Every finding on record at Miller's Merry Manor

Based on record review and interview, the facility failed to update the care plan for 1 of 1 residents reviewed for falls (Resident 1). Finding includes: A record review was completed on 4/4/2025 at 11:40 A.M., for Resident 1. Diagnoses included, but were not limited to: chronic pain, anxiety and depression. A Fall assessment, dated 1/10/2025, indicated Resident 1 fell in her room while being transferred from her bed to her wheelchair by a staff member. When the staff member assisted the resident to stand, her knees buckled and the resident fell on to her right knee. A Post IDT (interdisciplinary team) Fall Risk assessment, dated 1/10/2025 indicated the root cause for Resident 1's fall was because a gait belt was not used during the transfer. The assessment indicated the staff member was counseled on the proper use of a gait belt. A Fall assessment, dated 3/13/2025 indicated Resident 1 fell attempting to toilet herself via her wheelchair. It indicated the resident was found during rounds on the bathroom floor by a staff member. The assessment indicated a new intervention to keep her bed in the lowest position was to be put into place post fall. A Care Plan, initiated on 6/16/23 indicated Resident 1 was at risk for falls due to her condition and risk factors. Interventions included and were limited to: call light within reach, explain use of assistive device upon admission, encourage and assist with wearing non-skid foot-wear, encourage resident to use handrails or assistive devices properly, evaluate effectiveness and side effects of psychotropic drugs with physician for possible decreasing of dose or elimination of medication, keep most used items in arms length to prevent bending and reaching, monitor for changes in gait and positioning, notify Physician of changes in condition and safety strips on bathroom floor. The current Care Plan related to falls did not include the new interventions regarding gait belt use and keeping the resident's bed in the lowest position. During an interview on 4/07/2205 at 11:01 A.M., the DON indicated the residents care plan should have been updated with the new fall interventions. On 4/7/2025 at 12:00 P.M., the DON provided a policy titled, Care Plan Development and Review, dated 1/24/2020 and indicated it was the policy currently being used by the facility. The policy indicated 3. Care Plan Revision: A. Care plans will be revised daily and PRN as changes in the residents condition dictate. Changes include but are not limited to changes in Physician orders, diet changes, therapy changes, behavior changes, ADL changes, skin changes etc 3.1-35(d)(2)(B)

Based on observation, record review and interview, the facility failed to provide independent leisure activities for 1 of 2 residents reviewed for activities. (Resident 61) Finding includes: During an observation, on 4/2/2025 at 9:34 A.M. and 2:40 P.M., Resident 61 was observed in bed with her eyes closed without any visual or hearing sensory activities. During an observation, on 4/3/2025 at 2:17 P.M., Resident 61 was observed in bed with her eyes closed without any visual or hearing sensory activities. During an observation, on 4/4/2025 at 10:51 A.M., Resident 61 was observed in her Broda chair at the bedside with her eyes closed. There were no stimulating activities occurring in her room. During an observation, on 4/7/2025 at 8:56 A.M., Resident 61 was observed sitting in the hallway outside her room in a Broda chair. At 9:41 A.M. and 1:53 P.M., she was observed in her bed with her eyes closed and without any visual or hearing sensory activities. During an observation, on 4/8/2025 at 10:21 A.M., Resident 61 was observed in her bed with her eyes closed. A record review for Resident 61 was completed on 4/3/2025 at 1:46 P.M. Diagnoses included, but were not limited to: Alzheimer's disease, seizures, aphasia, mood disorder and altered mental status. Resident 61 received end of life care. A Quarterly Minimum Data Set (MDS) assessment, dated 3/12/2025, indicated Resident 61 was rarely or never understood and was dependent on staff for wheelchair locomotion. An Annual MDS assessment, dated 09/25/2024, indicated Resident 61's activity preferences were somewhat important for listening to music, having animals around, participating in activities with groups of people, participating in her favorite activities, getting fresh air when the weather was good and participating in religious services or practices. A Care Plan, initiated on 8/18/2023, indicated the Resident was considered cognitively impaired, was not capable of making decisions about activity involvement and would benefit from sensory related activities. The interventions included, but were not limited to: at times, Resident 61 preferred to vary her rest periods between morning and afternoon, through past history and/or family/resident interview it had been determined that religion had always been important and staff would provide religious music, opportunities to watch services on the television or special local church tapes, and Resident 61 always enjoyed music. During an interview, on 4/8/2025 at 8:54 A.M., the Activity Director indicated Resident 61 was not typically taken to the activity programs, but would generally receive a sensory activity once a week since she was the only activity staff working recently. She indicated Resident 61 was generally in bed. She indicated music was available in the resident lounge on the television and she tried to take Resident 61 to church services every other week. During an interview, on 4/8/2025 at 10:30 A.M., LPN 2 indicated Resident 61 laid down in bed after breakfast and lunch. She indicated Resident 61 sometimes attend a sensory activity a couple times a week. A policy was provided, on 4/8/2025 at 10:14 A.M., by the director of Nursing (DON). The policy titled, Enrichment Program Guidelines, indicated, .1. Purpose A. To enhance the lives of our residents through activity involvement. Benefits include: decreased behaviors, and increase overall satisfaction, and quality of life .III. Level 1/2 [these are lowest functioning-typically the ones who sleep during activities-they need sensory stem] a. Sensory stem-daily before lunch and supper- this will wake them up and stimulate appetite b. Musical programs c. spiritual activities d. Gross Motor movement active exercises-slow repetitive movements ie repetitively clapping hands to music, etc. at least 2 times a week 3.1-33(a)

Based on record review and interview, the facility failed to provide the recommended laboratory work recommended per the facility dietician for 1 of 3 residents reviewed for nutrition. (Resident 76) Finding includes: A record review for Resident 76 was completed on 4/3/2025 at 1:09 P.M. Diagnoses included, but were not limited to: fracture of the left femur, mild cognitive impairment and chronic kidney disease stage 3b. A Quarterly Minimum Data Set (MDS) assessment, dated 2/19/2025, indicated Resident 76 was cognitively intact and had a stage 2 and 3 pressure ulcer that were not present on admission. A Nursing Progress Note, on 12/2/2024 at 5:47 P.M., indicated Resident 76 had laboratory kidney function values of a blood urea nitrogen of 96 mg/dL (milligrams per deciliters) with a normal range of 7-20 mg/dL and a creatinine of 2.9 mg/dL with a normal range of 0.7-1.3 mg/dL An Admission/Annual/Significant Change/Other Registered Dietician Assessment, dated 1/2/2025, indicated to nursing a suggestion to monitor kidney function due to high protein supplementation and chronic kidney disease stage 3. The assessment indicated Resident 76 received greater than 107 grams of protein per day with supplementation and dietary recommendations. This was an increase from the recommended supplementation from 12/30/2024 of greater than 80 grams of protein per day. A Registered Dietician Note, on 1/2/2025 at 3:43 P.M., indicated the registered dietician assessment was completed and suggested lab monitoring for kidney function due to high protein supplementation with a diagnosis of chronic kidney disease stage 3. A Care Plan, initiated 11/25/2024, indicated Resident 76 was at nutritional risk related to chronic kidney disease stage 3, mild cognitive impairment, hypertension, anemia and pressure injury. Interventions included, but were not limited to: serve 8 ounces of milk and 4 ounces of orange juice at all meals, serve 4 ounces of super cereal at breakfast, serve 1-ounce additional protein at breakfast, oral pharmaceutical supplements as ordered: Ensure 237 milliliters twice daily and protein supplementation: ProHeal 30 milliliters twice daily. During an interview, on 4/7/2025 at 10:40 A.M., the Director of Nursing (DON) indicated recommendations from the registered dietician should be followed and the registered dietician usually puts a note in the medical record for recommendations. During an interview, on 4/7/2025 at 11:10 A.M., the DON indicated the registered dietician was not aware of laboratory results available in the medical record from 12/2/2024. During an interview, on 4/8/2025 at 8:47 A.M, the DON indicated the registered dietician did not know laboratory results were available in the medical record from 12/2/2025 and the nurse practitioner would not have drawn labs until six months after the laboratory results from 12/2/20205. However, there was no indication the MD or NP were made aware of the increased protein and the dietician's recommendation to closely monitor the resident's kidney function. A policy was provided, on 4/8/2025 at 10:14 A.M., by the DON. The policy titled, Dietician Clinical Communication, indicated, .The Dietary Manager will communicate clinical information to and from the consultant dietician and interdepartmentally .C. The Consultant Dietician or designee will: Make recommendations as needed. Communicate the recommendations and other comments/concerns to the Dietary Manager. D. The Dietary Manager will: Communicate recommendations, other comments and concerns to other departments for their follow-up. 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure medications were stored appropriately and were labeled and dated for 1 of 3 medication carts observed. (Windsor 1) Finding includes: During a medication storage observation, on 4/7/2025 at 2:00 P.M., with QMA 4, the following was observed: - an opened and undated bottle of dorzolamide eye drops with no resident identifiers. - an unsealed and unlabeled package of petrolatum gauze dressing. - an open and undated bottle of lactulose (stool softener). During an interview, on 4/07/2025 at 2:09 P.M., QMA 4 indicated the eye drops should have been labeled and dated. The lactulose should have been dated and the gauze dressing should have been sealed and labeled. On 4/8/2025 at 8:39 A.M., the Director of Nursing provided the policy titled, Storage of Medications, dated, 12/26/2024, and indicated the policy was the one currently used by the facility. The policy indicated .3. All medications dispensed by the pharmacy are stored in the container with the pharmacy label . 8.Expiration Dating . 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. A. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration 3.1-25(j)

