weekly Skin & [CONDITION(S)] assessment, dated 9/29/22, indicated the resident had intact/unbroken skin. The Weekly Skin & [CONDITION(S)] assessment, dated 10/13/22, indicated the resident had intact/unbroken skin. The Weekly Skin & [CONDITION(S)] assessment, dated 10/20/22, indicated the resident had intact/unbroken skin. The resident's treatment to the right heel was intact. The Weekly Skin & [CONDITION(S)] assessment, dated 10/27/22, indicated the resident had intact/unbroken skin. Staff were to apply skin prep to the resident's scabbed area on the right heel. The Pressure Wound assessment, dated 10/25/22, indicated the resident's right heel remained Unstageable measuring 0.7 by 0.8 by 0. (Scab at the present site) During an interview with the Wound Nurse on 11/3/22 at 11:20 a.m., she couldn't explain why the weekly skin assessments were indicating intact unbroken skin or why the nurses would also write treatment continues to heel. If treatment continued to the heel it would mean that the skin was not intact. All she could do was educate, educate, educate. During an interview with the Director of Nursing (DON) on 11/3/22 at 2:45 p.m., she indicated she was aware of the assessments not being coded correctly. All she could do was go over with the nurses on completing the weekly skin assessments to make sure they were being filled out correctly. 2. The clinical record for Resident 4 was reviewed on 11/1/22 at 10:03 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked documentation of therapy notes related to an evaluation or fitting for the soft helmet size. The nurse's note, dated 10/10/22 at 6:27 a.m., indicated the resident was found on the floor. She had a laceration to her head and was sent out to the hospital. The resident was diagnosed with a subdural hematoma from the fall. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Initial Pressure Wound Assessment, dated 10/29/22, indicated a suspected deep tissue injury to the right outer ear, measuring 0.3 cm long by 0.2 cm wide. The nursing staff were to monitor the skin integrity to the ears, jawline, and neck every shift related to the wearing of the soft helmet. A potential supply of another style of helmet was to be looked into, if available. During an interview on 11/7/22 at 9:27 a.m., the Rehabilitation Manager indicated the facility asked her to measure for the soft helmet. She had to guess on the size, because the resident was in the hospital at that time. She just found a resident with a similar sized head and used that as a guide for the helmet fit. She was not told of the rubbing and suspected deep tissue injury on the resident's ear, from the helmet. The facility had not asked her to find a different helmet. To properly fit a helmet, she would follow the guide book for ordering a helmet. She would measure the circumference of the resident's head usually. During an interview on 11/7/22 at 9:52 a.m., the Wound Nurse indicated therapy was consulted for the helmet to prevent further head injuries. She had assumed that therapy had fitted the helmet. She didn't feel the helmet was tight on the resident. The helmet had a Velcro strap under the chin. She was unsure if another helmet would be ordered. The resident was very demented and was unable to follow direction, and they had exhausted all interventions. The current therapy company's Position Description and Criteria, provided by the DON (Director of Nursing) on 11/7/22 at 12:34 p.m., included, but was not limited to, . 15. Provides/recommends/fabricates adaptive devices, orthotics or prosthetics . 3.1-31(a) 3.1-31(d) 3.1-31(e)

Based on observation and interview, the facility failed to ensure kitchen equipment, surfaces, and floors were free from food debris, rust, and grease build-up of the walk-in freezer, metal shelving, stove area, and deep fryer for 3 of 3 kitchen and dining observations. Findings include: During an observation of the kitchen, on 11/8/21 at 10:29 a.m., the following concerns were observed: 1. There was heavy white and yellow buildup of grease and food debris running down both sides of the deep fryer and the stove and coating the floor underneath and between them. There was a macaroni noodle lying in the grease between the fryer and stove. 