Based on observation, interview and record review, the facility failed to follow general Infection Control Practices for 1 of 1 staff observed providing a skin treatment and failed to use a barrier when obtaining a blood sugar sample for 1 of 1 staff observed for insulin administration. (LPN 2 & RN 5) Findings include: 1. During an observation, on 4/4/2025 at 10:00 A.M., LPN 2 was observed to complete a skin treatment on Resident 145's inner left glueteal cleft. LPN 4 applied gloves and assisted Resident 145 to lay on his right side. LPN 4 removed the dressing from the resident's inner cleft, then removed her right-hand glove and applied a new glove. LPN 4 opened a package of comfort foam dressing. She applied a small amount of Medi-honey (wound gel) to a cotton tipped applicator and then applied the gel to the left gluteal cleft. LPN 4 then placed the foam dressing over the open area. LPN 4 removed the right-hand glove, then used a marker to write the date on the dressing. She applied a new glove to her right hand and assisted the resident to position in the bed. She then applied skin prep (skin barrier) to an area on Resident 145's right heel. LPN 4 then applied skin prep to an area on the resident's left ankle. She then removed both gloves and assisted the aide in placing the bed spread on the bed. During an interview, on 4/4/2025 at 10:14 A.M., LPN 4 indicated she should have washed her hands after removing the old dressing and after removing her gloves. 2. During a medication observation, on 4/8/2025 at 11:00 A.M., RN 5 was observed to obtain a blood sample. RN 5 disinfected her hands and then applied a gown, mask, and gloves. She entered the residents' room and placed the glucometer (device to monitor blood glucose levels) on the bedside table. She used an alcohol pad and wiped the residents' finger and obtained the blood sample. RN 5 placed the glucometer device back on the table. RN 5 did not place any type of barrier on the table before placing the glucometer on the table. During an interview, on 4/8/2025 at 11:10 A.M., RN 5 indicated she probably should have placed a barrier on the table. 3.1-18(a)

Based on observation and interview, the facility failed to ensure food brought in by outside sources and placed in resident nourishment refrigerators was stored in accordance with professional standards for food safety and used for food and beverages only, for 3 out of 4 pantry rooms reviewed. This deficient practice had the potential to affect 67 of 67 residents who reside on the units. Findings include: 1. During an observation on 5/2/2024 at 1:32 P.M., the Boulevard unit pantry had an opened container with 5 slices of cheesecake, an opened package of milk chocolate morsels, and 3 full containers of Culver's ice cream in the refrigerator without a label. 2. During an observation on 5/3/3035 at 1:36 P.M., the Windsor unit pantry had a large blue ice pack in the freezer compartment only. The Dietary Manager did not know why it was in there. During an interview on 5/2/2024 at 1:38 P.M., CNA 9 indicated the ice pack was used for a resident and had been placed on her hip when she asked for it. LPN 8 then indicated that was where she had always seen it placed, but it should not be in a resident refrigerator. 3. During an observation on 5/2/2024 at 1:49 P.M., the Heritage unit freezer had 3 ice packs: one large blue pack, medium size and a small one. The large blue ice pack had a bag of frozen green beans underneath it and another bag of green beans in the door shelf. During an interview on 5/2/2024 at 1:50 P.M., the Dietary Manager indicated that all food should be labeled with a date and the resident's name, and ice packs used for the Residents should not be in the pantry refrigerators on the units. On 5/2/2024 at 2:00 P.M., the Dietary Manager indicated she did not have a policy on the storage of residents' ice pack in the nourishment freezers. On 5/2/2024 at 2:00 P.M., the Dietary Manager provided a policy titled, Resident Food From Outside Source, dated 11/28/2023, and indicated the policy was the one currently used by the facility. The policy indicated .1. Family and friends are welcomes to bring food from outside source into facility for a resident. 2. Items for a resident must be labeled with name and room number and date food brought into the facility . 3.1-21(i)(3)

Based on record review and interview, the facility failed to identify and clarify a change in advanced directive status related to not keeping physician orders current with a resident's advanced directive instructions for 1 of 1 resident reviewed for hospice. (Resident B) Finding includes: A record review for Resident B was completed on 4/30/2024 at 10:38 A.M. Diagnoses included, but were not limited to: diabetes mellitus type 2, atrial fibrillation, and status post below the knee amputation. A Significant Change Minimum Data Set (MDS) assessment, dated 3/16/2024, indicated Resident B was cognitively intact and was receiving hospice services. Advanced Directive forms indicated the following: - An Out of Hospital Do Not Resuscitate was signed by the Medical Director on 2/9/2024. - An Indiana Physician Orders for Scope of Treatment (POST) form dated, 3/13/2024, indicated, Do Not Attempt Resuscitation, comfort measures, use of antibiotics for infection only, and no artificial nutrition. The POST was signed by Resident B on 3/13/2024, and the facility Nurse Practitioner signed the form on 3/15/2024. - A POST form dated, 3/15/2024, indicated, Cardiopulmonary Resuscitation to be provided, comfort measures, use of antibiotics for infection only, and no artificial nutrition. The POST was signed by Resident B on 3/15/2024, and the hospice Medical Director signed the form on 3/27/2024. A Physician's Order dated, 2/17/2024, indicated, Do Not Resuscitate. A Care Plan dated, 2/8/2024, indicated the code status was no resuscitate. During an interview on 5/2/2024 1:06 P.M., LPN 4 indicated should Resident B's heart stop beating, or she stopped breathing, she would keep Resident B comfortable and follow her advanced directives. LPN 4 indicated Resident B had a do not resuscitate order. A policy was provided by the Director of Nursing on, 5/3/2024 at 8:02 A.M. The policy titled, Advanced Directives, indicated, .[company name] will honor all advanced care planning decisions in accordance with the resident and/or representative wishes .5 .If the resident's preference changes, the medical record documentation will reflect this change This citation relates to Complaint IN00431936. 3.1-4(f)(4)(A)(ii) 3.1-4(f)(5)

Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) assistance related to shaving and nail care, for 1 of 2 residents reviewed for activities of daily living. (Resident 234) Finding includes: During an observation on 4/29/2024 at 10:01 A.M., Resident 234 was observed to have long facial hair and long fingernails with a brown/black substance underneath them. Resident 234 indicated he did not normally have a beard, and preferred to not have a beard. He indicated his wife had requested for him to be shaved. During an observation on 5/1/2024 at 10:52 A.M., Resident 234 was observed to not have the longer beard hair, but still had significant stubble on his face. Resident 234 indicated his wife shaved him yesterday. Resident E continued to have long fingernails with the black/brown substance under the nails. A record review for Resident 234 was completed on 5/1/2024 at 12:49 P.M. Diagnoses included, but were not limited to: urinary tract infection, sepsis, quadriplegia, and diabetes mellitus type 2. An Admission Minimum Data Set (MDS) assessment dated , 4/24/2024, indicated Resident 234 had moderate cognitive impairment with impairment on both the upper and lower extremities. He required partial to moderate assistance for grooming and personal hygiene. The CNA documentation of showers in the electronic health record, dated 4/19/2024-5/1/2024, indicated Resident 234 received showers on 4/21/2024, 4/25/2024, and 4/29/2025. A Care Plan for late loss activities of daily living, dated 4/21/2024, indicated Resident 234 needed maximum assistance with dressing, grooming, and bathing. During an observation on 5/2/2024 at 10:36 A.M., Resident 234's fingernails remained long with black/brown debris under the nails and longer beard stubble. During an interview on 5/2/2024 at 1:13 P.M., CNA 6 indicated male residents were shaved on their scheduled shower days or when the resident requested to be shaved, and nails were evaluated for trimming on shower days. CNA 6 indicated the staff used shower sheets which indicated if shaving and nail care was provided, or a refusal occurred. The Shower Sheets were reviewed on 5/2/2024 at 2:06 P.M. Two shower sheets for Resident 234 were provided. On 4/21/2024, the shower sheet indicated Resident 234 was shaved and nail care was provided. The shower sheet on 4/25/2024 indicated no documentation of shaving or nail care. During an interview on 5/2/2024 at 2:29 P.M., LPN 3 indicated CNAs cannot trim the nails of diabetic residents. She indicated nails were evaluated when the resident was assessed daily, or when the resident was showered, the CNA would inform the nurses of the need for the nails to be trimmed. A policy was provided by the Director of Nursing on, 5/3/2024 at 8:02 A.M. The policy titled, Morning Care, indicated, .To cleanse and refresh resident, while stimulating circulation and providing comfort and preparing resident for the day .7. Remind or assist male residents to shave A policy was provided by the Director of Nursing on, 5/3/2024 at 8:02 A.M. The policy titled, Diabetic Nail Care, indicated, .1. Purpose: To promote cleanliness, prevent infection and skin irritation, and to promote a positive self image. To assure that each resident will have a weekly inspection of nails at the time of shower and/or complete bed bath and as needed 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)