2. There was a large, blackened area on the wall behind the oven, which appeared to be soot from the oven vent. 3. There was yellow and brown grease coating the wall behind and to the right of the stove. Dark brown grease could be observed coating the electrical plating on the wall beside the oven. 4. There was a heavy reddish-brown buildup on the underside of the metal shelf above the three compartment sink. During an observation of the kitchen, on 11/12/21 at 1:20 p.m., the following concerns were observed: 1. There was heavy white and yellow buildup of grease and food debris running down both sides of the deep fryer and the stove and coating the floor underneath and between them. There was a macaroni noodle lying in the grease between the fryer and stove. 2. There was a large, blackened area on the wall behind the oven, which appeared to be soot from the oven vent. 3. There was yellow and brown grease coating the wall behind and to the right of the stove. Dark brown grease could be observed coating the electrical plating on the wall beside the oven. 4. There was a heavy reddish-brown buildup on the underside of the metal shelf above the three compartment sink. 5. There were several boxes of food items in the walk-in freezer stacked up to the ceiling. During a follow-up visit to the kitchen, on 11/15/21 at 9:35 a.m., the following concerns were observed: 1. The fryer had been cleaned; however some white and yellow buildup did remain on the stainless steel sides. 2. There was dust accumulated on the back of the oven, which was hanging down underneath the vent. 3. There was still a large area of the wall stained with black soot. 4. Several boxes in the walk-in freezer, including frozen chicken breasts, were touching the ceiling of the walk in freezer. During an interview, on 11/12/21 at 1:30 p.m., the DM (Dietary Manager) indicated they had daily cleaning lists, but at the time they did not have enough people to do it all. The buildup under the shelf above the sink was rust she believed. She would clean it, and it would build back up due to the moisture. The area of soot had been there a while, they were going to eventually paint over it. It was due to an issue with the stove that was now fixed. The grease staining the wall had not been cleaned in a while. The deep fryer had been cleaned a couple of weeks ago, but the sides and floor had clearly not been cleaned and clearly needed to be done. During an interview, on 11/15/21 at 9:05 a.m., the DM indicated they had cleaned the deep fryer and stove, however there was some residual grease, and they would have to continue to work at it. They had tried to clean the burnt area of the wall. It was from where the oven had been pushed too far against the wall. They had pulled it out and tried to clean it, but it was taking the paint off the wall. They removed the shelf above the sink and cleaned it, it had been rusted. They had daily and weekly cleaning tasks to do, but some things had been missed. At 9:55 a.m., the DM indicated boxes in the freezer should not be touching the ceiling. Stuff should not be touching the ceiling, normally don't have this much in there, we normally don't even have the cart in there, but we've had trouble getting food and stocked up on what we could for holidays. At 10:54 a.m., the DM indicated she could not find a policy or a specific number on how far boxes should be from the ceiling in the walk in freezer, but they should not have been touching the ceiling, as it provided inadequate circulation. The most current end of shift reminder checklist, provided on 11/15/21 at 9:05 a.m., indicated the PM Cook was to clean the stove, fryer, and oven daily. The most current weekly cleaning list, provided on 11/15/21 at 9:05 a.m., indicated staff were to clean the ovens, and clean and polish all stainless steel. The most current Cleaning Policies and Procedures, provided on 11/15/21 at 10:54 a.m., included, but was not limited to, Cleaning . removes soil, grease, food . is a very important procedure in food handling. All surfaces must be cleaned on a routine basis as well as whenever necessary . Ranges will be kept clean and free of spills and grease . 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure appropriate infection control practices for COVID-19 related to employee screening for 3 of 31 staff members (LPN 2, DA 3, and CNA 4) and prompt isolation and testing of a resident with signs and symptoms of COVID-19 for 1 of 3 residents reviewed for infection control. (Resident 3) Findings include: 1. During the clinical record review on 10/21/20 at 10:45, Resident 3's [DIAGNOSES REDACTED]. The care plan, dated 4/20/20, indicated the resident had a chronic non-productive cough. Interventions included but were not limited to, observe for and report as needed, abnormal breathing patterns and signs and symptoms of respiratory distress. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Notify MD (medical doctor) if temperature 100 or greater and/or new onset of respiratory symptoms, twice daily for screening. The Physician's note, dated 9/23/20 at 11:08 a.m., indicated the resident was seen for poor intake and wheezing. The resident was assessed to have chest wheezing throughout the lungs and coarse lung sounds. The nurses note, dated 9/23/20 at 2:52 p.m., indicated the nurse practitioner (NP) had seen the resident for cough and congestion, new orders were given for antibiotics to treat for [MEDICAL CONDITION]. No orders for COVID testing or isolation were written at that time. The nurse's note, dated 9/24/20 at 11:16 a.m., indicated the resident had wheezing to the bilateral lungs and a wet cough. The clinical record lacked documentation of any orders to isolate or test the resident for COVID-19. During an interview on 10/21/20 at 11:08 a.m., the Infection Preventionist indicated staff should notify the physician immediately of any symptoms of COVID-19. The clinician typically ordered a test for any symptoms of COVID-19. Symptomatic residents should be tested . During a subsequent interview, on 10/21/20 at 12:02 p.m., the Infection Preventionist indicated she was notified of the resident having a cough but she was not sure why the clinician had not ordered a test. The resident had displayed symptoms of COVID-19, and she should have been tested for COVID-19. The placing a resident in isolation was a nursing measure and would not have required a physician's orders [REDACTED].> 2. A review of the Employee Entry Screen form, dated 10/21/20, indicated LPN (Licensed Practical Nurse) 2, Dietary Aide 3, and CNA (Certified Nursing Aide) 4 failed to screen for symptoms, and take their temperature before starting their shift. During an interview on 10/21/20 at 12:50 p.m., LPN 2 indicated she came to work at 6:15 a.m. She stated No, I didn't sign and complete the screening. She indicated she took her temperature, but did not write it down. They were supposed to take their temperatures and answer the screening questions, she had forgotten. During an interview on 10/21/20 at 1:11p.m., Dietary Aide 3 indicated she did not screen in or take her temperature when she arrived to work at 11:37 a.m. She stated I forgot. I was supposed to screen in when I came in. During an interview, on 10/26/20 at 1:25 p.m., the IP indicated she had spoken to CNA 4, and she said she had not screened in that day before her shift started. The staff were supposed to screen in and take their temperature before the start of their shift. 3.1-18(a)

Based on observation and interview, the facility failed to follow appropriate infections control guidelines related to indwelling urinary catheter and suprapubic catheter bags resting directly on the floor for 2 of 2 residents reviewed for catheter care. (Residents C and D) Findings include: 1. During an observation, on 10/1/20 at 5:50 a.m., Resident C's catheter bag was observed lying directly on the floor to the right side of the resident's bed. The clinical record was reviewed on 10/1/20 at 8:15 a.m. The resident's [DIAGNOSES REDACTED]. The care plan, dated 7/5/20, indicated the resident was at risk for UTI (urinary tract infection) due to incontinence of bladder. The resident had a indwelling catheter. The progress note, dated 9/26/20 at 11:47 p.m., indicated the resident's catheter was draining dark amber urine. During an observation on 10/1/20 at 9:50 a.m., QMA (Qualified Medication Aide)/CNA 7 emptied the catheter bag for Resident C. She indicated she observed the urine for cloudiness and sediment. She also observed for blockage from the tubing. She felt the bag needed to be changed. She would check the position of the catheter for good drainage while performing care. She indicated she noticed the catheter bag on the floor at the beginning of her shift and she repositioned it. 2. During an observation, on 10/1/20 at 7:25 a.m., Resident D's suprapubic catheter bag was observed scrunched on the floor beside his bed. The resident's bed was in the lowest position. During an observation on 10/1/20 at 10:07 a.m., the resident's supra pubic catheter bag was observed