Based on observation, record review, and interview, the facility failed to provide care for a central venous catheter (a long, flexible tube inserted into a large vein that leads to the heart) for 1 of 3 residents reviewed for antibiotics (Resident 234) and failed to follow physician orders for 1 of 2 residents reviewed for skin conditions non-pressure related. (Resident 236) Findings include: 1. During an observation on, 4/29/2024 at 10:01 A.M., Resident 234's central venous catheter to the right chest had a transparent dressing dated 4/19. A record review was completed on 5/1/2024 at 12:49 P.M. Diagnoses included, but were not limited to: urinary tract infection, sepsis, quadriplegia, and diabetes mellitus type 2. An Admission Minimum Data Set (MDS) assessment, dated 4/24/2024, indicated Resident 234 had intravenous access with medications administered. A Physician Order dated, 4/25/2024, indicated to change the transparent dressing to the intravenous line every 7 days and as needed if soiled or loose. A Care Plan dated 4/19/2024, indicated Resident 234 had an intravenous infusion with the potential of infection to the central line site in the right chest. On 5/2/2024 at 10:38 A.M., Resident 234's central venous catheter continued to be dated 4/19, and the transparent dressing was not adhered to the skin in the 6 o'clock position. During an interview on, 5/2/2024 at 2:30 P.M., LPN 3 indicated the central venous catheter dressing was to be changed every 7 days. She indicated the Treatment Administration Record (TAR) had been signed by the nurse on 4/25/2024 as being completed, but the facility didn't have a new bio-patch (a dressing that surrounds the central venous catheter entrance to prevent infection) in house to replace the current bio-patch when the dressing change was to be completed, so the dressing was not changed. During an observation with LPN 3 on, 5/2/2024 at 2:31 P.M., LPN 3 observed Resident 234's central venous catheter dressing and indicated the dressing was dated 4/19, and was not adhered to the skin in the 6 o'clock position. A policy was provided on, 5/3/2024 at 8:02 A.M. by the Director of Nursing. The policy titled, VADs: [Vascular Access Devices] Ongoing Assessment, Site Care, and Dressing Changes was dated, 10/2/2017. The policy indicated, .Central vascular device and Midline catheter site care and dressing changes are performed every 7 days and when the integrity of the dressing is compromised, if moisture, drainage, or blood is present, or for further assessment if site infection or inflammation is suspected 2. A record review for Resident 236 was completed on 5/1/2024 at 9:37 A.M. Diagnoses included, but were not limited to: cellulitis of right and left lower limb, chronic venous hypertension with ulcer and inflammation of bilateral lower extremity, peripheral vascular disease, and lymphedema. Physician Orders, dated 4/25/2024, indicated to apply single tubigrip (an elasticated tubular bandage that provides support and reduces swelling) to left lower extremity daily, on in the morning and off in the evening for wound care and lymphedema. During an observation on 5/1/2024 at 10:51 A.M., Resident 236's right lower extremity was wrapped with a compression wrap, and the left lower extremity was bare, and appeared very swollen and tight in appearance. During an observation on 5/2/2024 at 9:45 A.M., and 10:40 A.M., Resident 236's right lower extremity was wrapped with a compression wrap, and the left lower extremity was bare. The compression wrap to the right lower extremity was to remain intact. An Outpatient/emergency room Services Return Assessment on 4/25/2024 at 4:00 P.M., indicated Resident 236 had an appointment at the wound clinic. The assessment indicated the lymphedema had improved from the prior week, and to start the single tubigrip to the left lower extremity on the morning and off in the evening. During an interview on 5/2/2024 at 2:40 P.M., RN 5 indicated Resident 236's right lower extremity was wrapped, and those wraps were not removed. The left lower extremity had a single tubigrip placed in the morning and removed in the evening. During an observation with RN 5 on 5/2/2024 2:42 P.M., RN 5 indicated the tubigrip was on the left lower extremity. RN 5 indicated maybe the staff thought it was evening and removed the tubigrip. Resident 236 interjected and indicated the tubigrip had not been placed all day. A policy was provided by the Director of Nursing on, 5/3/2024 at 8:02 A.M. The policy titled, New Order Transcription, indicated, .It is the policy of [facility name] to ensure that physician orders are transcribed and maintained in a manner that ensures safety upon administration 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment/tubing was properly stored when not in use and cleaned, for 2 of 4 residents reviewed for respiratory care. (Residents 46 & 62) Findings include: 1. During an observation and interview on 4/29/2024 at 9:50 A.M., Resident 42 indicated he slept in his recliner, so the continuous positive airway pressure (CPAP) machine was on top of his bed. The tubing and mask were on top of the machine uncovered. The staff had not cleaned the mask or the tubing for the past 3 months. During an observation on 4/30/2024 at 9:42 A.M., the mask and tubing were lying on the bed not covered. During an observation and interview on 5/1/2024 at 2:30 P.M., he indicated no one had cleaned his CPAP tubing or mask yesterday, it was sitting on his bed uncovered. A record review was completed for Resident 42, on 5/1/2024 at 2:16 P.M. Diagnoses included, but were not limited to: Parkinson's Disease with dyskinesia, and obstructive sleep apnea. A Physician's Order, dated 3/31/2023, indicated to disinfect tubing, mask and humidifier basin by soaking for 30 minutes in 1 part white vinegar and 4 parts water and air dry monthly, every day shift, on the last day of the month. The Treatment Administration Record (TAR), dated 4/1/2024 to 4/30/2024, indicated on 4/30/2024 during day shift the task was signed as completed. During an interview on 5/2/2024 at 8:54 A.M., QMA 7 indicated she had never washed any type of respiratory equipment, the nurses do it. She worked on 4/30/2024 with LPN 8 and LPN 8 would have cleaned the equipment for Resident 42. During an interview on 5/2/2024 at 8:59 A.M., LPN 7 indicated when she worked with a QMA, she would do the insulin injections, G-tube feedings, breathing treatments, assessments for pain, treatments for open areas, and contact the physician. She did not clean the CPAP equipment for Resident 42 on 4/30/2024. 2. During an observation on 4/29/2024 at 11:26 A.M., Resident 62's nebulizer machine was on the bed with the mask/tubing sitting on the machine uncovered. During an observation on 4/30/2024 at 9:06 A.M., the nebulizer machine was on Resident 62's bed with mask/tubing sitting on the machine uncovered. During an observation and interview on 5/2/2024 at 9:47 A.M., Resident 62 indicated she did the breathing treatments 4 times a day, the staff rinsed the equipment out once every other day. She had never had a bag for the mask before, but yesterday the nurse washed it out and said it needed to be in a plastic bag after she used it. A record review was completed for Resident 62 on 4/30/2024 at 2:33 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease with exacerbation, chronic respiratory disease with hypoxia, and bronchitis. During an interview on 5/2/2024 at 10:29 A.M., RN 2 indicated after a breathing treatment was completed, she assessed the resident, then wiped the mask with a wet wash cloth, dried it and placed it in a bag, then washed the resident's face. During an interview on 5/2/2024 at 10:36 A.M., LPN 8 indicated after a breathing treatment, she would reassess the resident, listened to the lungs, and the door needed to be shut for an hour. During an interview on 5/2/2024 at 2:58 P.M., the DON indicated she would assess the patient then clean the equipment with soap and water, let it air day and place in a plastic bag. The CPAP is cleaned with vinegar and water weekly. On 5/3/2024 at 8:02 A.M., the DON provided a policy titled, CPAP'/BiPAP. dated 4/4/2024, and indicated the policy was the one currently used by the facility. The policy indicated, .6. Circuits are to be cleaned every week and PRN with sterile water and soap. Hang to dry. Disinfect monthly by soaking for 30 minutes in 1 part white vinegar to 4 parts sterile water. Hang to dry . On 5/3/2024 at 8:02 A.M., the DON provided a policy titled, High Mist Nebulizer or Oxygen Tank, dated 8/23/2012, and indicated the policy was the one currently used by the facility. The policy indicated . 20. If desired, have the resident rinse mouth with tap water after using nebulizer. Place the nebulizer set into a plastic bag between uses. Do not rinse. Neb set is changed weekly per facility schedule . 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure pharmacy recommendations were given to the physician for review, for 1 of 7 residents reviewed for unnecessary medications. (Resident 47) Finding includes: A record review for Resident 47 was completed on 5/1/24 at 3:17 P.M. Diagnoses included, but were not limited to: overactive bladder, allergies and insomnia. A Quarterly Minimum Data Set (MDS) assessment, dated 2/21/24, indicated the resident had intact cognition. Physician's Orders, dated 4/30/24, indicated the following: Loratidine (used for allergies) 10mg daily. Myrbetriq (used for urinary urgency/frequency) 50mg daily. Melatonin (used for insomnia) 6mg at bedtime. A Pharmacy Recommendation, dated 2/14/24, indicated Loratadine 10mg to be reduced to every other day. The recommendation lacked documentation it was acted upon in a timely manner. A Pharmacy Recommendation, dated 3/13/24, indicated Myrbetriq 50mg to be reduced to 25mg daily. The recommendation lacked documentation it was acted upon in a timely manner. A Pharmacy Recommendation, dated 3/13/24, indicated Melatonin 6mg to be reduced to 5mg at bedtime. The recommendation lacked documentation it was acted upon in a timely manner. During an interview on 5/2/24 at 11:24 A.M., the Director of Nursing (DON) indicated the new pharmacy representative for the facility was sending communication through a different portal and she was not aware, so she did not complete the recommendations in a timely manner. On 5/2/24 at 3:20 P.M., the DON provided the policy titled, Response to Pharmacist Recommendations, dated 4/11/17, and indicated the policy was the one currently used by the facility. The policy indicated .3. DON or designee will monitor for physician response and will re-submit to practitioner within 7 days .4. If after resending there is no response within 72 hours, the DON or designee will telephone the physician for verification the physician has reviewed the recommendation and for any new orders 3.1-48(a)(3)

Based on observation and interview, the facility failed to ensure medications were kept in a locked cart when unattended for a random observation of 1 of 3 facility medication carts. (Windsor Hall cart) Finding includes: On 5/2/24 at 10:48 A.M., the medication cart for Windsor Hall was observed with the keys in the drawer and with no licensed nursing staff within sight of the cart. The nurse left the medication cart at 10:48 A.M. and returned to the cart at 10:56 A.M. During an interview on 5/2/24 at 10:57 A.M., RN 2 indicated she heard a staff member call for help and she left the cart without taking the keys out of the lock. She was not to leave her cart unattended while unlocked and should have taken the cart keys with her. During an interview on 5/2/24 at 3:25 P.M., the Director of Nursing (DON) indicated the employee should have locked the cart and taken the keys with her, they are not to be left in the medication cart. On 5/3/24 at 8:00 A.M., The DON provided the policy titled, Storage of Medications, dated 4/24/19, and indicated the policy was the one currently used by the facility. The policy indicated Medications and biological's are stored safely, securely, and properly, following manufacturers recommendations or those of supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications 3.1-25(m)

Based on record review and interview, the facility failed to ensure residents fund statements were sent out timely for 21 of 21 residents with a personal funds account at the facility. Finding includes: During an interview, on 3/3/2023 at 1:43 P.M., Business office staff 6 indicated resident statements were sent out every 6 months. During an interview on, 3/320/23 at 3:07 P.M., the Administrator indicated the business office staff had only worked a year and was not aware that the statements should have been sent out quarterly and not every 6 months. On 3/6/2023 at 4:10 P.M., the Administrator provided the policy titled, Resident Fund Procedures with PCC, undated, and indicated the policy was the one currently used by the facility. The policy indicated . 21. Send quarterly statements of account activity to the resident and /or responsible party and have them return with proper signature. These statements should be mailed within 30 days of the end of the quarter 3.1-6(g)

Based on record review and interview, the facility failed to ensure residents are able to withdrawal their money during the evening hours Monday through Thursday for 1 of 21 residents reviewed for personal funds. (Resident 36) Finding includes: During an interview, on 3/01/2023 at 10:49 A.M., Resident 36 indicated she could not get her money at any time. A clinical record review was completed on, 3/6/2023 at 10:39 A.M. Resident 36's diagnoses included, but were not limited to: anemia, diabetes, anxiety, and depression. An Annual MDS (Minimum Data Set) Assessment, dated 12/14/2022, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 15, cognition intact. During an interview, on 3/3/2023 at 1:43 P.M., business office staff 6 indicated the residents could get money on Monday through Friday from 8:00 A.M. to 4:30 P.M., and all hours on the weekends. Business office staff 6 indicated the nurse on the rehab unit would be given the cash bag on Friday afternoon until Monday morning when the bag would be reconciled then given back to the receptionist. During an interview, on 3/3/2023 at 3:07 P.M., the Administrator indicated the residents should be able to get their money during the evenings also. On 3/6/2023 at 4:10 P.M., the Administrator provided the policy titled,Resident Fund Procedures with PCC, undated, and indicated the policy was the one currently used by the facility. The policy indicated . 4. Funds should be readily available for residents. It is suggested that at the time of admission, the family and /or the resident be advised of the business office hours. 03/25/11 Petty Cash is available to residents as they request it even on weekends.9. A minimum balance of $50.00 should be kept in the resident fund petty cash box at all times. Federal and State laws require that we be able to supply a resident with $50.00 cash upon demand 3.1-6(f)(1)

Based on record review and interview, the facility failed to prevent verbal abuse to 1 of 2 resident reviewed for abuse. (Resident 176) Finding includes: On 3/02/2023 at 8:02 A.M., the Administrator indicated there was an allegation of abuse. It was between the night nurse and Resident 176. She provided a copy of the reportable that was submitted on 3/2/2023. The reportable indicated: Incident Time: 11:35 P.M. Brief Description of Incident: Other nurse on the unit overheard LPN 8 call resident 176 an a-- h---. No injury noted to the resident. Immediate Action Taken: LPN 8 left residents room as she made the a-- h--- comment. CNA 9 went into the residents' room to checked on resident. Resident 176 indicated he was alright and that he had a rough day and apologized for having also called LPN 8 an a--h--- and wanted to apologize to her. CNA 9 told Resident 176 he could speak to LPN 8 shortly, she wanted to give the nurse time to cool off from the situation. Preventative Measures Taken: Other Nurse on the unit called the Director of Nursing, who then called the Administrator to alert of the incident. The Director of Nursing and the Administrator arrived at the building and interviewed LPN 8. LPN 8 was then sent home from her shift pending investigation. The NP (Nurse Practitioner) also notified of event. A clinical record review was completed on, 3/3/2023 at 5:30 A.M. Resident 176's diagnoses included, but were not limited to, obesity, end stage renal disease, diabetes, respiratory failure, congestive heart failure and anxiety. A 5 day MDS (Minimum Data Set) Assessment, dated 2/25/2023, indicated the resident had a BIMS (Brief Interview of Mental Status) score of 15, cognition intact, had no mood issues or behaviors. The Follow up report, dated 3/6/2023, indicated: Investigation of the occurrence, from 3/1/2023, revealed that Resident 176 was disgruntled when the LPN 8 indicated that he had a fluid restriction and that was why there was no water pitcher at his bedside. LPN 8 provided education on fluid restriction and provided the resident with a cup of water. Resident 176 continued to express his desire to have a water pitcher and LPN 8 confirmed as she was exiting the residents' room, she mumbled a-- h---. Resident 176 was interviewed and indicated that he yelled at the nurse over not having a water pitcher at bedside, and that LPN 8 did call him an a-- h---. Other residents on the unit were interviewed and voiced no concerns of care or verbal exchanges with staff, specifically LPN 8. Following suspension and investigation of the occurrence, LPN 8 was terminated. During an interview, on 3/7/2023 at 9:35 A.M., the Administrator indicated the resident was not free from abuse by what the staff nurse had said to the resident. On 3/2/2023 at 11:50 A.M., the Administrator provided the policy titled,Abuse Prohibition, Reporting, and Investigation, dated 12/4/2017, and indicated the policy was the one currently used by the facility. The policy indicated . Policy: .all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion . C. Verbal Abuse- The use of oral, written and/or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. I. Staff to Resident -any episode . Investigating and Reporting To Correct Authority .11. Any staff member implicated in the alleged abuse will be removed from the facility at once and will remain suspended until the investigation is completed 3.1-27(b)

Based on record review and interview, the facility failed to report to state agencies an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident 34) Finding includes: During an interview, on 3/01/2023 at 9:59 A.M., Resident 34 indicated about a month ago a nurse on evenings yelled at her. On 3/2/2023 at 9:00 A.M., the Administrator provided a concern report for Resident 34, dated 2/14/2023. The concern report indicated the resident had reported to the Director of Nursing about the nurse telling her to get back to her room and she would come later to give her the medications. The concern report indicated the nurse was heard telling the resident to go back to her room and was not demeaning in any way. The Administrator interviewed 4 other residents on the unit and had no negative responses. The Staff member was educated. A clinical record review was completed on, 3/3/2023 at 2:27 P.M. Resident 34's diagnoses included, but were not limited to: renal failure, diabetes, and depression. A Quarterly MDS (Minimum Data Set) Assessment, dated 2/15/2023, indicated the resident had a BIMS (Brief Interview of Mental Status) score of 15, cognition intact and had no behaviors. During an interview, on 3/2/2023 at 3:53 P.M., the Administrator indicated she did not report the concern to the state. She stated they determined that the nurse was not willful in her response to the residents request and the resident did not have any emotional outcome and the resident did not allege any abuse of any kind. On 3/2/2023 at 11:50 A.M., the Administrator provided the policy titled,Abuse Prohibition, Reporting, and Investigation, dated 12/4/2017, and indicated the policy was the one currently used by the facility. The policy indicated . 3 . {Name of Facility} has policies and procedures in place that ensures that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) . Investigating and Reporting to Correct Authority: 1. All reports of alleged abuse/abuse and all unusual occurrences, must be reported to the Administrator immediately . 2. Violations of the aforementioned will be reported to the Long Term Care Division of the Indiana State Department of Health and other officials in accordance with state law through established procedures as outlined in the Incident Reporting to the ISDH procedure 3.1-28(c)