hanging on the side of the trash can. The resident was sitting up in his recliner. The clinical record was reviewed on 10/1/20 at 8:50 a.m. The resident's [DIAGNOSES REDACTED]. The care plan, dated 7/28/20, indicated the resident received a [MEDICATION NAME] antibiotic for a history of recurrent UTIs. The care plan, dated 9/17/20, indicated the resident had an UTI related to Escherichia Coli and Proteus mirabilis. The interventions included, but were not limited to, .Catheter care every shift. Change catheter bag and catheter as ordered. Empty catheter bag at least q (every) shift and as needed. Ensure catheter is intact and patent q shift Standard precautions in place while providing all resident care. During an interview on 9/30/20 at 1:09 a.m., CNA (Certified Nursing Aide) 9 indicated she does not check each resident when doing morning rounds, they have been bothered enough during the night. During an interview on 10/1/20 at 10:01 a.m., the DON (Director of Nursing) indicated the catheter bag shouldn't hang on the trash can or be on the floor. If the bed was in the lowest position, the bag should have been placed in a basin. The facility had no policy for the catheter bags being kept off of the floor. This Federal tag relates to Complaint IN 048 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure a mechanical lift pad was appropriately placed on a resident (Resident B) during a lift transfer which resulted in a fall from the mechanical lift for 1 of 3 residents reviewed for accidents. Findings include: The clinical record for Resident B was reviewed on 2/4/20 at 11:30 a.m. [DIAGNOSES REDACTED]. The incident report, dated 1/24/20 at 5:25 a.m., indicated CNA (Certified Nursing Assistant) 6 was getting Resident B up for the day using the mechanical lift. During the transfer the resident slipped out from the lift pad and landed on the floor. The nurse's note, dated 1/24/20 at 6:21 a.m., indicated CNA 6 was in the resident's room, provided care to resident and was getting her up for the morning. CNA 6 placed a cross sling under the resident to use the mechanical lift to place the resident in her chair. While CNA 6 was lifting the resident with the mechanical lift, the resident slipped from the lift pad on to the floor. The progress note, dated 1/24/20 at 8:49 a.m., indicated the hospital emergency room called to inform the facility the resident had no injuries from the fall. The progress note, dated 1/24/20 at 10:51 a.m., indicated upon the resident's return from the emergency room , a full body assessment was completed. The resident's skin was clear. During an interview on 2/4/20 at 12:52 p.m., the Director of Nursing indicated CNA 6, had been educated on transfers with mechanical lifts. CNA 6 transferred the resident with the mechanical full body lift and failed to criss cross the pad, which caused the resident to slip out of the lift pad. During an interview on 2/4/20 at 1:25 p.m., CNA 3 indicated when using a mechanical full body lift there should be two staff members present and the leg straps needed to be criss crossed. On 2/4/20 at 1:12 p.m., the Director of Nursing provided a copy of the orientation information for agency CNA staff. It included, but was not limited to, Orientation info for agency staff: CNA .15) Mechanical Lift Usage .I have received, reviewed and understand the policy and procedures that have been provided to me The document was signed by CNA 6 on 12/17/19. The Care Lift Operations for positioning the lift sling under a patient/resident from the lying down position included, but was not limited to, Pull leg strap under patient's/resident's thigh. Ensure no twisting has occurred. Repeat procedure with other leg .Criss cross the leg straps On 2/4/20 at 1:12 p.m., the Director of Nursing provided a current copy of the document titled Mechanical Lift dated August 2018. In included, but was not limited to, It is the intent .provide and utilize mechanical lifts on resident who are identified that might receive benefit for the use of these lifts during transfers .when using full body lift, ensure you are working with a buddy . This Federal tag relates to Complaint IN 322 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure documentation on the Narcotic Count Sheet of administered narcotics for 6 of 28 residents observed for medication storage (Residents 9, 46, 41, 37, 2, and 17) and document an open date on an insulin vial for 1 of 28 residents