Based on observation, clinical record review, and interview, the facility failed to develop a person-centered care plan for 1 of 25 residents reviewed. (Resident 19) Finding includes: During an interview on 3/6/2023 at 11:04 A.M., LPN 3 indicated Resident 19 had a skin tear on her left outer arm but could not find the skin tear on the care plan. LPN 3 indicated that current skin issues should be on the care plan. During a clinical record review conducted on 3/3/2023 at 2:13 P.M., a Significant Change MDS (Minimum Data Set) Assessment for Resident 19, dated 12/14/2022, included, but was not limited to, a BIMS (Brief Interview for Mental Status) of 3, severe impairment and no behaviors. She required limited assist of 1 staff person for bed mobility, extensive assist of 2 staff persons for transfers and toileting, and extensive assist of 1 staff person for dressing. Skin condition indicated skin tears present. Diagnoses for Resident 19 included, but were not limited to: unspecified dementia with other behavioral disturbances. Physician orders for Resident 19 included, but were not limited to: on 2/3/2023 cleanse area on left outer arm with soap and water apply ABD pad cover the site of concern with dressing and wrap with kerlix. On 2/8/2023 geri-sleeves to both upper extremities at all times to prevent further skin tears and abrasions. A care plan for Resident 19, dated 1/2/2023, included, but was not limited to: a problem for chronic bruises and skin tears. Interventions included, but not limited to, apply geri-legs, apply geri-sleeves, apply lotion to skin as needed, keep fingernails trimmed and filed, and be aware that resident picks at geri-sleeves as well as skin at times. A policy provided by the Executive Director on 3/6/2023 at 4:10 P.M., included, but was not limited to: .Care plans will be revised daily and as needed as changes in the resident's condition dictate. Changes include but are not limited to, changes in physician orders, diet changes, therapy changes, behavior changes, ADL (Activities of Daily Living) changes, skin changes etc 3.1-35(d)(1)(2)(A)

Based on record review and interview, the facility failed to follow physicians orders for fluid restriction for 1 of 1 resident receiving dialysis. (Resident 176) Finding includes: During an interview, on 3/1/2023 at 9:16 A.M., Resident 176 indicated he received dialysis three times a week on Monday, Wednesday and Friday and was on a fluid restriction. A clinical record review was completed, on 3/3/2023 at 5:30 AM. Resident 176's diagnoses included, but were not limited to: obesity, end stage renal disease, diabetes, respiratory failure, congestive heart failure and anxiety. Resident 176'2 current Physician Orders included: 2000 cc fluid restriction ordered on 2/22/2023, carbohydrate controlled diet, daily weights after voiding (urination) and before breakfast/medications with the same clothes each day every evening shift on Monday, Wednesday and Friday, and Notify the physician of a 2 Lb. gain in 1 day and 4 Lb. gain in 5 days. A current care plan, dated 3/1/2023, indicated the resident had the potential for alteration in fluid balance related to: end stage renal disease, congestive heart failure, and often drinks more fluids beyond the ordered restricted amount of 2000 daily. Interventions included, but were not limited to fluid restriction as ordered. A Nutritional Risk Assessment, dated 3/1/2023, indicated Resident 176 was at nutritional risk related to: recent hospitalization , diagnosis of End Stage Renal Disease with dialysis, diabetes, congestive heart failure, and fluid restriction. Monitor weights and intakes. Provide fluid restriction of ml (milliliters). Nursing to provide 920 ml's and dietary 1080 ml's. A Physician's Order, dated 3/1/2023, indicated the resident was allowed 300 cc fluids per shift from nursing. The Fluid Intakes, dated from 2/22/2023 to 3/6/2023, indicated Resident 176 had received the following extra fluids from the aides: 2/23/2023 a total of 1840 ml. 2/24/2023 a total of 1580 ml. 2/25/2023 a total of 2040 ml. 2/26/2023 a total of 1990 ml. 2/27/2023 a total of 1840 ml. 2/28/2023 a total of 2170 ml. 3/2/2023 a total of 2020 ml. 3/3/2023 a total of 1380 ml. 3/4/2023 a total of 2020 ml. 3/5/2023 a total of 2030 ml. 3/6/2023 a total of 1500 ml. During an interview, on 3/6/2023 at 1:54 P.M., the Director of Nursing indicated the aides should not have given him more fluids. On 3/ 7/2023 at 9:36 A.M., the Social Service staff provided the policy titled, Nursing Fluid Restriction Procedure, dated 3/13/2012. The policy indicated .Purpose: To plan and schedule fluid amounts to be offered to any resident on a fluid restriction in an effort to follow the prescribed order.4. Place amount of fluids in ml/cc to be given with each meal on the Medication Administration Record so all nurses are aware of the amount allotted at each meal . 7. Indicate the allotted fluid amounts and times on the nurse aide assignment sheet. 8. Resident should not be provided with a water pitcher or be given water when passes unless a part of the fluid restriction plan of care 3.1-37(a)

Based on record review and interview, the facility failed to provide a routine ordered medication for 1 of 9 residents whose medications were reviewed. (Resident 18) Finding includes: During an interview, on 3/01/2023 at 9:40 A.M., Resident 18 indicated she had been without the inhaler for awhile they said I used it too much. A clinical record review was completed on, 3/7/2023 at 10:00 A.M. Resident 18's diagnoses included, but were not limited to:+ diabetes, depression, chronic obstructive pulmonary disease, respiratory failure and dementia. A Quarterly MDS (Minimum Data Set) Assessment, dated 12/7/2022, indicated the resident BIMS (Brief Interview for Mental Status) score of 14, cognition intact and received oxygen. The January MAR (Medication Administration Record) indicated Resident 18 had an order for Breo Ellipta aerosol powder inhaler 1 puff inhale orally one time a day COPD (chronic obstructive pulmonary disease) with a start date of 2/7/2022 and a discontinued date of 1/30/2023. The MAR was coded as a 3 (hold see progress notes) on 1/27, 1/28, 1/29 and 1/30/2023 for the Breo inhaler. A Progress Note, dated 1/27/2023 at 10:08 A.M., indicated the Breo Ellipta Aerosol Powder inhaler was not available, called pharmacy will provide on the 24 th. A Progress Note, dated 1/28/2023 at 8:53 A.M., indicated the Breo Ellipta Aerosol Powder inhaler was not available, NP notified. A Progress Note, dated 1/29/2023 at 8:21 A.M., indicated the Breo Ellipta Aerosol Powder inhaler was not available, NP aware. A Progress Note, dated 1/30/2023 7:06 A.M., indicated the inhaler was unavailable, insurance to refill on 2/14/2023. A Physician's Order, dated 1/30/2023 at 3:41 A.M., indicated to give Resident 18 Torsemide (diuretic) 20 mg STAT (immediately) for COPD exacerbation. A NP (Nurse Practitioner) Progress Note, dated 1/30/2023, indicated the resident was seen by the NP and new orders included; stop the Breo inhaler; start Anoro inhaler 1 puff daily for COPD; and Prednisone (steroid/anti inflammatory) 40 mg (milligrams) one time a day for COPD exacerbation (acute increase) for 3 days starting on 1/30/2023. A current care plan, dated 7/30/2021, indicated the resident had chronic respiratory disease, and had the potential for exacerbation of: COPD, chronic respiratory failure. Interventions included, but were not limited to: administer medications as ordered and monitor vital signs at least weekly. During an interview, on 3/7/2023 at 3:05 P.M., the Director of Nursing indicated there was an issue with the inhaler due to a prior authorization was needed. The NP knew about it and was working on it, so she started a new inhaler for the resident. The Director of Nursing indicated that the nurses did not chart in the nurses notes about not having the medication and or the fact that it needed a prior authorization. She also indicated the nurses did not inform or call the NP about the inhaler not available or to get another medication out of the emergency drug kit (Pyxis). On 3/7/2023 at 3:45 P.M., the Director of Nursing provided the policy titled,Use of the PYXIS Specialty Station dated 11/3 2022. The policy indicated . Other Information: 1. Medications needed, but not available in the Pyxis machine, contact the pharmacy for delivery arrangements 3.1-25(a) 3.1-25(g)(2) 3.1-25(g)(3)

Based on record review and interview, the facility failed to ensure a narcotic pain medication for 2 reisdents was administered as ordered and not taken by a staff member. (Resident resident's narcotic medication card and log sheet was not taken from the facility, for 1 of 3 medication carts reviewed. (Resident F and G) Finding includes: A self reported incident, dated 5/28/2022 indicated durinng a routine medication administration record audit, the facility discovered two residents, who received routine narctoric pain medication (Resident F and G) ,had missed two doses each . An investigation was initiated and it was revealed a staff member (QMA 1) had taken the narcotic medication for herself. The Employee (QMA 1) was terminated and the following persons were notified: the Medical doctor, the resident's responsible party and law enforcement. During an interview, on 6/15/2022 at 2:00 P.M., with the Corporate Nurse Consultant, she indicated on 5/26/2022, an audit of medication administration records revealed QMA 1 has signed out the routine narcotics for Resident F and G for 2 consecutive days, but did not sign the Medication Administration Record to indicate the medicaitons were administered. In addition, the QMA was not assigned to the dementia unit, where Resident F and G resided. On 5/26/2022, the Administrator and Director of Nursing had a meeting with QMA 1 and when questioned about the discrepencies in the charting, QMA 1 admitted to taking the medication for herself. The Corporate Nurse consultant indicated the employee was immediately terminated, a whole house audit regarding medicaiton administration records was completed, all required notifications were made and all nursing staff with access to medications were inserviced immediately regarding the facility's abuse policy and procedure, which included misappropriation of resident property and the process for documenting and safe guarding narctoric medicaitons. There were no other residents noted to have discrepencies with their medicaiton administration records. Review of the facility's policy and procedure, titled, Abuse Prohibition, Reporting and Investigation, provided by the Administrator on 6/15/2022 at 3:00 P.M., included the following: .2. (Name of Corporation) has policies and procedures in place that prohibit mistreatment, neglect and babuse of resient and misappropriation of resident property 5. Misappropriation of resident funds or property - Deliberate misplacemtn, expoitation or wrongful, temporary or permanent use of a resident's property or money without the resident's consent This Federal tag relates to complaint IN 367.