reviewed (Resident 35) in the 100 hall medication cart. Findings include: During an observation, on 8/7/19 at 10:55 a.m., of the 100 hall medication cart the following was observed: 1. Resident 9's [MEDICATION NAME]/APAP ([MEDICATION NAME]) 10-325 mg (milligrams) Controlled Drug Use Record sheet indicated the resident had a count of 13 tablets left. The resident's medication card only contained 12 tablets of [MEDICATION NAME]/APAP. The last dose signed out on the Controlled Drug Use Record sheet was on 8/6/19 at 8:00 p.m. During a clinical record review on 8/8/19 at 8:15 a.m., the physician's orders [REDACTED]. The review of Resident 9's MAR (Medication Administration Record) indicated the resident's last dose of [MEDICATION NAME] 10-325 mg was administered on 8/7/19 at between 8:00 a.m. and 11:00 a.m. 2. Resident 46's [MEDICATION NAME]/APAP ([MEDICATION NAME]) 5-325 mg Controlled Drug Use Record sheet indicated the resident had a count of 8 tablets left. The resident's medication card only contained 7 tablets of [MEDICATION NAME]/APAP. The last dose signed out on the Controlled Drug Use Record sheet was on 8/6/19 at 8:00 p.m. During a clinical record review on 8/8/19 at 8:15 a.m., the physician's orders [REDACTED]. The review of Resident 46's MAR indicated [REDACTED] 3. Resident 41's [MEDICATION NAME]/APAP 7.5-325 mg Controlled Drug Use Record sheet indicated the resident had a count of 19 tablets left. The resident's medication card only contained 18 tablets of [MEDICATION NAME]/APAP. The last dose signed out on the Controlled Drug Use Record sheet was on 8/7/19 at 5:00 a.m. The review of Resident 41's MAR indicated [REDACTED] During a clinical record review on 8/8/19 at 8:15 a.m.,the physician's orders [REDACTED]. 4. Resident 37's [MEDICATION NAME]/APAP 5-325 mg Controlled Drug Use Record sheet indicated the resident had a count of 33 tablets left. The resident's medication card only contained 32 tablets of [MEDICATION NAME]/APAP. The last dose signed out on the Controlled Drug Use Record sheet was on 8/6/19 at 9:00 p.m. During a clinical record review on 8/8/19 at 8:15 a.m., the physician's orders [REDACTED]. The review of Resident 37's MAR indicated [REDACTED] 5. Resident 2's [MEDICATION NAME]/APAP 7.5-325 mg Controlled Drug Use Record sheet indicated the resident had a count of 24 tablets left. The resident's medication card only contained 23 tablets of [MEDICATION NAME]/APAP. The last dose signed out on the Controlled Drug Use Record sheet was on 8/6/19 at 8:00 p.m. During a clinical record review on 8/8/19 at 8:15 a.m., the physician's orders [REDACTED]. The review of Resident 2's MAR indicated [REDACTED] 6. a. Resident 17's [MEDICATION NAME]/APAP 5-325 mg Controlled Drug Use Record sheet indicated the resident had a count of 46 tablets left. The resident's medication card only contained 45 tablets of [MEDICATION NAME]/APAP. The last dose signed out on the Controlled Drug Use Record sheet was on 8/6/19 at 8:00 p.m. The review of Resident 17's MAR indicated [REDACTED] During a clinical record review on 8/8/19 at 8:15 a.m., the physician's orders [REDACTED]. b. Resident 17's [MEDICATION NAME] (klonopin) 0.25 mg Controlled Drug Use Record sheet indicated the resident had a count of 14 tablets left. The resident's medication card only contained 13 tablets of [MEDICATION NAME]. The last dose signed out on the Controlled Drug Use Record sheet was on 8/6/19 at 8:00 p.m. The review of Resident 17's MAR indicated [REDACTED] During a clinical record review on 8/8/19 at 8:15 a.m., the physician's orders [REDACTED]. 7. Resident 35's Troujeo [MEDICATION NAME] Solution Pen injector seal had been broken. No open date could be located on the pen. During a clinical record review on 8/8/19 at 8:15 a.m., the physician's orders [REDACTED]. The review of Resident 35's MAR indicated [REDACTED] During an interview, on 8/7/19 at 11:00 a.m., (Licensed Practical Nurse) 3 indicated she had just opened the Troujeo pen today and forgot to put an open date on the vial. We need to start putting the open dates. If I give a prn (as needed) narcotic, I write it down, but with the routine (narcotics) I don't write it down then, because I just know what I gave. During an interview on 8/8/19 at 8:15 a.m., the DON (Director of Nursing) indicated the nursing staff were to sign out narcotics when they were pulled. The procedure was for the nurse to put an open date on the insulin at the time of the first use. The review on 8/8/19 at 9:00 a.m., of the current CONTROLLED SUBSTANCE MONITORING AND ADMINISTRATION Policy & Procedure, provided by the DON, included, but was not limited to, .Controlled medication counts should be performed at the following times .With each controlled medication administration .When documenting withdrawal of medication from the locked narcotic drawer .the actual date and actual time of the withdrawal is to be documented on the Narcotic Sign-out Sheet . 3.1-25(e)(3) 3.1-25(g)(1)