Based on observation, interview and record review, the facility failed to have appropriate interventions related to pressure area prevention, for 1 of 3 residents reviewed for pressure ulcers, resulting in the development of three deep tissue injuries. (Resident 1) Finding includes: A clinical record review was completed, on 1/31/2020 at 3:00 P.M., and indicated Resident 1's [DIAGNOSES REDACTED]. A MDS(Minimum Data Set) assessment, dated 10/28/2019, indicated Resident 1 was totally dependent for bed mobility, transfers, toilet use and personal hygiene. A SKIN RISK care plan, dated 1/5/2017, last reviewed on 1/27/2020, indicated the following: Assist to toilet &/or check and change frequently, Monitor labs as available, Monitor skin daily during care, Notify physician and family of any change in skin integrity, Provide pericare as needed, Provide pressure reducing device to bed, Remind or assist to turn at least every 2 hours, See nutritional plan of care and Skin assessment at least weekly by nurse, however no interventions related to pressure ulcers on the feet were listed. A form, titled Nursing-Weekly Assessment, dated 1/8/2020, indicated Resident 1 received a skin assessment and no skin concerns were noted. An Occupational Therapy Plan Of Care, dated 1/9/2020, indicated .The patient will achieve postural alignment and optimal positioning in wheelchair in order to reduce pressure areas and reduce risk for skin breakdown and .Patient exhibits poor positioning while utilizing a standard w/c (wheelchair) with extending leg rests, foot buddy, and wedge supporting B(bilateral) LEs(lower extremities) d/t (due to) increased extension of B knees and ankles and increased hip width A form, titled Nursing-New Skin Alteration Assessment, dated 1/15/2020, indicated Resident 1 had a new wound. The form indicated .top in middle right foot on bottom pressure area dark 3 cm(centimeter) x 2 cm bottom middle right foot pressure area 2cm x 1cm dark around edges with cream color in center bottom top of right foot scar area 0.5x0.1 cm bottom of left foot brown edge with cream color in middle measures 4cm x 1CM peri(area around wound) wound blanchable(color returns when depression is off) A form, titled Wound: Pressure Injury Assess w/Braden, dated 1/28/2020, indicated Resident 1 had a deep tissue pressure injury to her left plantar foot, measuring 2.9 cm x 2.9 cm, .dark purple discoloration to center with dark brown edges A form, titled Wound: Pressure Injury Assess w/Braden, dated 1/28/2020, indicated Resident 1 had a deep tissue pressure injury to her right plantar foot, measuring 0.4 cm x 0.5 cm, .dark purple discoloration A form, titled Wound: Pressure Injury Assess w/Braden, dated 1/28/2020, indicated Resident 1 had a deep tissue pressure injury to her right plantar foot, measuring 1.6 cm x 1.9 cm, .flesh toned center with dark purple During an observation, on 1/31/2020 at 3:30 P.M., Resident 1 was observed to have a quarter sized dark brown area and a nickel sized dark brown area to the bottom of her right foot. She was observed to have a dark brown area to the bottom of her left foot the size of a silver dollar. During an interview, on 1/31/2020 at 3:30 P.M., the facility wound nurse indicated Resident had two areas to the bottom of her right foot and one area to the bottom of her left foot, both dark brown in color and with a hardened surface. The wound nurse indicated Resident 1 had developed these deep tissue injuries a couple of weeks ago from her wheelchair pedels related to not holding her feet like she used to because her body was rigid. During an interview, on 1/31/2020 at 4:06 P.M., the Director of Nursing indicated Resident 1 experienced a change in the way she was positioning her feet in her wheelchair and that was the reason she was referred to therapy. During an interview, on 1/31/2020 at 5:00 P.M., the DON indicated there were no interventions placed related to protecting the skin integrity of Resident 1's feet following the positioning notification, prior to 1/15/2020. A policy was provided by the DON(Director of Nursing), on 1/31/2020 at 5:15 P.M., titled Skin Management Program, dated 8/14/2014, and indicated this was the policy currently used by the facility. The policy indicated .Interventions will be implemented according to the individual residents risk factors that will best reduce the risk of development of pressure, diabetic ulcers, arterial or venous ulcers and/or promote the most effective healing of existing areas and .The plan of care will be updated with all changes to treatments or other interventions as they occur 3.1-40(a)(1)

Based on on observation, record review and interview, the facility failed to complete weekly skin assessments, accurately identified pressure areas, notified the physician and provided appropriate treatments resulting in an unstageable pressure ulcer to buttocks requiring oral antibiotics for symptoms of infection (Resident 6), an unstageable pressure ulcer to to right heel (Resident 74 & 32) and a Stage 2 pressure ulcer to buttocks (Resident 19) in 4 of 8 residents reviewed for pressure ulcers. Findings include: 1. During a interview, on 2/5/19 at 2:50 P.M., Resident 6 indicated she had a sore on buttocks that caused her pain that she rated at an 8 on a scale of 0-10 with 10 being the worst pain. During an observation, on 2/5/19 at 2:50 P.M., Resident 6 was observed laying on a low air mattress with the setting set in Fowler's position and low air loss was not on. During an interview, on 2/5/18 at 3:00 P.M., the UM (Unit Manager) indicated she was not aware of the settings on the low air loss mattress and was unable to explain what Fowler's position setting was for. The clinical record for Resident 6 was reviewed on 2/6/19 at 2:27 P.M. The [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 11/26/18, indicated Resident 6 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact, and did not have any pressure areas. A care plan, dated 3/9/15, for potential for skin breakdown related to [MEDICAL CONDITION], decreased mobility and incontinence. The interventions included, but were not limited to, check and change every 2-3 hours, monitor skin daily during care, notify physician and family of any changes to skin integrity and skin assessment to be completed weekly by nurse. A Braden Scale, dated 9/10/18, indicated Resident at 6 was at skin for skin breakdown related to very limited sensory perception, constant moisture, chairfast, completely immobile, probably inadequate nutrition and a problem with friction and shear. A Non-Pressure Wound Assessment, dated 1/27/19 at 6:31 P.M., indicated Resident 6 had a traumatic injury wound to the left thigh, measuring 4.1 cm (centimeters) x 4 cm x UTD (unable to determine) with 75% firm tan slough and moderate amount to seroanguinous exudate that was first noted on 12/30/18. The treatment and notification section indicated Resident 6 had an abrasion from brief to area which developed into an open area. The sensicare had been discontinued and [MEDICATION NAME] and dry sterile dressing daily wound be applied. The wound progression was non-healing due to poor nutrition and decreased mobility due to [MEDICAL CONDITION]. There were no wound assessment available from 12/30/18 to 1/27/19. A Non-Pressure Wound Assessment, dated 2/6/19 at 3:10 A.M., indicated Resident 6 had a traumatic injury wound that was non healing to posterior left thigh, measuring 4 cm x 4 cm x 0.8 cm and the wound base was covered with 75% soft than slough with moderate amount of serosanguinous exudate. The treatment and notification section indicated had an abrasion from brief to area which developed into a boil then an open area. Order was to pack with MeSalt and cover with dry sterile dressing daily. NP was notified of changes. The wound progression was non-healing due to poor nutrition and decrease mobility related to [MEDICAL CONDITION]. There was no documentation or physician notification for when the abrasion turned into a boil. A care plan for abrasion, dated 2/6/19, indicated Resident 6 had an abrasion to inner left thigh from brief from 12/30/18. The interventions included to administer treatment as ordered, monitor for complaints of pain or discomfort and monitor for signs and symptoms of infection and notify physician as needed. There was no care plan available for the date when the abrasion from brief was first present. During an observation, on 2/6/19 at 1:30 P.M., Resident 6 was observed laying in bed on low air loss mattress with her head slightly elevated and the setting was in Fowler's position. During an interview, on 2/6/19 at 1:35 P.M., the UM indicated she was not aware of how to change the settings on the low air loss mattress. A Progress Note, dated 2/6/19 at 12:30 P.M., indicated the NP (Nurse Practitioner) had been in to observe left thigh with a boil that had opened despite interventions has not progressed towards healing. The area of eschar and dark slough, measured for depth and width per facility. The [DIAGNOSES REDACTED]. A Progress Note, dated 2/7/19 at 1:16 P.M., indicated the NP had been to assess wound to left thigh. Resident 6 reported pain to her left buttock, odor was noted to the wound per the NP. Resident 6 was started on [MEDICATION NAME] 300 mg (milligrams) every 8 hours for ten days for wound infection. During an observation, on 2/7/19 at 2:13 P.M., the wound to Resident 6's left inner thigh was visualized. The wound presented as an unstageable pressure area to left inner buttocks, size of golf ball, with dark brownish tan slough noted to wound base, red granulation and stringy green slough around wound edges. Resident 6's leg were observed in frog leg style position (bilateral hips opened with legs abducted) due to contractures, so that when in sitting positioning the pressure would have been right where the wound was located. During an interview, on 2/7/19 at 2:15 P.M., Resident 6 indicated she was having pain and drainage from wound. The wound indicated to Resident 6 that was being started on an antibiotic to treat her wound. During an interview, on 2/7/19 at 2:49 P.M., the Wound Nurse indicated she was not monitoring the wound from 12/30/18 because she thought it was just an abrasion from the brief. She indicated she was not made aware by the nursing staff and no new skin alteration sheets were started when the abrasion became a boil. She indicated the NP was not made aware of the change of condition of the left inner thigh wound. She indicated that the wound was now classified as a unstageable pressure ulcer caused by pressure. During an interview, on 2/8/19 at 9:58 A.M., Resident 6 indicated her pain to buttocks was an 8 and no pain medication had been given to her or offered. On 2/7/19 at 11:00 A.M., the DON (Director of Nursing) provided the Alternating Pressure Low Mattress User Manual, dated (YEAR), and indicated this was the manual for the bed that Resident 6 was currently in. The manual indicated the Static button maintains all air cushions in the mattress at a constant pressure, the Fowler mode increases pressure in the mattress to prevent resident from bottoming out when in a 45 degree angle and the low air loss mode the mattress goes into on-demand low air relief mode. On 2/7/19 at 11:00 A.M., the DON provided the Speciality Mattress Use policy, dated 4/2/13, and indicated this was the policy currently being used by the facility. The policy indicated the facility would obtain physician orders [REDACTED]. follow manufacturer's recommendations for settings: static mode, comfort settings and how to assess for bottoming out . staff will be inserviced on use at the time of implementation and then annually . include use of speciality mattress on the TAR (treatment administration record); check function each shift, check resident's comfort, static mode use, checking setting related to weight as applicable. (Refer to manufacturer's operations manual for further instruction on routine monitoring) . 2. During an interview, on 2/5/19 at 2:30 P.M., Resident 32 indicated she had developed an unstageable pressure ulcer to her right heel that was found by a friend while the resident was elevated up in the hoyer sling. The resident and her family member indicated the low air loss mattress was not placed on to the bed until after the pressure area to coccyx developed on 1/1/19. During an observation, on 2/5/19 at 2:30 P.M., Resident 32's pressure injury to right heel was noted to have dry, black eschar and appeared to be healing. The clinical record for Resident 32 was reviewed on 2/6/19 at 1:43 P.M. The [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) assessment, dated 12/24/18, indicated Resident 32 had a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact, and she currently had an unstageable pressure ulcer. A care plan, dated 11/2/18, for at risk for skin breakdown related to cervical spinal cord lesion/tumor and [MEDICAL CONDITION] had interventions that included, but were not limited to, float heels while in bed, monitor skin daily during care and skin assessment at least weekly by nurse. A Weekly Assessment, dated 11/8/18 at 3:35 P.M., indicated Resident 32 had +2 [MEDICAL CONDITION] (moderate) to bilateral lower extremities and no skin issues were noted. There were no other Weekly Assessments available from 11/8/18 to 12/7/18. A PT (Physical Therapy) Treatment Note, dated 11/23/18, indicated Resident 32 had voiced concern with increased lower extremity [MEDICAL CONDITION]. A Progress Note, dated 12/7/18 at 4:06 P.M., indicated the NP (Nurse Practitioner) had made an acute visit for right heel darkness and back of heel with deep purple area and was a deep tissue injury. A Pressure Injury Assessment with Braden, dated 12/11/18 at 12:27 P.M., indicated Resident 32 had a deep tissue pressure injury to right heel that originally noted on 12/7/18 and measured 5.4 cm (centimeters) x 4.8 cm x 0 cm. The Braden score was 17, mild risk for development of pressure ulcers. A Progress Note, dated 12/17/18 at 8:52 P.M., indicated Resident 32 was upset about her right heel pressure wound, that no one had told her the blister on her heel had popped open. A Progress Note, dated 12/19/18 at 9:48 A.M., indicated the NP had come in to see Resident 32 because she had concerns about her wound to the right heel, stating the wounds had to heal by (MONTH) in order to proceed with a spinal fusion. A OT (Occupational Therapy) Daily Treatment Note, dated 12/21/18, indicated Resident 32 was given a calf board to use while in wheelchair with legs elevated. If the calf board was appropriately positioned the resident's heels will float and will not touch foot rest or calf board. During an interview, on 2/8/19 at 11:17 A.M., Resident 32 indicated her heels were not floated in bed as care plan indicated, she indicated some staff did and some staff didn't. He did indicated that she did not always like to wear her boots to relieve pressure and no staff had offered a pillow to alleviate pressure. She indicated her Life coach was the one who found it when she was up the hoyer. During an interview, on 2/8/19 at 12:32 P.M., the DON (Director of Nursing) indicated the weekly skin assessments should have been completed and heels should have been elevated as ordered and educated and offered a pillow. She did indicate that the pressure area to right was found by friend while resident was up in hoyer lift. On 2/7/18 at 11:00 A.M., the DON provided the Alternating Pressure Low Mattress User Manual, dated (YEAR), and indicated this was the manual for the bed that Resident 6 was currently in. On 2/8/18 at 1:00 P.M., the DON provided the Skin Management Program policy, dated 8/4/14, and indicated this was the policy currently being used by the facility. The policy indicated its purpose was to assess for and reduce the risk factors that may contribute to the development of pressure ulcers . A comprehensive head to toe assessment (inspection) would be completed by a licensed nurse upon admission/return, and at least weekly thereafter . Residents who receive assistance with bathing and/or peri care would be observed daily by nursing staff and any notation of red areas, open areas, skin tears, bruises, rashes, excoriations or other alterations would be reported to the licensed nurse for further assessment. The wound nurse would follow up on all non-pressure wounds weekly and prn (as needed) and document in the EMR (electronic medical record) . 3. During an interview, on 2/5/19 at 2:14 P.M., Resident 19 indicated he had an open area to his bottom for a couple months now, and it wasn't getting any better. A clinical record review was completed on, 2/06/19 at 11:52 P.M., indicating Resident 19's current [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 12/10/18, indicated Resident 19 required extensive assist of 1 staff for bed mobility, transfers, walking, dressing, toilet use and supervision for eating. He was frequently incontinent of bladder and continent of bowels. A Nursing Admission form, dated 11/7/18, indicated Resident 19 was at risk for skin breakdown and was admitted with a wound potentially related to pressure, vascular insufficiency, diabetic [MEDICAL CONDITION] or severe burn. Reddened buttocks, scabbed area to right buttock, approximately 1 cm (centimeter) x 1 cm, skin intact with no drainage noted. A current care plan, dated 11/7/18, indicated Resident 19 was admitted with a wound that was potentially related to pressure, reddened buttocks with scabbed area to right buttock approx. 1 cm x 1 cm, skin intact. Interventions included, but were not limited to: administer treatment as ordered, follow interventions listed on Potential for skin breakdown problem, in addition. Monitor for complaints of pain or discomfort. A new skin alteration form, dated 1/23/19, indicated a. New skin alteration findings: 1. New wound potentially related to pressure, vascular insufficiency or diabetic [MEDICAL CONDITION]: need further assessment by wound nurse (if checked, B1 must be completed). B1-Description of new skin alterations: 1.4 cm (centimeters) X 1 cm superficial open area to left low buttock where brief rubs. Small amount of bloody drainage noted. Resident complained of soreness. No redness around open area. Sensicare applied. Offered to try other briefs, resident stated I don't want the other ones. Resident 19's clinical record lacked documentation to show the wound was assessed by the wound nurse. During an observation, on 2/08/19 at 10:38 A.M., Registered Nurse 4 measured a new pressure area noted to Resident 19's right buttocks and indicated the area to the left buttocks was healed, but the resident continues to have a scabbed area to the right lower buttocks. A current, 2/8/19, care plan indicated: I have developed actual pressure injury. Location: right inner buttock related to: Impaired/decreased mobility and decreased functional ability. Resident sleeps in recliner and uses wheel chair for mobility. During an interview, on 2/08/19 at 1:07 P.M., the Director of Nursing indicated the wound nurse should have assessed the area that was noted on 1/23/19. 4. A clinical record review was completed on 2/06/19 at 1:58 P.M., indicating Resident 74's current [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 1/22/19, indicated Resident 74 had a BIMS (Brief Interview for Mental Status) score of 14, cognition intact. He required extensive assist of 2 staff for bed mobility, transfers, toilet use, 1 for dressing and supervision for eating. He was occasionally incontinent of bladder and continent of bowels. A care plan, dated 7/26/18, indicated: SKIN RISK: I am at risk for skin breakdown.[MEDICAL CONDITION] Left [MEDICAL CONDITIONS], incontinence, dementia. Interventions included: assist to toilet &/or check and change frequently. Float heels while in bed. Monitor labs as available. Monitor skin daily during care. Notify physician and family of any change in skin integrity. Provide peri-care as needed. Provide pressure reducing device to bed and chair. Remind or assist to turn at least every 2 hr. See nutritional plan of care. Skin assessment at least weekly by nurse. A skin alteration form, dated 1/8/19, indicated Resident 74 had a 5 cm x 6 cm (centimeter) popped blister to the right heel. A weekly skin assessment, dated 1/9/19, indicted the resident had a stage II to the right heel measuring 5 x 5.8 x 0 depth, blister intact. Appears to have been fluid filled but not fully filled at this time. A current, 1/9/19, care plan indicated, I have developed actual pressure injury. Location: right heel related to: Exposure of skin to urinary and fecal incontinence, Impaired/decreased mobility and decreased functional ability. Interventions included: Monitor each shift for dressing placement and sign/symptoms worsening. Notify NP and hospice as needed. Treatment as ordered. The nursing weekly assessments, indicated Resident 74's skin was assessed on 10/23/18, and then 7 weeks later on 12/11/18. A pressure injury assessment, dated 1/9/19, indicated Resident 74 had a stage II wound to his right heel originally noted on 1/8/19. A pressure injury assessment, dated 1/22/19, indicated Resident 74's wound to his heel was an unstageable area now. Resident 74's wound assessment forms lacked documentation to show the resident's wound was assessed between 1/9/19 and 1/22/19. A weekly nursing assessment, dated 12/26/18 indicated no skin issues noted. The next weekly nursing assessment was completed on 1/16/19, 22 days later, indicating no skin issues. During an interview,on 2/07/19 at 11:56 A.M., the Director of Nursing and the Assistant Director of Nursing indicated the area should have been assessed by the would nurse. On 2/11/19 at 10:58 A.M., the Director of Nursing provided the policy titled, Wound (Pressure Injury) & Non-Wound Assessment & Documentation, dated 5/17/17, and indicated the policy was the one currently used by the facility. The policy indicated .All wounds, as defined below, will be managed by the facility wound nurse (s). Assessment findings will be documented on the Pressure Injury assessment and non pressure injury assessment. Each week or more often if needed, the wound assessment will be completed to include: location, stage, current status, measurements, description, pain associated, PUSH score and current treatment On 2/11/19 at 10: 58 A.M., the Director of Nursing provided the policy titled, Skin Management Program, dated 8/14/14, and indicated the policy was the one currently used by the facility. The policy indicated . I. A comprehensive head to toe skin assessment (inspection) will be completed by a licensed nurse upon admission/return, and at least weekly thereafter 3.1-40(a) 3.1-40(b)