Based on record review and interview, the facility failed to ensure a resident received the daily dosage of antibiotics per the physician's order for 1 of 2 residents reviewed for pharmacy Services. (Resident 3). Findings include: A clinical record for Resident 3 was reviewed on 8/6/19 at 1:53 p.m. The resident's [DIAGNOSES REDACTED]. The review of the Oral/Dental Evaluation, dated 7/29/19, indicated the resident was .Seen by dentist on 7/25/19 with root canal performed. The Infection Follow Up Report dated 7/31/19, included L (left) side facial swelling, confusion . The review of the physician's order, dated 7/26/19, for Resident 3 indicated the resident was prescribed .[MEDICATION NAME] 500 mg (milligrams) x (times) 1, 250 mg once daily x 4 days . The review of the Controlled Drug Use Record, dated from 7/26/19 thru 7/28/19, indicated [MEDICATION NAME] ([MEDICATION NAME]) was administered on the following days and times: -7/26/19 at 11:00 p.m. 2 tablets of 250 mg each was administered. -7/27/19 at 9:00 a.m. 1 tablet of 250 mg was administered. -7/27/19 at 9:00 p.m. 1 tablet of 250 mg was administered. -7/28/19 at 9:00 a.m. 1 tablet of 250 mg was administered. -7/28/19 at 8:00 p.m. 1 tablet of 250 mg was administered. During an interview, on 8/9/19 at 9:49 a.m., RN 4 indicated the [MEDICATION NAME] was administered on her shift. The resident received it also on the night shift. The [MEDICATION NAME] was confused with the [MEDICATION NAME] which was originally ordered 3 times a day, but was discontinued. The review of the current MEDICATION ADMINISTRATION policy & procedure included, but was not limited to, .Medication Administration Times .Medications should be administered no sooner than 60 minutes nor 60 minutes later than the time scheduled. If a medication is administered outside these times, a progress note from the nurse is to be documented with the administered medication(s) in the Medication Administration Record [REDACTED]. 3.1-48(a)(1)

Based on record review and interview, the facility failed to ensure a resident's blood thinner was discontinued after a [MEDICAL CONDITION]. This deficient practice affected 1 of 6 residents reviewed for unnecessary medications. (Resident 29). Findings include: The clinical record for Resident 29 was reviewed on 8/07/19 at 09:42 a.m. The resident's [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The start date was 1/12/19 and the discontinued date was 6/17/19. The resident's care plan for anticoagulant medication, dated 1/27/17, indicated the need to observe for bleeding such as hematuria, tarry colored stools, bleeding after brushing teeth. Notify nurse if noted with notification of medical director or nurse practitioner as needed. Review of the resident's nursing notes, dated 6/14/19, indicated resident having two large loose bowel movements with copious amounts of blood and clots in them. Review of the resident's nurses notes, dated 6/16/19, indicated resident had large dark stool with some dark red blood noted in moderate amount. A review of the order note, dated 6/17/19, indicated Pt (patient) seen and examined by Doctor Name with n.o's (new order) 1) Consult Hosparus - r/t (related to) Res decline 2) CBC (Complete Blood Count) in am - r/t bloody stool 3) D/C (Discontinue) [MEDICATION NAME]. A review of the laboratory results, dated 6/18/19, indicated the resident had a critical Hemoglobin at 4.6 and a critical Hematocrit of 14.6. During an interview on 8/7/19 at 1:50 p.m., LPN 5 (Licensed Practical Nurse) indicated when a resident was on a blood thinner the staff were to monitor for blood in the resident's stool or urine, watch for bruising, bleeding gums or bleeding anywhere and monitor the INR (International Normalized Ratio) and the PT ([MEDICATION NAME] Time). During an interview on 8/8/19 at 2:04 p.m., the DON (Director of Nursing) indicated the physician came in on Monday and discontinued the [MEDICATION NAME]. During an interview on 8/9/19 at 9:45 a.m., LPN 6 indicated if a resident was on [MEDICATION NAME] and had bleeding in their stool, staff were to call the doctor and not give the [MEDICATION NAME]. The current Medication Administration policy and procedure, provided by the DON included, but was not limited to, The purpose of this policy is to establish guidelines to promote the health and safety of residents by ensuring the safe administration of medications and treatments. The policy will also review documentation and procedures regarding medication administration. 3.1-48(a)(5) 3.1-48(c)(2)

Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistance during transfers in that a resident who required maximum assist of two for transfers sustained a fracture of the ankle while being transferred by an insufficient number of staff. The staff also failed to immediately notify the nurse when the resident got her foot caught during the transfer. This deficient practice affected 1 of 3 residents reviewed for accidents. (Resident #42) Findings include: Clinical record review for Resident #42 on 8/22/16 at 11:35 a.m., indicated the resident had [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimum Data Set) assessment, dated 7/8/16, indicated Resident #42 had a BIMS (brief interview of mental status) of 13 which indicated the resident was alert and oriented. The resident required extensive assistance of two physical staff members for transfers. Review of Resident #42's Care Plan for ADLS (Activities of Daily Living) and Risk for Falls, date of 7/26/16, indicated Resident requires extensive assist to total assist with ADLS . and .Transfer with max (maximum) assist of 2 or more, use total body life. Review of the incident report, dated 8/13/16, indicated the following: On 8/12/16 at 2:01 p.m., Resident #42 was being transferred back to bed by one CNA (Certified Nursing Assistant) when the CNA heard the resident complain of her shoe getting caught on the carpet. Initially when the resident got her foot unstuck, she did not complain of pain but later on after dinner the resident complained of pain and it was reported to the nurse. The resident was monitored by the nursing staff and the ankle was noted to be swollen, bruised, and tender to touch. As her condition got worse, an order was obtained during the night for a STAT X-ray of the right ankle. The x-ray reports showed a fracture involving the distal fibula with minimal displacement being noted. Review of the facility follow investigation, dated 8/15/16, indicated CNA involved in injury was found to have violated policy and procedure with transferring and reporting injuries of a resident. During interviews on 8/22/16 at 11:45 a.m., CNA #2 and CNA #6 both indicated they would report any injury immediately to the resident's nurse and stay with the resident. During an interview on 8/22/16 at 12:00 p.m., the DON (Director of Nursing) indicated during rounds at 6:30 p.m. with the night shift CNA #5 came to the desk and said By the way, she (Resident #42) got her foot caught earlier in the day. The CNA told us it happened at 2:00 p.m. earlier in the day, but did not explain why she waited to report it. The DON indicated Resident #42 did require extensive assistance of two physical staff and it was documented on the CNA work sheet. The resident can stand and slowly turn to ambulate but two staff must be present. On 8//22/16 at 12:10 p.m., the Director of Nursing presented a copy of the facility's current policy and procedure titled Incident Reports. Review of this policy at this time included, but were not limited to: .The report is to be filled out as soon after the incident as possible by the person who actually witnessed the incident or was most directly involved .All accidents, however minor, must be immediately reported to your supervisor .Lifting Policy: All employees who are transferring or lifting resident, or any heavy object, must seek assistance from another staff member .Safety Rule: Nurses and Nursing Assistants: .1. If you are unsure whether you can support a particular patient, do not attempt to lift the patient. Get assistance . 