Based on record review, observation, and interviews, the facility failed to ensure supervision of a totally dependent resident while eating resulting in the resident incurring an unwitnessed fall from the bed to the floor and sustaining a nasal fracture for 1 of 3 residents reviewed in a sample of 3. (Resident C) Finding includes: The record of Resident C was reviewed on 03/14/16 at 11:30 a.m. Resident C was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The Nursing-Admission/Return Assessment, dated 01/29/16, indicated the following areas checked under Fall Risk: . Confusion/forgetfulness . [DIAGNOSES REDACTED]/paresis . Weakness . Uses assitive device for mobility . Mechanical lift transfer . Poor trunk control . Poor positioning . Use of narcotics or psychoactive meds The risk assessment did not contain a risk scale for scoring. A Care Plan, dated 02/09/16, indicated the following: Focus: NEEDS ASSIST W (with) ADLS (Activities Daily Living) DUE to: (Resident's name) is requiring extensive to total assist with all care r/t (restated/to) CVA with Right [DIAGNOSES REDACTED], aphasia. Extensive to total assist of 1-2 for bed mobility and toileting Extensive assist with eating Goal: Will have needs met/anticipated as evident by . Interventions/Tasks: .Assist at meals with tray set-up and meals/eating as needed The MDS (Minimum Data Set) assessment, dated 02/25/16, indicated Resident C's cognitive score was 7 indicating a severe cognitive impairment. Resident C required supervision and assistance of 1 for eating and extensive assist of 2 or more for transfers. The Assessments indicated Resident C had incurred an unwitnessed fall on 03/02/16. The resident was observed on the floor next to the (R) side of the bed approximately 5 minutes after being set up in bed for breakfast. The facility's investigation indicated Resident C incurred a 5 cm (centimeter) X 2 cm reddened area on the left side to mid forehead. The resident was seen in a local ER (emergency room ) and X-ray of nasal boned indicated: 03/02/16 12:13 p.m IMPRESSION: There is a nondisplaced nasal bone fracture at the distal tip of the nasal bones. Resident C was observed, on 03/14/16 at 11:40 a.m., sitting up in bed with her lunch tray across the bed and feeding herself. No staff were observed to be with the resident. The Unit Manager/LPN (Licensed Practical Nurse) was interviewed on 03/14/16 at 1:45 p.m. The Unit Manager indicated she arrived to work at approximately the time of the fall and the resident was being assessed by Resident C's assigned nurse. The Unit Manager noted the resident had been using multiple bolsters for positioning and alignment since admission and they were in use prior to the fall. CNA (Certified Nursing Assistant) #5 was interviewed on 03/14/16 at 1:54 p.m. CNA #5 indicated the Resident C was set up for breakfast and wedges were placed for safety to prevent the resident from rolling out of bed. The CNA indicated leaving the room to continue to pass trays and while walking down the hall, less than 5 minutes later, the resident was observed on the floor between the bed and the wall in the right side of the bed. The CNA indicated a nurse was summoned and the resident was immediately assessed. CNA #5 indicated being unaware Resident C required supervision for eating. The CNA worksheets (a tool which cues direct care staff of residents needs) did not denote any residents who required supervision for eating. This Federal tag relates to Complaint IN 349. 3.1-45(a)(2)

Based on observation, interviews and record review, the facility failed to ensure 1 of 2 residents with gastrostomy tubes ([DEVICE]) in a sample of 4 received appropriate care and services to prevent vomiting, aspiration pneumonia and diarrhea related to monitoring the flow rate of enteral feeding being administered. (Resident B) Findings include: During the orientation tour, on 6/14/11 at 9:00 a.m., Licensed Practical Nurse (LPN) #8 identified Resident B as having recently been sent to the hospital for aspiration pneumonia. She indicated he was fed via [DEVICE] and took some foods orally. He was observed with his head up at a 40 degree angle and the feeding had been turned off for the daytime hours. A feeding pump was in the room and had been detached from Resident B's [DEVICE]. The clinical record of Resident B was reviewed on 6/14/11 at 11:30 a.m., and indicated the resident had been admitted to the facility 11/3/10 with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The feeding ordered was [MEDICATION NAME] 1.2 calories at 115 ml/hr (milliliters per hour) over 15 hours. This was from 5:00 p.m., to 8:00 a.m., with allowance for mealtimes. During an interview with LPN #10, on 6/14/11 at 2:20 p.m., she indicated she had gone into the room of Resident B "around 7:00 or 8:00 p.m.," the evening of 5/28/11 and hung the tube feeding solution. She indicated she had "primed" the pump by setting it on 300 ml per hour and had been distracted by another resident. She indicated she had forgotten to go back and set the feeding rate at the 115 ml/hr and had not discovered the problem until she checked the resident at 11:00 p.m. She indicated he was vomiting tube feeding solution and having diarrhea when she found him. She indicated she put his head up higher and called the doctor, who ordered the resident sent to the hospital for evaluation. LPN #10 indicated she had checked Resident B's vital signs when he returned at 4:15 a.m., on 5/29/11. Review of a transfer form, dated 5/29/11 at 00:30 (12:30 a.m.), indicated the resident had been sent to the hospital for large amounts of emesis and possible aspiration. The vital signs on the transfer sheet were: blood pressure 165/110, pulse 100, respirations not indicated and blood oxygen 91 percent on room air. The hospital record, dated 5/29/11, indicated the resident was treated with antibiotics for a urinary tract infection and sent back to the facility at 4:15 a.m., on 5/29/11. Hospital records, obtained on 6/15/11 at 8:00 a.m., indicated the resident was assessed in the emergency department with clear breath sounds and respirations regular and unlabored. During an interview with LPN #4, on 6/14/11 at 9:15 a.m., she indicated she had worked the day shift on 5/29/11 and when she was told Resident B had gotten too much [DEVICE] feeding she went to his room and found him with coarse lung sounds and a temperature of 102.8. She indicated she sent him back to the hospital immediately. Review of the transfer sheet, dated at 7:00 a.m., on 5/29/11, indicated LPN #4 had assessed Resident B and found him with a blood pressure of 126/85, pulse of 138 and respirations of 24. The comment section of the form indicated, "resident was sent out at 1230 am (sic) on this date to (hospital) due to multiple emesis and large amounts of loose stools. Resident came back at 415 am (sic) on this date and symptoms have gotten worse Course (sic) lung sounds and temp went from 98.0 to 102.8 writer has notified both the physician and the POA (power of attorney). Writer believes resident may have possibly aspirated." The hospital record, obtained 6/15/11 at 8:00 a.m., indicated an x-ray of the chest had been done during the second trip to the emergency room and the report indicated, "There is a localized patchy infiltrate in the right and left lung field. Based on the clinical and radioactive presentation this is likely due to aspiration pneumonia." The resident was admitted to the hospital and treated for [REDACTED]. Review of a medication and treatment error report, dated 5/29/11, indicated LPN #10 had been counseled for an error described as "used pump to prime tubing at 300 ml/hr hooked resident up & (and) got called away & forgot to reset the pump." The negative outcome was listed as "resident had emesis (with) possible aspiration." Review of LPN #10's nursing skills check-off on 6/16/11 at 1:45 p.m., indicated she had received inservicing related to "Administering a Continuous-Drip Tube Feeding" on 3/24/09. This federal tag relates to Complaint IN 498. 3.1-44(a)(2)