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to assess, and plan and implement care to manage pain for 1 of 3 residents reviewed in a sample of 7 who met the criteria for pain management. (Resident #38) Resident #38 continuously complained of pain during all observations requiring movement or repositioning. Findings include: 1. On 5/21/12 at 12:15 p.m., during observation of repositioning of Resident #38 by LPN #2 and CNA #5, the resident cursed and groaned as he was rolled onto the right side. During interview at this time, LPN #2 indicated recently the resident had been sent to the hospital for placement of a [MEDICATION NAME] (muscle relaxant) pump, but a urinary tract problem requiring placement of a suprapubic catheter had caused postponement of the pump placement. The resident's legs were observed to be contracted up toward the body. During observation of incontinence care on 5/24/12 at 10:35 a.m., Resident #38 complained throughout with groaning and cursing that the care was hurting him. During interview at this time, the resident indicated his legs hurt when the staff moves them. During observation of a wound dressing changes to Resident #38's gastrostomy tube stoma and pressure ulcers in the right and left groin areas on 5/24/12 at 1:55 p.m., the resident cursed and complained of pain when moved. LPN #3 and LPN #4 worked together to complete the care, which required repositioning of the resident in bed, and separation of the contractured legs to cleanse and dress the groin wounds. The resident complained and cursed, especially when the legs were moved. The nurses instructed the resident repeatedly to relax. During interview at this time, the resident indicated the pain was in the lower legs. LPN #3 indicated she worked nights previously, and the nurse on nights had a way of moving the resident's legs to open them for the dressing change, which caused less pain, but she indicated she was unable to remember how the nurse moved the legs. The clinical record for Resident #38 was reviewed on 5/23/12 at 2:56 p.m. The resident's [DIAGNOSES REDACTED]. The Pain Assessment, dated 8/26/11, and updated most recently on 2/22/12, indicated the resident verbalizes pain, and described the pain as stabbing and sharp. The assessment also indicated the resident displayed the following non-verbal signs of pain: grimacing/distorted face, clenched jaw/teeth, frowning/scowling, glazed eyes, moaning, cursing, and irritability. The assessment indicated, "Pain is increased by: movement of any type." The assessment indicated the resident received [MEDICATION NAME] (narcotic pain medication) twice daily and every eight hours as needed for pain. Comments on 2/22/12 indicated, "Remains A&O X 2 (alert and oriented times 2), clearly voices needs, denies pain/discomfort at this time but states, "hurts when they move me." The nursing Monthly Summary, dated 5/2/12, indicated checkmarks related to pain: "almost constantly" indicated by non-verbal sounds, vocal complaints of pain, and facial expressions. The Restorative Care Flow Record indicated, "Restorative Nursing Program: Turn and Reposition." The Monthly Summary for the program, dated 5/1/12, indicated, "Resident is turned and repositioned per schedule, routinely complains of pain with nearly all movement, charge nurse/staff are aware...." The resident had no specific Care Plan related to management of pain. The only Care Plan that mentioned pain indicated, "2/28/11 Medication - Pain - Signs and Symptoms potential for side effects r/t (related to) use of anticoagulant - ASA (aspirin). Also received [MEDICAL CONDITION] meds (medications)." The Goal indicated, "(Name of resident) will have no drug related side effects by 5/28/12." The Approaches listed were related to side effects of medications. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order date of 3/27/12) from 5/1 through 5/24/12. The resident also received a [MEDICATION NAME] four times daily. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order date of 1/23/12) and also [MEDICATION NAME] 7.5/500 mg three times daily as needed (with physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation failed to indicate other doses of as needed pain medications were administered. During interview on 5/25/12 at 10:55 a.m., the Director of Nursing (DON) indicated Resident #38 did not have a care plan related to pain except the plan indicated above. The DON indicated the resident always complains of pain, even before staff touches him. She indicated she thought the resident was afraid care would cause pain, so he began complaining as soon as staff entered the room. She indicated the care related to pain management or the fear of pain had not been planned. 3.1-37(a)